For this patient (Dilated Cardiomyopathy with LVEF 25%, COPD, Severe Pulmonary Hypertension, Right Pleural Effusion, Orthopnea, Breathlessness), physiotherapy should be low-intensity and closely monitored because of the severe cardiac dysfunction. Physiotherapy Treatment Short-Term Goals Reduce dyspnea (breathlessness). Improve ventilation and oxygenation. Promote airway clearance (if secretions are present). Improve chest expansion. Prevent complications of prolonged bed rest. Improve functional mobility. Conserve energy during activities. --- Long-Term Goals Improve cardiopulmonary endurance. Increase exercise tolerance. Improve independence in activities of daily living (ADLs). Improve quality of life. Educate the patient regarding lifestyle modifications and home exercise program. --- Physiotherapy Management 1. Positioning High Fowler's position (45–90°). Supported sitting with pillows. Avoid prolonged supine lying. Frequent position changes every 2 hours. Purpose Reduces breathlessness. Improves lung expansion. Decreases cardiac workload. --- 2. Breathing Exercises Diaphragmatic Breathing Place one hand on the abdomen. Slow inspiration through the nose. Abdomen rises during inspiration. Slow expiration through pursed lips. Dosage: 10 repetitions × 3–4 sessions/day. --- Pursed-Lip Breathing Inhale through the nose for 2 seconds. Exhale through pursed lips for 4 seconds. Dosage: 5–10 minutes. Repeat several times/day. Benefits: Prevents airway collapse. Improves oxygenation. Reduces dyspnea. --- Segmental Thoracic Expansion Exercise Therapist provides manual facilitation over lower ribs. Encourage deep inspiration. Hold for 2–3 seconds. Relax during expiration. Dosage: 10 repetitions × 3 sets/day. --- 3. Airway Clearance Techniques (If Secretions are Present) Huffing. Supported coughing. Active Cycle of Breathing Technique (ACBT). Avoid vigorous percussion in severe cardiac patients unless indicated. --- 4. Active Range of Motion (AROM) Perform active exercises for: Shoulder Elbow Wrist Hip Knee Ankle Dosage: 10 repetitions. 2–3 sets/day. Purpose: Prevent stiffness. Improve circulation. Prevent deep vein thrombosis. --- 5. Bed Mobility Training Teach the patient: Rolling. Supine to sitting. Sitting balance. Sit to stand. --- 6. Early Mobilization Progress gradually: Day 1 Bed exercises. Sitting on edge of bed. Day 2 Standing with support. Day 3 Short-distance walking. Increase activity only if: HR remains stable. BP remains stable. SpO₂ ≥ 90%. No excessive dyspnea or chest pain. --- 7. Ambulation Training Short-distance walking. Use Borg Dyspnea Scale (keep ≤3–4/10). Rest whenever needed. Progress gradually. --- 8. Endurance Training After medical stabilization: Walking. Corridor ambulation. Low-intensity aerobic activity. Intensity: 40–60% of functional capacity. RPE (Borg Scale): 11–13. Duration: 10–20 minutes. Frequency: 3–5 days/week. --- 9. Inspiratory Muscle Training (If Prescribed) Threshold Inspiratory Muscle Trainer. Begin at 30% of maximal inspiratory pressure. Duration: 15–20 minutes/day. --- 10. Relaxation Techniques Controlled breathing. Relaxed sitting. Shoulder relaxation exercises. Purpose: Reduce anxiety. Decrease respiratory effort. --- 11. Energy Conservation Techniques Teach the patient to: Pace activities. Take frequent rest breaks. Avoid rushing. Sit while performing daily activities. Avoid lifting heavy objects. Coordinate breathing with movement. --- 12. Patient Education Educate regarding: Smoking cessation. Alcohol avoidance. Medication compliance. Salt-restricted diet (as advised). Fluid restriction (if prescribed). Daily weight monitoring. Home exercise program. Recognition of warning signs: Increased breathlessness. Chest pain. Swelling of legs. Sudden weight gain. Dizziness or syncope. --- Monitoring During Physiotherapy Monitor before, during, and after each session: Heart Rate Blood Pressure Respiratory Rate Oxygen Saturation (SpO₂) Borg Dyspnea Scale Borg Rating of Perceived Exertion (RPE) Fatigue level Symptoms of chest pain or dizziness --- Stop Physiotherapy Immediately If Chest pain develops or increases. Severe breathlessness occurs. SpO₂ falls below 90% (or below the physician-prescribed limit). Heart rate increases excessively or becomes irregular. Blood pressure drops significantly or rises excessively. Patient experiences dizziness, syncope, or palpitations. Excessive fatigue or cyanosis develops. --- Home Exercise Program (After Discharge) Diaphragmatic breathing: 10 repetitions × 3 sessions/day Pursed-lip breathing: 5–10 minutes, 3–4 times/day Walking: 10–20 minutes/day, progressing gradually as tolerated Upper and lower limb active ROM exercises: 10 repetitions × 2 sets/day Energy conservation techniques during ADLs Follow-up with the cardiologist and physiotherapist regularly. > Precaution: Since this patient has severe LV systolic dysfunction (LVEF 25%), severe pulmonary hypertension, and COPD, physiotherapy should be gentle, symptom-limited, and performed only after medical clearance with continuous monitoring of vital signs and symptoms.