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Physiotherapy Treatment Plan

Clinical Reasoning Before Intervention

• Lactic acidosis - indicates tissue hypoperfusion/metabolic compromise; demands cautious exertion monitoring
• Pulmonary edema - fluid in alveoli impairs gas exchange; positioning and breathing techniques are key
• LRTI - active infection with secretion retention; needs careful airway clearance

Assessment (Before Starting Any Treatment)

Phase 1 - Acute/Unstable Phase (Days 1-2)

1. Positioning (PRIORITY INTERVENTION)

• High sitting / upright at 45-90 degrees - reduces venous return to the heart, decreases pulmonary congestion, improves functional residual capacity (FRC)
• Maintain this position continuously, not just during sessions
• If unilateral lung involvement (LRTI one side) - consider good lung down positioning to improve V/Q matching
• Avoid supine - worsens pulmonary edema and increases work of breathing
• Supported arm position - arms on pillows/overbed table to fix accessory muscles and reduce respiratory effort

2. Oxygen Therapy Monitoring

• Ensure nasal cannula is patent, correctly placed, flow rate as prescribed
• Monitor SpO2 continuously during all physiotherapy
• If SpO2 drops during treatment - STOP, reposition, inform medical team
• Advise medical team if patient desaturates persistently despite cannula - may need step-up to Venturi mask or HFNC

3. Breathing Control / Diaphragmatic Breathing

• Breathing control (relaxed abdominal breathing) - reduces accessory muscle use
• Instruct patient: slow, relaxed breaths in through nose, relaxed expiration
• 3-4 breaths only per set initially - do not fatigue
• Frequency: every 1-2 hours when awake
• Avoid deep breathing exercises in acute pulmonary edema phase - can worsen fluid redistribution

4. Rest and Energy Conservation

• Minimize unnecessary movements and procedures
• Ensure patient does not sit on edge of bed unsupported
• All activities must be accompanied by monitoring SpO2

Phase 2 - Stabilizing Phase (Days 3-5, when edema improves + SpO2 stabilizes)

1. Active Cycle of Breathing Technique (ACBT)

1. Breathing control (relaxed breaths, 3-4 breaths)
2. Thoracic expansion exercises (3-4 deep, relaxed inspirations, hold 3 seconds at peak, passive expiration) - reopens collapsed segments
3. Breathing control again
4. Forced expiration technique (FET) / Huff - medium lung volume huff to mobilize secretions from periphery, followed by deep breath and cough to clear central airways

2. Assisted Cough Techniques

• If cough is weak: Supported cough - patient crosses arms over chest or places hands over lower ribs and coughs
• Manual assisted cough (if very weak) - therapist applies inward/upward pressure to abdomen on cough attempt
• Avoid in cases of uncontrolled lactic acidosis with hemodynamic instability

3. Postural Drainage (Modified)

• Use only if secretions are significant and patient can tolerate
• Modified positions only - avoid head-down tilt (Trendelenburg) given pulmonary edema risk
• Side-lying or slightly tilted positions are acceptable
• Duration: 5-10 minutes per position maximum
• Always maintain SpO2 monitoring

4. Percussion and Vibration (if tolerated)

• Gentle chest percussion to affected lobe(s) in modified positions
• Vibration on expiration phase to loosen peripheral secretions
• Do NOT percuss over areas of acute edema, fractured ribs, or if patient is distressed
• Use palm cupping technique, not vigorous clapping

5. Early Mobilization

• Sitting out of bed - when hemodynamically stable (Day 3-4 typically)
• Start with 5-10 minutes sitting in chair
• Gradual progressive mobilization: bed - sitting - standing at bedside - supervised walking (short distances with nasal cannula portable)
• Monitor SpO2, HR, RR, and BP at each stage
• Stop if SpO2 <90%, HR >120, or patient reports severe dyspnea

Phase 3 - Recovery Phase (Days 5+ / Pre-discharge)

1. Incentive Spirometry

• Use incentive spirometer to maximize inspiratory volume
• 10 breaths per hour when awake
• Encourages sustained maximal inspiration to prevent and reverse atelectasis
• Particularly important in elderly patients at risk of consolidation

2. Progressive Ambulation

• Supervised walking on the ward, progressively increasing distance
• Stair climbing (if relevant for home) before discharge
• Monitor vitals at start, during, and end

3. Upper Limb Exercises

• Gentle shoulder circles, arm raises - improves thoracic mobility and prevents deconditioning
• Can be performed seated

4. Patient Education

• Breathing techniques to continue at home (pursed lip breathing if needed)
• Energy conservation strategies
• Warning signs for worsening (increased breathlessness, cough, fever)
• Smoking cessation (if applicable)
• Medication adherence (antibiotics, diuretics as prescribed)
• Activity pacing

Contraindications / Precautions Summary

SpO2 Targets (Nasal Cannula Patient)

• Target SpO2: 94-98%
• If SpO2 <90% at rest - escalate oxygen delivery, inform medical team
• During therapy - allow brief dips to 92% only if quick recovery; otherwise pause
• Remember: lactic acidosis means tissue oxygenation may be compromised even with normal SpO2

Coordination with Medical Team

• Liaise with the physician regarding timing of diuretics - physiotherapy is most effective when edema is being actively treated
• Confirm antibiotic therapy is running (for LRTI)
• Request ABG or lactate trends to gauge metabolic recovery
• Suggest step-up to HFNC or NIV (BiPAP/CPAP) if patient fails to maintain SpO2 on nasal cannula - this has strong evidence for reducing intubation rates in cardiogenic pulmonary edema (PMC RCT evidence)

Summary Table - Treatment by Phase

Updated Physiotherapy Treatment Plan

Why NCPE Changes the Approach - Key Differences

Assessment Parameters (Mandatory Before Each Session)

Phase 1 - Acute Phase (Days 1-2): Stabilize and Protect

Priority 1: Positioning

• High sitting (60-90°) - improves FRC, reduces work of breathing, promotes dependent fluid redistribution away from airways
• Prone or semi-prone positioning - strong evidence in ARDS for improving oxygenation by recruiting dorsal lung units (where edema pools in supine position). In a conscious, cooperating patient on nasal cannula:
  • Awake prone positioning - patient prone or in 3/4 prone (semi-prone/recovery position) for 1-2 hour sessions, 2-3 times/day if tolerated
  • Monitor SpO2 during position changes - improvement of 3-5% SpO2 is a positive response
  • If patient cannot tolerate full prone, use lateral decubitus with more affected side up (recruits dependent lung)
• Avoid prolonged supine - in NCPE, supine worsens edema distribution to dependent zones, reducing ventilated lung volume

Priority 2: Breathing Control

• Slow, controlled breathing at a comfortable rate - reduces respiratory muscle fatigue
• Diaphragmatic breathing technique - hand on abdomen, gentle abdominal rise with inspiration
• Keep sessions brief: 3-5 minutes, 3-4 times/day
• Do NOT start deep breathing exercises yet - in acute NCPE the alveolar-capillary barrier is fragile; large tidal volumes can worsen permeability injury (similar to ventilator-induced lung injury principle)

Priority 3: Oxygen Optimization

• Ensure nasal cannula fit is secure and flow rate is adequate
• If SpO2 does not improve with positioning and controlled breathing, alert team for step-up to HFNC or NIV (CPAP/BiPAP)
  • HFNC delivers 31-60 L/min of heated, humidified oxygen, generates mild PEEP (~3-7 cmH2O), and has been shown to reduce work of breathing and improve lactate clearance in acute hypoxemic respiratory failure
  • This step-up should be a clinical team decision but physiotherapists should proactively advocate for it if the patient is struggling on conventional cannula

Priority 4: Energy Conservation

• Minimize unnecessary activity
• Cluster cares to allow adequate rest
• Use supported arm position (arms resting on overbed table) to offload respiratory accessory muscles

Phase 2 - Stabilizing Phase (Days 3-5): Airway Clearance + Gentle Recruitment

1. Active Cycle of Breathing Technique (ACBT)

1. Breathing control - 3-4 relaxed diaphragmatic breaths
2. Thoracic expansion exercises - 3-4 deep slow inspirations, 3-second hold at peak, passive relaxed expiration - recruits collapsed alveolar segments
3. Breathing control again - 2-3 breaths
4. Huff (FET - Forced Expiration Technique) - medium volume huff (not a cough, a sustained "haaaa") to shear secretions from peripheral airways; follow with deep breath
5. Productive cough to clear central secretions

2. Incentive Spirometry

• Start once patient can follow instructions and RR is controlled
• 10 breaths per hour when awake
• In NCPE/ARDS, this serves to sustain alveolar recruitment and counteract atelectasis driven by surfactant disruption
• Particularly important here because NCPE destroys surfactant, making alveoli prone to collapse between breaths

3. Assisted Cough / Supported Cough

• In LRTI, sputum retention worsens hypoxia and perpetuates infection
• Self-supported cough: patient wraps arms across chest and coughs
• Manual assisted cough: therapist applies firm upward-inward pressure at lower costal margin synchronized with cough effort, if independent cough is weak
• Follow cough with 2-3 relaxed breaths before next attempt

4. Postural Drainage (Modified - NCPE Specific Rules)

• Head-down tilt is permitted in NCPE (unlike cardiogenic PE where it worsens cardiac load) - but use cautiously given lactic acidosis and potential hemodynamic instability
• Use modified side-lying positions targeting the affected lobe(s) from LRTI - 10-15 minutes per position
• Gentle percussion and vibration over involved segments to loosen secretions
• Always combine with ACBT and assisted cough for maximum effect
• Avoid in the first 48 hours (acute phase) - wait for hemodynamic stability

5. Lateral Rotation / Position Changes

• Regular 2-hourly position changes (supine → left lateral → right lateral → semi-prone) to prevent dependent atelectasis
• Document SpO2 in each position - use the best-tolerated position as the preferred rest position

Phase 3 - Recovery Phase (Day 5 onwards): Mobilization + Reconditioning

1. Progressive Early Mobilization

• NCPE/ARDS patients decondition very rapidly - early mobilization reduces ICU-acquired weakness
• Step ladder:
  • Sitting up in bed independently
  • Sitting over edge of bed (with SpO2 monitoring)
  • Sitting in chair out of bed - 15-30 minutes, twice daily
  • Standing at bedside with support
  • Supervised ambulation with portable nasal cannula - start 10-20 meters, increase daily
• Monitor SpO2, HR, RR, BP at each step - stop if SpO2 <90%, HR >120, or severe dyspnea

2. Upper Limb Active Exercises

• Shoulder flexion, abduction, elbow extension - seated
• Improves thoracic mobility and respiratory mechanics
• Helps counteract deconditioning and prevents ICU-acquired weakness in an already metabolically stressed patient

3. Lower Limb Exercises (Bed-based initially)

• Ankle pumps (prevent DVT in immobile patient)
• Knee extensions, hip flexion in lying/sitting
• Graduated to standing and walking

4. Breathing Re-education

• Pursed lip breathing - slows expiratory flow, maintains airway patency, reduces dynamic hyperinflation if present
• Lateral costal breathing - maximizes lateral expansion, recruits basal lung zones
• Practice 2-3 times daily as home program preparation

5. Patient and Family Education

• What is NCPE, why it differs from "heart water" (non-cardiac)
• Signs of worsening: increased breathlessness, fever, confusion, cyanosis - when to call for help
• Importance of completing antibiotic course for LRTI
• Activity pacing after discharge
• Breathing techniques to continue at home
• Smoking cessation if relevant

Specific NCPE Precautions (Different From Cardiogenic PE)

Escalation Triggers - Tell the Medical Team

Quick Reference Summary Table