Physiotherapy Treatment Plan

CLINICAL REASONING

• Lactic acidosis indicates tissue hypoperfusion or metabolic dysregulation - physiotherapy must not increase oxygen demand beyond what the patient can tolerate
• Non-cardiogenic pulmonary edema (NCPE) - alveolar flooding from increased capillary permeability (ARDS spectrum), not elevated cardiac filling pressures; diuretics/vasodilators have limited role, ventilatory support and lung-protective strategies are key
• LRTI - likely the precipitating cause; produces retained secretions, V/Q mismatch, and consolidation requiring active airway clearance

PRE-TREATMENT ASSESSMENT

Baseline Parameters (Assess Before Each Session)

Contraindications / Precautions for This Patient

• Unstable lactic acidosis (pH < 7.25, rising lactate > 4 mmol/L) - defer active exercise, focus on positioning only
• Severe hypoxemia (SpO2 < 88% at rest on nasal cannula) - do not proceed with airway clearance techniques without MDT discussion
• Hemodynamic instability - systolic BP < 90 mmHg, HR < 40 or > 130/min: defer session
• Active bronchospasm - contra-indication to percussion
• Thrombocytopenia - use vibration instead of percussion if platelets < 50,000

PHYSIOTHERAPY GOALS

TREATMENT PLAN - PHASE 1 (Days 5-7): ACUTE PHASE

1. Positioning and Postural Management

• Head of bed elevation 30-45° at all times - reduces pulmonary congestion, improves functional residual capacity (FRC), and reduces aspiration risk in LRTI
• High side-lying positions (alternating left and right) - recruits non-dependent lung zones affected by edema pooling
• Prone positioning - strongly consider if SpO2 remains borderline (88-91%) on nasal cannula; supported by evidence in ARDS-spectrum disease for improving oxygenation through better V/Q redistribution. Coordinate with nursing team for 4-hour prone periods if tolerated
• Avoid supine flat position - worsens dyspnea, increases WOB, and promotes edema distribution to posterior lung zones
• Frequency: Position change every 2 hours

2. Active Cycle of Breathing Techniques (ACBT)

1. Breathing Control (BC): Relaxed diaphragmatic breathing at the patient's own rate and depth. Interspersed between active components to prevent fatigue and bronchospasm. Duration: 30-60 seconds per cycle.
2. Thoracic Expansion Exercises (TEE): 3-4 deep breaths, with a 3-second hold at end-inspiration (inspiratory hold promotes collateral ventilation via pores of Kohn and channels of Lambert, helping air to get behind mucus). Can be combined with manual chest compression on expiration.
3. Forced Expiration Technique (FET) / Huff Coughing: One or two huffs (forced expiration from mid-to-low lung volume with an open glottis) followed by breathing control. Huff is less tiring and less likely to cause dynamic airway collapse compared to explosive coughing.

3. Breathing Retraining

• Inhale slowly through the nose for 2 counts, exhale through pursed lips for 4 counts
• Slows respiratory rate, increases tidal volume, prevents dynamic airway collapse, and reduces the oxygen cost of breathing
• Particularly useful during activities, position changes, and any exertional dyspnea
• Evidence: PLB has been shown to reduce hypoxemia and decrease dyspnea in patients with obstructive and restrictive respiratory disease (Murray & Nadel's Textbook of Respiratory Medicine)

• Place one hand on chest, one on abdomen; breathe so the abdomen rises preferentially
• Consciously coordinate abdominal wall expansion with inspiration
• Reduces accessory muscle use, lowers RR, increases tidal volume
• Evidence: Diaphragmatic breathing exercises significantly reduced dyspnea scores and fatigue in hospitalized respiratory patients and improved NYHA functional classification (Nasirmoghadas et al., 2025, BMC Cardiovascular Disorders, PMID: 39794689, RCT)

4. Manual Chest Physiotherapy

• Percussion (Clapping): Rhythmic manual force applied over lung segments for 1-2 minutes per affected zone. Use padded hand/cupped technique. Loosens adherent secretions by mechanical energy transfer.
• Vibrations: Applied during expiration phase (chest vibration or shaking). Increases peak expiratory flow, promoting mucus movement toward central airways. Safer alternative if percussion is contraindicated.
• Postural Drainage: Place patient in positions that use gravity to drain the affected segment. In NCPE, avoid aggressive head-down positions as they may worsen dyspnea - use modified positions (semi-reclined side-lying).

5. Incentive Spirometry

• Set initial target: 70-80% of predicted inspiratory capacity or at patient's comfortable maximum
• 10 repetitions per hour while awake, with rest between efforts
• Evidence: Early pulmonary rehabilitation with incentive spirometry in acute exacerbations significantly improved pulmonary function and reduced complications vs. standard care (Andrea Ban et al., 2024, Med J Malaysia, PMID: 39352158, RCT)

6. Secretion Clearance - Adjuncts (if Available)

• Flutter VRP1 / Oscillating PEP device: Patient exhales through the device, which creates oscillating positive expiratory pressure + airflow oscillations - both mechanically loosens mucus and improves expiratory flow
• High Frequency Chest Wall Oscillation (HFCWO): If available, consider for Day 7+ if secretion burden persists
• Manual Assisted Cough: If cough is weak, the therapist applies abdominal thrust during expiratory phase to augment peak cough flow

TREATMENT PLAN - PHASE 2 (Days 7-10): PROGRESSIVE MOBILIZATION

7. Early Mobilization Protocol

• Continuous SpO2 monitoring - suspend if SpO2 < 88% for > 30 seconds
• Borg dyspnea and exertion scale should not exceed 5/10
• Titrate nasal cannula flow rate upward during exercise if required
• Stop immediately: chest pain, palpitations, pallor, confusion, SpO2 < 85%

8. Upper and Lower Limb Strengthening

• Lower limbs: Ankle dorsiflexion/plantarflexion, straight leg raises, knee extension - performed in supine/sitting to prevent peripheral muscle wasting
• Upper limbs: Shoulder flexion/abduction, elbow flexion/extension, grip exercises with a soft ball
• Frequency: Once daily, 10-15 minutes
• Rationale: Peripheral muscle weakness is a major driver of exercise limitation in respiratory patients. Maintaining limb strength reduces the deconditioning spiral.

TREATMENT PLAN - PHASE 3 (Days 10+): PRE-DISCHARGE & EDUCATION

9. Functional Exercise Training

• Supervised walking program: begin with 10-metre corridor walks, progressing to 50-100 metres with rest stops
• Stair climbing if discharge environment requires it (practice with physiotherapist present)
• 6-Minute Walk Test (6MWT) as discharge readiness marker when stable

10. Patient and Carer Education

11. Discharge Planning

• Refer to outpatient pulmonary rehabilitation program post-discharge
• Home-based exercise diary (steps per day, Borg scale tracking)
• Spirometry and 6MWT at 2-week and 6-week follow-up
• Physiotherapy discharge summary to GP with objective findings and home plan

PRECAUTIONS SPECIFIC TO THIS PATIENT'S DIAGNOSES

Lactic Acidosis Precautions

• Lactic acidosis resolves when the underlying cause is treated and tissue perfusion is restored (Washington Manual of Medical Therapeutics). Physiotherapy must not increase systemic oxygen demand when it cannot be met.
• Daily review of serum lactate with medical team before planning exercise intensity
• Any physiotherapy-induced increase in WOB must be compensated by increased nasal cannula O2 flow

Non-Cardiogenic Pulmonary Edema Precautions

• Unlike cardiogenic pulmonary edema, NCPE does not respond to diuretics in the same way and does not benefit from positional fluid redistribution strategies used in heart failure
• Avoid aggressive fluid administration (not a physiotherapy role but relevant to positioning in context of edema)
• Prone positioning and lung recruitment strategies (via breathing exercises) are the mainstays of physiotherapy management in NCPE/ARDS spectrum (Barash Clinical Anesthesia, 9e)

LRTI Precautions

• Use appropriate PPE (mask, gloves) when managing productive cough
• Ensure patient has tissue or sputum pot for expectoration
• Track sputum colour and volume - purulent increase warrants medical review
• Bronchospasm during ACBT/percussion: stop session, allow patient to use prescribed bronchodilator, resume with gentler techniques

OUTCOME MEASURES

SESSION SUMMARY TABLE

REFERENCES

1. Fishman's Pulmonary Diseases and Disorders (2-Volume Set) - Respiratory and Chest Physiotherapy Techniques; Breathing Retraining Techniques; Bronchial Hygiene; Exercise Prescription (Chapters on Pulmonary Rehabilitation)
2. Murray & Nadel's Textbook of Respiratory Medicine - Inspiratory Muscle Training, Breathing Training and Chest Physical Therapy - Section on pursed-lip breathing, hypoxemia reduction, and oxygen cost of breathing
3. Washington Manual of Medical Therapeutics - Lactic Acidosis: Treatment - "Lactic acidosis will resolve once the underlying cause is treated and tissue perfusion is restored"
4. Barash, Cullen, and Stoelting's Clinical Anesthesia, 9e - Distribution of Ventilation - Non-cardiogenic pulmonary edema mechanism (increased capillary permeability causing V/Q mismatch and impaired diffusion)
5. Pecorelli N, Eggmann S, Jeitziner MM, et al. Early Rehabilitation Interventions and Physical Therapy in Adults Who Were Critically Ill With COVID-19 Pneumonia. Phys Ther. 2023 Feb;103(2):pzac157. PMID: 37104624 - Early PT within 72 hours is safe and feasible in critically ill respiratory patients; median time to edge-of-bed mobilization < 4 days.
6. Nasirmoghadas A, Monjazebi F, Nasiri M, et al. Comparison of diaphragmatic breathing exercises and incentive spirometry on the functional status of heart failure patients: a randomized controlled trial. BMC Cardiovasc Disord. 2025;25(1). PMID: 39794689 - Both diaphragmatic breathing and incentive spirometry significantly reduced dyspnea, fatigue, and improved functional class in hospitalized cardiorespiratory patients (RCT, n=90).
7. Andrea Ban YL, Siti Istiana AS, Nik Nuratiqah NA, et al. The benefits of early pulmonary rehabilitation with incentive spirometer among COPD patients with exacerbation. Med J Malaysia. 2024 Sep. PMID: 39352158 - Early pulmonary rehab with incentive spirometry improved pulmonary function in hospitalized acute exacerbation (RCT).
8. Huang C, Zhao X, Geng S, et al. Non-drug perioperative interventions to reduce postoperative pulmonary complications after abdominal surgery: systematic review and meta-analysis. BMJ. 2026 Apr. PMID: 41956522 - Breathing exercises and early mobilization reduce pulmonary complications in hospitalized patients (Systematic Review/Meta-Analysis).