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Integrating Physiological Principles into the Comprehensive Management of Cardiopulmonary Dysfunction

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Abstract

Impairment of oxygen transport can be conceptualized as a motion disorder based on the framework previously reported by Hislop and Zadai. Extensive literature exists that demonstrates the beneficial effects of body positioning and mobilization on impaired oxygen transport. This article integrates this existing information and attempts to extend the framework of Hislop and Zadai in cardiopulmonary physical therapy. To provide a basis for discussion, we describe the multisystemic consequences of immobility from bed rest. We also discuss the role of body positioning and mobilization as therapeutic interventions that can be used to directly enhance all components of oxygen transport in patients with cardiopulmonary dysfunction. This approach may improve the efficacy of treatment in these patients and thus may address some of the limitations of current methods of practice. Further research is needed, however, to clarify and extend the application of this approach. Related PubMed Citation:1161801
Integrating Physiological Principles into the
Comprehensive Management of
Cardiopulmonary Dysfunction
Jocelyn Ross
Elizabeth Dean
Impairment of oxygen
transport
can be
conceptualized as
a motion
disorder
based
on the
framework
previously reported by Hislop
and Zadai
Extensive
literature exists that demonstrates the beneficial effects
of body
positioning
and
mobilization on
impaired oxygen
transport.
This article integrates this existing
information and
attempts
to extend
the
framework
of
Hislop
and Zadai in
cardiopulmonary
physical
therapy.
To provide a basis for
discussion,
we
describe
the
multisystemic consequences
of immobility
from
bed
rest.
We also discuss the
role of body positioning and
mobilization
as
therapeutic interventions that
can be
used to
directly
enhance all
components
of oxygen
transport
in patients
with
cardiopulmonary
dysfunction.
This approach
may
improve the efficacy
of
treatment in these patients and
thus
may
address some
of
the limitations
of
current
methods
of
practice.
Further research is
needed,
however,
to
clarify-and
extend
the application
of
this
approach.
[Ross
J,
Dean
E:
Integrating physiological
principles
into the
comprehensive
management of
cardiopulmonary
dysfunction.
Phys Ther
69:255-259,
1989.]
Key Words:
Hemodynamics;
Homeostasis;
Pathokinesiology;
Pulmonary,
general.
Hislop originally proposed that
pathokinesiology is the underlying
scientific discipline of physical therapy.
1
Using such an approach, she described
the three principal goals of physical
therapy as follows: 1) to restore motion
homeostasis to the person or to the
person's subsystems, 2) to enhance the
adaptive capacities of the person to
impairment, and 3) to prevent the
disruption of motion homeostasis. She
proposed that physical therapy attempts
to nullify the effects of disruptive forces
or potential disturbances that are
manifested as motion disorders.
Recently, Zadai discussed the clinical
implications of Hislop's framework
with respect to cardiopulmonary
physical therapy.
2
The purpose of this
article is to illustrate how the
integration of specific physiological
principles can further extend the
contributions of Hislop and Zadai to
cardiopulmonary physical therapy.
The movement or transport of oxygen
in the body depends on optimal
pulmonary and cardiovascular function
including ventilation of the alveoli,
diffusion of
gases
across the alveolar
capillary membrane, perfusion of blood
to the lungs, and gas transport to the
tissues.
3
When one or more of these
components fails, arterial hypoxemia,
the hallmark of cardiopulmonary
dysfunction, is precipitated.
4
A
particularly common cause of arterial
hypoxemia is mismatching of
ventilation and perfusion in the lung.
4
Considerable evidence exists
supporting the beneficial effect of
specific body positioning and
mobilization on oxygen transport, in
particular on ventilation-perfusion
matching, thus arterial oxygenation.
5-15
Both ventilation and perfusion increase
from the top to the bottom of the
upright lung. Thus, the lowermost lung
J Ross, BSR, is Clinical Instructor, School of Rehabilitation Medicine, University of British Columbia,
2211 Wesbrook Mall, Vancouver, British Columbia, Canada
V6T
1W5,
and Physical Therapist, Critical
Care,
Vancouver General Hospital, 855
W
12th
Ave,
Vancouver, British Columbia, Canada
V5Z
1M9.
E Dean, PhD, is Assistant Professor, School of Rehabilitation Medicine, University of British Columbia.
Address correspondence to Ms Ross at School of Rehabilitation Medicine, University of British
Columbia, 2211 Wesbrook Mall, Vancouver, British Columbia, Canada
V6T
1W5.
This work was supported in part by the Canadian Lung Association.
This article was
submitted
April
6,
1988;
was
with the
authors for revision for
eight
weeks;
and
was
accepted
November
9,
1988.
Physical Therapy/Volume 69, Number
4/April
1989
255/13
zones are both better ventilated and
perfused than the uppermost lung
zones.
Optimal ventilation-perfusion
matching occurs in the midzone of
each lung. During exercise, however,
both ventilation and perfusion increase,
and regional differences are less
pronounced. Thus, oxygen transport
and ventilation-perfusion matching
throughout the lungs are both
increased. We propose that these
physiological principles can be
integrated into cardiopulmonary
physical therapy to enhance treatment
efficacy.
Specifically, this article discusses the
role of body positioning and
mobilization as therapeutic
interventions to directly enhance
oxygen transport in patients with
cardiopulmonary dysfunction. Body
positioning refers to positioning an
individual to optimize oxygen
transport.
Mobilization,
in the context
of cardiopulmonary care, refers to the
administration of progressive exercise
to elicit hemodynamic responses to
gravity and to stimulate increases in
ventilation, thereby increasing oxygen
transport. The negative consequences
of immobility, in the form of bed rest,
are presented first to provide a
framework for the discussion on body
positioning and mobilization. We have
selected clinical examples related to
the critically ill individual to illustrate
the effects of body positioning and
mobilization on impaired oxygen
transport. The physiological principles
described, however, can be applied to
any patient with cardiopulmonary
dysfunction.
Consequences off Immobility
Until the 1940s, when the negative
effects of immobility were better
understood, many disorders involving
the cardiovascular system were
commonly treated with prolonged
periods of bed rest. At that time,
Harrison emphasized that activity
should be limited only to the point of
reducing patients' symptoms resulting
from their particular pathological
condition.
16
An important consequence
of immobility on the cardiovascular
system is orthostatic intolerance
resulting from the shift of body fluids
into the thorax from the extremities
and the loss of the stimulus of
gravity
needed to maintain hemodynamic
status in the upright position.
13,17-19
This fluid shift, which occurs after only
six hours of bed rest, is more
instrumental than reduced physical
activity in promoting orthostatic
intolerance.
13
For example, it has been
shown that although bed exercises
during a period of bed rest prevented
loss of muscle strength in healthy
subjects, orthostatic intolerance was not
affected.
19,20
Chase et al observed that
vigorous exercise performed at
75%
of
maximum oxygen consumption
(Vo
2
max
) for 45 minutes a day also did
not prevent orthostatic intolerance.
21
In
addition, Miller et al reported that the
exercise tolerance of healthy subjects
who performed daily supine cycling
exercises was comparable to that of
subjects who had not exercised, when
tested in the upright position following
a period of bed rest.
22
Thus, Winslow
concluded that measures to counteract
fluid shift directly are more important
than exercise alone in minimizing the
negative effects of bed rest on
cardiovascular hemodynamics.
13
The
results of these studies strongly support
the use of mobilization involving a
gravitational stimulus in patients
immobilized by bed rest. This form of
mobilization is particularly beneficial
for acutely ill patients for whom the
consequences of orthostatic intolerance
may be severe.
With respect to the pulmonary system,
immobility promotes monotonous tidal
ventilation, which compromises the
ventilation of the dependent lung
fields.
Consequently, airway closure,
atelectasis, secretion retention, and
interstitial fluid accumulation may
occur. The specific distribution of these
changes within the lung is affected by
the body positions that the patient
assumes.
6,8,10-12
Crosbie and Myles, for
example, investigated the effect of the
slumped Fowler's position commonly
assumed by hospitalized patients on
the lung volumes of healthy subjects
and concluded that this position could
precipitate pulmonary complications.
23
Craig et al reported significant
decreases in lung volumes with closure
of inferior airways in the posterior lung
fields when patients changed from the
upright to the supine position.
24
Froese
and Bryan further studied the
distribution of ventilation in the
dependent lung zones of an
anesthetized paralyzed subject in the
supine position.
8
Their conclusions
were significant in that effective
ventilation of inferior regions was
achieved only by manipulating body
position. Considering the effect of body
position on oxygen transport, the body
position between treatments is clearly
as important as that during treatment.
In addition to its marked effect on the
cardiopulmonary system, immobility
has other systemic consequences
including decreased total blood volume
and decreased hemoglobin
concentration,
25
increased resting heart
rate,
26
and decreased
Vo
2
max
.
25,27
Immobility promotes fluid stasis in the
kidneys, which may lead to kidney
stones and infection.
28
Furthermore,
increased calcium excretion,
20
musculoskeletal changes,
29
and
emotional and behavioral disorders
30
have been associated with prolonged
bed rest. The cardiopulmonary system
is unique in that its function affects all
other body systems, which in turn
influence overall cardiopulmonary
efficiency. Thus, the multisystem
sequelae of immobility are of
considerable clinical significance
because of their potential to cause or
exacerbate cardiopulmonary
dysfunction.
Role of Body Positioning
and Mobilization
Body positioning alone can be an
effective means of enhancing oxygen
transport via improving
ventilation-perfusion matching in the
lung. The physiological principles
underlying the use of body positioning
specifically for optimizing
ventilation-perfusion matching and
arterial oxygenation are well
established
6
and thus will not be
discussed further. Body positioning,
however, may also be applied to
address each component of
ventilation-perfusion matching. Murphy
et al, for example, studied the effects of
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Physical Therapy/Volume 69, Number
4/April
1989
postural drainage positions on the
pulmonary function of patients with
cystic fibrosis.
31
These investigators
observed that postural drainage
positions alone had a beneficial effect
on peak expiratory flow rate, forced
expiratory volume, and forced vital
capacity and that this effect was not
augmented with other physical therapy
techniques such as manual percussion,
mechanical percussion, and forced
expiratory maneuvers. In addition,
Chulay et al studied the effect of
routine body positioning on the
incidence of pulmonary complications
following coronary artery bypass
surgery.
5
One group of patients
remained in the supine position for the
first 24 hours postsurgery, and a
second group of patients was turned to
alternate sides every two hours during
this time period. Turning resulted in a
significantly decreased incidence of
postoperative fever and a 32%
reduction in length of stay in the
intensive care unit. Despite the
beneficial effects of routine turning in
this study, these effects may have been
enhanced if position selection was
specific to the underlying
pathophysiology for each individual.
Although the effect of body positioning
on pulmonary perfusion has been well
established,
5-15
specific clinical studies
to examine the therapeutic use of body
positioning to improve pulmonary
perfusion are lacking.
In addition to the specific pulmonary
pathophysiology, other factors must be
considered when using body
positioning to enhance pulmonary
function. Hurewitz et al, for example,
reported a decrease in ventilation in
the dependent lung fields of a patient
with an obese abdomen.
32
An
analogous situation occurs in patients
undergoing peritoneal dialysis or
following major abdominal surgery.
The normal aging process also affects
the distribution of ventilation via a loss
of elastic recoil and thus the normal
negative intrapleural pressure that acts
as an expansive force on the alveoli.
This altered intrapleural pressure
results in greater ventilation to the
apex rather than the base of the
upright lung because of compression
of dependent airways.
33
As
a
consequence, ventilation-perfiision
matching is compromised.
Furthermore, the influence of age on
the distribution of ventilation is
magnified by the body positions the
individual assumes. Leblanc et al, for
example, reported that airway closure
occurred in the dependent airways of a
44-year-old subject positioned supine
and in a 65-year-old subject sitting
upright.
10
Breathing at low lung
volumes also decreases the elastic
recoil forces and thus has the same
effect as age on the distribution of
ventilation.
3
In addition, factors such as
the individual's multisystem status and
medical interventions will limit the
positioning alternatives. Thus, the
effective application of body positioning
to improve pulmonary function
challenges the physical therapist to
address these various factors in
identifying optimal body positioning for
each patient.
Although selective body positioning can
significantly affect oxygen transport, it
will not fully address the negative
consequences of immobility for which
mobilization is essential. The goal of
mobilization is to elicit
cardiopulmonary responses sufficient to
increase minute ventilation and cardiac
output while maintaining normal
hemodynamic responses.
A
singularly
important consequence of such graded
exercise for the immobilized critically
ill individual is the recruitment and
distension of lung zones with low
ventilation and those with low
perfusion.
3
As
a result, these zones
have improved ventilation-perfiision
matching and, therefore, a greater
contribution to oxygen transport.
15,34
These effects can only be achieved if
the exercise stimulus is sufficient to
elicit an adequate cardiopulmonary
response and is not in excess of the
patient's oxygen transport capacity.
Relatively few studies have investigated
the responses of patients with acute
and critical cardiopulmonary
conditions. Dull and Dull investigated
the effect of early mobilization on
cardiopulmonary status in patients
following coronary artery bypass
surgery.
7
They concluded that the
beneficial effect of early mobilization
was not enhanced by the addition of
maximal inspiratory breathing exercises
or incentive spirometry. Wolff et al
studied the effects of exercise and
eucapnic hyperventilation on bronchial
clearance in healthy subjects using
radioactive isotopes.
14
They reported
that exercise significantly increased
secretion clearance in the exercise
group as compared with the control
group, which performed quiet
breathing exercises at rest. In addition,
this effect was greater in the exercise
group than in the group performing
resting eucapnic hyperventilation.
These studies provide support for the
beneficial effects of mobilization on
cardiopulmonary function.
Guidelines for the prescription of
mobilization for the acutely ill patient,
however, are needed. Physical
therapists have had to rely on their
clinical judgment to define the limits of
exercise intensity for acutely ill
patients. With advancements in
technology and the availability of
sophisticated monitoring equipment,
such as telemetry and arterial saturation
monitors, acutely ill patients can be
mobilized effectively and safely.
Research is warranted to refine clinical
guidelines for progressively mobilizing
these patients to further improve the
safety and efficacy of this procedure.
Implications
Extending current definitions of
cardiopulmonary physical therapy
practice to emphasize all aspects of
oxygen transport is consistent with the
scientifically based approach to practice
advocated by Hislop
1
and Zadai.
2
A
physiological approach to
cardiopulmonary physical therapy as
described may also have an important
role in explaining some of the
apparent limitations of current methods
of practice reported in the literature.
For example, ventilation is often the
focus of treatment with less attention
given to overall oxygen transport. Thus,
impaired ventilation is frequently
attributed to alterations in breathing
pattern or mucous retention, which are
considered to be the basis for the
primary pathophysiology and,
Physical Therapy/Volume 69, Number
4/April
1989
257/15
therefore, the focus of treatment.
35,36
The physiological approach, however,
places greater emphasis on the
pathological mechanisms underlying
these clinical signs. This emphasis can
be exemplified by the incidence of
pulmonary complications in
23%
of
patients who have received
conventional cardiopulmonary physical
therapy after upper abdominal
surgery.
37
The high incidence of
postoperative complications seen in
these patients has been explained by
reflex phrenic nerve inhibition, and
blocking this reflex or increasing
phrenic nerve output has been
suggested.
38
'
39
We could infer,
therefore, that selective body
positioning may prevent encroachment
of the viscera on the thorax (because of
the loss of the diaphragmatic barrier)
and thereby directly optimize
ventilation.
Some evidence exists that does not
support the efficacy of physical therapy
techniques, such as percussion, in
achieving secretion clearance and
optimizing ventilation.
31,35,40-44
In part,
this evidence may reflect deficiencies
in the experimental designs of
reported studies. For example,
variables such as body position and
treatment outcome measures have
been poorly standardized.
35
Thus,
Kirilloff et al concluded that although
postural drainage can be effective in
improving the status of patients with
cardiopulmonary dysfunction, no
convincing data exist showing that this
effect is enhanced with the addition of
percussion and vibration techniques.
35
Furthermore, vibration and percussion
have been shown to compromise
cardiopulmonary function in some
instances.
44,45
Connors et al, for
example, reported a significant drop in
arterial oxygen pressure in patients
with acute cardiopulmonary
dysfunction treated with postural
drainage in combination with
percussion and vibration in the
presence of minimal sputum
production.
44
They attributed this effect
to impaired ventilation-perfusion
matching and suggested that these
techniques were potentially hazardous
in this patient population. Campbell et
al reported an immediate decrease in
forced expiratory volume in one
second (FEV
1
) during postural drainage
combined with percussion and
vibration that did not occur with
postural drainage alone. These
investigators attributed the decrease in
FEV
1
to bronchospasm, which they
concluded was induced by
percussion.
45
Further research and
application of the physiological
approach will elucidate its role in
addressing these limitations of current
cardiopulmonary practice.
Conclusions
Integrating physiological principles to
optimize oxygen transport extends the
pathokinesiologic perspective of
practice advanced by
Hislop
1
and
Zadai.
2
Furthermore, this approach is
directed at the underlying
pathophysiology and thus may enhance
the efficacy of cardiopulmonary
physical therapy. The application of this
approach demands an integration of
the patient's multisystem status so that
treatment can be prescribed to
optimize oxygen transport as a whole.
Continuing research is necessary,
however, to further refine the
application of
this
approach and
explore its full potential.
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Article
Full-text available
Background: Despite the unequivocal role of progressive mobilization in post-surgical patient management, its specific effects and timing, particularly after abdominal surgery, remain debated. This study's aim was to examine the short-term effects of mobilization on oxygenation in hemodynamically stable patients after open surgery for pancreatic cancer. Methods: A randomized controlled clinical trial was conducted in which patients (n = 83) after open pancreatic surgery were randomized to either the same-day mobilization group (mobilized when hemodynamically stable within four hours after surgery) or the next-day mobilization group (mobilized first time in the morning of the first post-operative day). Mobilization was prescribed and modified based on hemodynamic and subjective responses with the goal of achieving maximal benefit with minimal risk. Blood gas samples were taken three times the evening after surgery; and before and after mobilization on the first post-operative day. Spirometry was conducted pre-operatively and on the first post-operative day. Adverse events and length of stay in postoperative intensive care were also recorded. Results: With three dropouts, 80 patients participated (40 per group). All patients in the same-day mobilization group, minimally sat over the edge of the bed on the day of surgery and all patients (both groups) minimally sat over the edge of the bed the day after surgery. Compared with patients in the next-day mobilization group, patients in the same-day mobilization group required lower FiO2 and had higher SaO2/FiO2 at 1800 h on the day of surgery (p < .05). On the day after surgery, FiO2, SaO2/FiO2, PaO2/FiO2, and alveolar-arterial oxygen gradient, before and after mobilization, were superior in the same-day mobilization group (p < 0.05). No differences were observed between groups in PCO2, pH, spirometry or length stay in postoperative intensive care. Conclusions: Compared with patients after open pancreatic surgery in the next-day mobilization group, those in the same-day mobilization group, once hemodynamically stable, improved oxygenation to a greater extent after mobilization. Our findings support prescribed progressive mobilization in patients after pancreatic surgery (when hemodynamically stable and titrated to their individual responses and safety considerations), on the same day of surgery to augment oxygenation, potentially helping to reduce complications and hasten functional recovery. Trial registration: This prospective RCT was carried out at the Sahlgrenska University Hospital, Sweden. The study was approved by the Regional Ethical Review Board in Gothenburg (Registration number: 437-17). Trial registration: "FoU in Sweden" (Research and Development in Sweden, URL: https://www.researchweb.org/is/vgr ) id: 238701 Registered 13 December 2017 and Clinical Trials (URL:clinicaltrials.gov) NCT03466593. Registered 15 March 2018.
Article
The purpose of this case report is to discuss the efficacy of physical therapy for a patient following acute surgical pulmonary embolectomy (SAPE) complicated by lung hemorrhage. A 69-year-old woman was admitted to our hospital following chest discomfort and unconsciousness. She was diagnosed as having acute pulmonary embolization and underwent emergency SAPE. During the operation, the complication of lung hemorrhage arose due to lung reperfusion injury, so she had to be supported by percutaneous cardiopulmonary support. On the postoperative day 5, we started respiratory physical therapy for prevention of respiratory complications and arange of motion exercises for prevention of deep venous thrombosis. On the postoperative day 10, she was able to sit on the edge of the bed and sit in a wheel chair. On the postoperative day 14, she did away with the mechanical ventilator and started standing and ambulating. On the postoperative day 21, She was transferred to another hospital. Physical therapy with early mobilization is suitable for the mechanism of respiratory dysfunction following SAPE. Her course of treatment was uneventful with regard to respiratory function and she improved ambulation and undertook activities of daily living. Physical therapy with early mobilization seems to be suitable for a patient following SAPE with lung hemorrhage.
Article
Postoperatieve pulmonale complicaties (PPC) werden al in 1910 door Pasteur 1 geïdentificeerd. Pasteur gaf als hypothese het falen van de ademspierpomp.
Article
SummaryIn this era of quality assurance and cost effectiveness, physiotherapy management of cardiopulmonary conditions needs to be aligned with the physiologic and scientific literature, which current practice does not reflect. This article presents a conceptual framework for practice based on oxygen transport, and describes five factors that contribute to the lack of efficacy of conventional chest physiotherapy with special reference to manual chest percussion.First, the theoretical conceptualisation of chest physiotherapy primarily based on secretion clearance and its purported clinical goal of improved ventilation is no longer tenable. This focus is too narrow in that it fails to address oxygen transport as a whole.Second, sputum production is a highly questionable measure of treatment outcome. Its relationship with pulmonary function and gas exchange overall is inconsistent.Third, the potent physiologic effects of body positioning and mobilisation/exercise can explain treatment effects that are frequently attributed to conventional chest physiotherapy.Fourth, chest physiotherapy is associated with various adverse side effects.Fifth, the literature supports the use of judicious as opposed to routine positioning and mobilisation/exercise as primary interventions to remediate acute as well as chronic cardiopulmonary dysfunction or minimise its threat.If cardiopulmonary physiotherapy is to be an essential physiologically-based specialty in this area of accountability, practice must be aligned with the physiologic and scientific literature and continually updated with the integration of new knowledge.
Article
The values of vital capacity and forced expiratory volume in one second were obtained for 20 young adults, recordings being taken in four different body positions: sitting, supine lying, prone lying and in a slumped half-lying position. The values derived were analysed using simple statistical methods and there were found to be significant reductions in some pulmonary capacities in the slumped position compared with the values obtained with the subjects in the other positions. These findings tend to support the suggestion that the posture frequently adopted by hospitalised patients in bed creates a set of circumstances which may place the patients at risk due to reduced respiratory function.
Article
The effects of a 20-day period of bed rest followed by a 55-day period of physical training were studied in five male subjects, aged 19 to 21. Three of the subjects had previously been sedentary, and two of them had been physically active. The studies after bed rest and after physical training were both compared with the initial control studies. Effects of Bed Rest All five subjects responded quite similarly to the bed rest period. The total body weight remained constant; however, lean body mass, total body water, intracellular fluid volume, red cell mass, and plasma volume tended to decrease. Electron microscopic studies of quadriceps muscle biopsies showed no significant changes. There was no effect on total lung capacity, forced vital capacity, one-second expiratory volume, alveolar-arterial oxygen tension difference, or membrane diffusing capacity for carbon monoxide. Total diffusing capacity and pulmonary capillary blood volume were slightly lower after bed rest. These changes were related to changes in pulmonary blood flow. Resting total heart volume decreased from 860 to 770 ml. The maximal oxygen uptake fell from 3.3 in the control study to 2.4 L/min after bed rest. Cardiac output, stroke volume, and arterial pressure at rest in supine and sitting positions did not change significantly. The cardiac output during supine exercise at 600 kpm/min decreased from 14.4 to 12.4 L/min, and stroke volume fell from 116 to 88 ml. Heart rate increased from 129 to 154 beats/min. There was no change in arterial pressure. Cardiac output during upright exercise at submaximal loads decreased approximately 15% and stroke volume 30%. Calculated heart rate at an oxygen uptake of 2 L/min increased from 145 to 180 beats/min. Mean arterial pressures were 10 to 20 mm Hg lower, but there was no change in total peripheral resistance. The A-V 0 2 difference was higher for any given level of oxygen uptake. Cardiac output during maximal work fell from 20.0 to 14.8 L/min and stroke volume from 104 to 74 ml. Total peripheral resistance and A-V 0 2 difference did not change. The Frank lead electrocardiogram showed reduced T-wave amplitude at rest and during submaximal exercise in both supine and upright position but no change during maximal work. The fall in maximal oxygen uptake was due to a reduction of stroke volume and cardiac output. The decrease cannot exclusively be attributed to an impairment of venous return during upright exercise. Stroke volume and cardiac output were reduced also during supine exercise. A direct effect on myocardial function, therefore, cannot be excluded. Effects of Physical Training In all five subjects physical training had no effect on lung volumes, timed vitalometry, and membrane diffusing capacity as compared with control values obtained before bed rest. Pulmonary capillary blood volume and total diffusing capacity were increased proportional to the increase in blood flow. Alveolar-arterial oxygen tension differences during exercise were smaller after training, suggesting an improved distribution of pulmonary blood flow with respect to ventilation. Red cell mass increased in the previously sedentary subjects from 1.93 to 2.05 L, and the two active subjects showed no change. Maximal oxygen uptake increased from a control value of 2.52 obtained before bed rest to 3.41 L/min after physical training in the three previously sedentary (+33%) and from 4.48 to 4.65 L/min in the two previously active subjects (+4%). Cardiac output and oxygen uptake during submaximal work did not change, but the heart rate was lower and the stroke volume higher for any given oxygen uptake after training in the sedentary group. In the sedentary subjects cardiac output during maximal work increased from 17.2 L/min in the control study before bed rest to 20.0 L/min after training (+16.5%). Arterio-venous oxygen difference increased from 14.6 to 17.0 ml/100 ml (+16.5%). Maximal heart rate remained constant, and stroke volume increased from 90 to 105 (+17%). Resting total heart volumes were 740 ml in the control study before bed rest and 812 ml after training. In the previously active subjects changes in heart volume, maximal cardiac output, stroke volume, and arteriovenous oxygen difference were less marked. Previous studies have shown increases of only 10 to 15% in the maximal oxygen uptake of young sedentary male subjects after training. The greater increase of 33% in maximal oxygen uptake in the present study was due equally to an increase in stroke volume and arteriovenous oxygen difference. These more marked changes may be attributed to a low initial level of maximal oxygen uptake and to an extremely strenuous and closely supervised training program.
Article
Rest of injured parts and of diseased bodies is probably the oldest and most valuable of all methods of treatment, with the possible exception of psychotherapy. Nevertheless we seem from time to time to forget that this therapeutic method—like all others—may lead to untoward results when utilized either injudiciously or excessively. Within the past three decades there has developed a tendency to regard prolonged rest in bed and complete abstinence from normal economic activity as the sine qua non of the proper management of the more serious forms of heart disease. My purpose in the present report is to review certain experimental and clinical observations which seem to indicate that this concept may be unsound.During the eighteenth and nineteenth centuries, while the basic framework for our present understanding of heart disease was being fashioned, little emphasis was placed on the desirability of rest as it is now employed. Such
Article
Twenty-two healthy men were confined to bed in a hospital ward (clinical bed rest) for one week. Variables related to physical fitness were measured before and immediately after the bed rest period, as well as one and three months thereafter. As a result of bed rest, maximal oxygen uptake, W170 and total Hb decreased to 94%, and calculated blood volume to 93% of the initial value. Hb concentration and Hct were unaltered. Thus, red cell and plasma volumes were proportionately reduced. No significant orthostatic dysfunction developed. The blood lactate peak at maximum work remained unchanged (14.0 mM/l). The resting exertion of noradrenaline decreased moderately during the bed rest period, whilst that of adrenaline was unchanged. Body weight decreased by a mean of 0.7 kg.
Article
To determine the effect of change in body position on gas exchange after thoracotomy, 12 patients with potentially resectable lung tumours were studied before and 24 hours after operation. Measurements of arterial blood gas tension (PaO2, PaCO2), alveolar-arterial oxygen difference (A--adO2), venous admixture effect (Qs/Qt percent), and physiological dead space to tidal volume ratio (Vd/Vt), were made in the supine, and left and right lateral decubitus positions. Preoperatively, altering position did not affect gas exchange significantly. After thoracotomy in the lateral position with the unoperated side dependent, PaO2 was significantly higher, and A--adO2 and Qs/Qt percent significantly lower than in the supine position. Postoperatively, the lateral position with the side of thoracotomy dependent was usually associated with the worst gas exchange. Only three patients achieved their best postoperative gas exchange in this position. In two this may have resulted from dependent small airway closure during tidal breathing, due to airways obstruction and old age, and in the third from postoperative atelectasis in this unoperated lung. No significant changes in mean PaCO2, Vd/Vt, or minute ventilation (VE) occurred with different positioning.
Article
When a patient remains immobile for any length of time, he risks developing secondary disabilities - muscle and joint degeneration, metabolic and circulatory disturbances, and other such disorders. Their cause is simple: disuse. But their effects can be devastating: physical and psychological deterioration, and perhaps death. Yet, prevention of most of these disabilities is also simple: keeping the patient mobile. Promoting mobility does take a little time, though, because it must be done often. This book selection tells you what causes and how to prevent the most common secondary disabilities.
Article
The effects of exercise and eucapnic hyperventilation on bronchial clearance were assessed in 10 healthy nonsmoking adults. A 99mTc-albumin aerosol was inhaled as a bolus in late inspiration under controlled conditions to produce deposition primarily in large airways. Lung retention of radioactivity was quantified using a gamma camera and subsequent computer analysis. Compared with quiet breathing (control), exercise significantly speeded clearance (P less than 0.05). Resting eucapnic hyperventilation at levels similar to those achieved during exercise produced less speeding. Compared to control conditions these changes may be brought about by a) mechanical effect of increased lung movement, and b) effects on the autonomic nervous system, mediated via the parasympathetic pathway producing stimulation of airway mucus glands and/or sympathetic stimulation of cilia due to exercise-induced catecholamine release.