OT 6: CARDIAC AND

PULMONARY
DISEASES

MEMBERS:
LABASTIDA, JOY
LAVIDES, JULIA
LEE, MAISIE
MAKILING, RYAN
PATI-AN, GAYLE
PERENA, KAY
POLANCOS, RUCHIN

CARDIAC AND PULMONARY DISEASES

ANATOMY AND CIRCULATION
The heart and blood vessels work together to maintain a constant flow of
blood throughout the body.
The heart, located between the lungs, is pear shaped and about the size of a
fist. It functions as a two-sided pump. The right side pumps blood from the
body to the lungs; the left side simultaneously pumps blood from the lungs to
the body. Each side has two chambers, the upper atrium, and the lower
ventricles.
Blood flows to the heart through the venous system. Blood enters the right
atrium, which contracts the blood into the right ventricle. Next, the right
ventricle contracts and ejects the blood into the lungs, where CO2 is
exchanged for O2. The blood then goes to the left atrium. When the left
atrium contracts, it send the blood to the right ventricle which then contract
and sends the blood in the aorta where it goes to all the parts of the body.
Each ventricle has two valves. These open and close as the heart contracts
and relaxes. The input valves are the mitral, between the left atrium and
ventricle, and the tricuspid valve between the right atrium and ventricle. The
output valves consist of the aortic and pulmonary valves.
Coronary arteries cross over the myocardium to supply it with blood. The
arteries are named after their location on the myocardium. The left anterior
descending artery is in the left anterior portion and runs a downward direction,
it supplies part of the left ventricle. Blockage to this artery will interrupt supply
to the left ventricle, and thus lead to serious consequences.

WHAT CAUSES THE HEART TO CONTRACT?

In addition to ordinary muscle tissue the heart also contains nodal and pukinje
tissue. These are part of a specialized electrical conduction system that
cause the heart to contract and relax. An impulse usually originates in the
sinoatrial (SA) node then travels to the atrioventricular (AV) node through the
bundle of His then to the purkinje fibers. Nerve impulses travel this pathway
60-100 times per minute, first causing the atria to contract, then the ventricles.
Studying these impulses are done with an electrocardiogram (ECG).
The SA node responds to vagal and sympathetic nervous system input. This
way, the heart rate increases with anxiety and exercise and decreases
through relaxation techniques. Electrical impulses causing the heart to

contract can be generated from anywhere along the system. This is desirable
when the conduction system has been damaged, but is undesirable when lifethreatening conduction irregularities develop.

CARDIAC CYCLE
The cardiac cycle occurs in two phases input (diastole), and output (systole).
During the input phase, blood flows through the atria and into the ventricles.
The atria contracts and pushes more blood into the ventricles. Once pressure
is even in the atria and ventricles, the input valves (bicuspid, and tricuspid)
close. The ventricles then contract which results in increases ventricular
pressure. When the pressure inside the ventricles exceed that of the blood
vessels, the output valves (aortic and pulmonary) open and diastolic BP is
attained.
Systolic BP is attained when pressure in the emptying ventricles falls below
that of the blood vessels, which causes the output valves to close.

ISCHEMIC HEART DISEASE

Ischemic heart disease or ischemia occurs when a part of the heart is
temporarily deprived of sufficient oxygen to meet its demand. The most
common cause of cardiac ischemia is coronary artery disease (CAD). CAD
is the most common type of heart disease and the leading cause of death in
the United States in both men and women. CAD usually develops over time a
period of many years without causing symptoms. The internal wall of an
artery can become injured. Once the wall is damaged it becomes irregular in
shape and more prone to collect plaque (fatty deposits such as cholesterol).
Platelets also gather along the arterial wall and clog the artery, thereby
creating a lesion in the same manner in which rust can clog a pipe. The artery
gradually narrows and thus allows a smaller volume of blood to pass through
it. This disease process is called atherosclerosis.
If a coronary artery is partially or completely blocked, the part of the heart
supplied by that artery may not receive sufficient oxygen to meet its needs.
Persons with partial blockage of a coronary artery may be free of symptoms
at rest but have angina, a type of chest pain with eating, exercise, exertion or
exposure to cold. Angina varies from individual to individual and has been
described as squeezing, tightness, fullness, pressure, or a sharp pain in the
chest. The pain may also radiate to other parts of the body, usually he arm,

back, neck or jaw. Angina has also been confused with indigestion. Rest or
medication or both will frequently relieve angina. Angina is a warning sign that
should not be ignored. It is a sign that CAD is present- that the individual may
be a candidate for a heart attack.
Chest pain that is not relieved by rest or nitroglycerin indicates a myocardial
infarction (MI), or heart attack. A patient who has this type of pain should seek
emergency medical help immediately. Individuals who attribute their
symptoms to anxiety and stress are more likely to delay emergency care. MI
is significant because part of the heart muscle dies as a result of lack of
oxygen. If a substantial section of the heart is damaged, it will stop pumping
(cardiac arrest).
Restrictions in activity are prescribed for the first 6 weeks after a heart attack
because newly damaged heart muscle, like any injured body tissue is easily
reinjured. During a heart attack, metabolic waste products accumulate in the
damaged myocardium and make it irritable and prone to electrical
irregularities such as premature ventricular contractions. A delicate balance of
rest and activity must be maintained to allow the damage area of myocardium
to heal while also maintaining the strength of the healthy part of the heart. OT
is frequently recommended to guide the patient toward a safe level of activity
or participation in occupation, during this acute period of recovery.
At approximately 6 weeks after an MI, scar tissue forms and the risk of
extending the MI decrease. The scarred part of the heart muscle is not elastic
and does not contract with each heartbeat. Therefore the heart does not
pump as well. A graded exercise program will help strengthen the healthy part
of the myocardium and improve cardiac output.
CAD can also lead to congestive heart failure (CHF). Similarly, infections can
lead to CHF. This disease process develops over time with the heart
becoming progressively weaker. CHF occurs when the heart is unable to
pump effectively enough to meet the demand and fluid backs up into the
lungs or the body. The fluid buildup in the lungs causes shortness of breath.
Fluid overload is serious because it puts a greater workload on the heart as
the heart strains while attempting to clear the excess fluid, which may result in
further congestion. Heart size if often enlarged in persons with CHF to
promote fluid loss through the urinary system. Low-sodium diets and fluid
restriction reduce the overall amount of fluid in the body, CHF cannot be cure
but with diet, medications and rest, people with this condition can live longer
and participate more fully in life.

Once an acute exacerbation of CHF is controlled, gradual resumption of

activity will promote improved function. If activity is resumed to quickly,
another acute episode may follow. Patients who have difficulty resuming their
former level of activity may self limit their recovery. OT can guide clients with
acute CHF toward an optimal level of function via graded self-care tasks.

VALVULAR DISEASE
The heart valves, which are responsible for controlling the direction and flow
of blood through the heart, may become damaged by disease or infection.
Two complications result from valvular disease: volume overload and
pressure overload. A fibrous mitral valve will fail to close properly, and blood
will be regurgitated back to the atria when the left ventricle contracts. Volume
overload results when fluid accumulates in the lungs, thereby causing
shortness of breath. Volume overload increases the potential for atrial
fibrillation, which results in irregular and ineffective contraction in both atria.
Blood flow through the heart slows, and blood clots (emboli) may develop in
the ventricles. Many cerberovascular accidents are caused when emboli
ejected from the left ventricle enter the circulatory system of the brain.
If the aortic valve fails to close properly (aortic insufficiency), CHF or ischemia
may result. Another disorder of the aortic valve is aortic stenosis (narrowing),
which results in pressure overload. The left ventricle, which must work harder
to open the sticky valve, becomes enlarged and cardiac output decreases.
Ventricular arrhythmia (irregular rhythm of heartbeat), cerebral insufficiency,
confusion, syncope (fainting) and even sudden death may result from aortic
stenosis. Surgery to repair or replace the damaged valves is frequently
recommended.
Cardiac Risk Factors
Many scientific studies have been conducted to determine the causes of heart
disease. The most famous of these, the Framingham study, helped identify
many factors that put an individual at risk for atherosclerosis. Risk factors are
divided into three major categories: those that cannot be changed (heredity,
male gender, and age), those that can be changed (high blood pressure,
cigarette smoking, cholesterol levels, and inactive lifestyle) and contributing
factors (diabetes, stress, obesity). Other factors that contribute to CAD
include sleep apnea, high levels of triglycerides and high level of C-reactive
protein. The more risk factors that an individual has, the greater the
individuals risk for CAD. All team members- the physician, nurse, physical

therapist, case manager, social worker, nutrionist, and occupational therapistshould support the patients attempts to reduce risk factors.
Medical Management
A heart attack is a medical emergency and treatment with aspirin and oxygen
is usually indicated before diagnosis. Nitroglycerin and other measures to
control chest pain are included in these early measures. After emergency
treatment, heart attack survivors are typically managed in a coronary care unit
where they are closely observed for complications. Approximately 90% of
persons who have suffered an MI will have arrhythmia. Heart failure, the
development of blood clots (thrombosis and embolism), aneurysms, rupture
of part of the heart muscle, inflammation of the sac around the heart
(pericarditis), and even death are potential outcomes of MI. Close medical
management is imperative.
Generally, patients are managed for 2 to 3 days after MI in an intensive care
unit. Once their condition is stabilized, they graduate to a monitored hospital
bed. Patients typically stay 4 to 6 days in the hospital after acute MI. Vital
signs are monitored closely while activity is gradually increased. OT
personnel may be called on to monitor the patients response to an activity
and educate the patient about the disease process, risk factors and lifestyle
modifications.
Various surgical procedures can correct the circulatory problems associated
with CAD. Balloon angioplasty, also called percutaneous transluminal
coronary angioplasty (PTCA), and coronary artery bypass grafting (CABG)
are most common. During PTCA, a wire meth tube, called a stent may be
implanted into the coronary artery to keep the artery open.
In PTCA, a catheter is inserted into the femoral artery and guided through the
circulatory system into the coronary arteries. Radioactive dye is injected into
the arteries, and the site of lesion is pinpointed. A balloon is then inflated at
the site of the lesion to push the plaque against the arterial wall. When the
balloon is deflated and the catheter removed, improved circulation to the
myocardium usually results. Ensuring that the patient rests in bed for 8 hours
after PTCA helps prevents hemorrhage from the femoral artery.
If a lesion is too diffuse or if an artery reoccludes after PTCA, CABG may be
performed. The diseased section of the coronary arteries is bypassed with
healthy blood vessels (taken from other parts of the body), thus improving the
coronary circulation. In performing CABH, the surgeon usually open the chest
wall by cracking the sternum and spreading the ribs to gain access to the
heart. Postsurgical precautions to prevent trauma to the new graft sites,

inclusions and sternum generally last about 8 weeks after surgery and include
the following: avoiding Valsalva maneuvers (e.g. straining during a bowel
movement), avoiding a rapid movement of the upper part of the body
adhering to a 10-lb lifting restriction, wearing comprehensive hose, refraining
from diving (which creates problems because of upper body torque), and
traveling in a seat without an airbag when riding in a car, Following CABG,
85% of people have significantly reduced symptoms and a decreased chance
of dying within 10 years.
Arrhythmias that cannot be controlled with medications may be managed by
the insertion of a pacemaker in the chest. Wires are run from the pacemaker
to specific spots on the heart. The pacemaker delivers a small electrical
impulse to the heart muscles and sets the pace of the hearts electrical
conduction. The impulse may be set to deliver a regular impulse or to send an
impulse only if the heart rate drops below a certain number of beats pr
minutes (demand). Modern pacemakers can monitor physiologic responses
such as BP and temperature. Implantable cardioverterdefibllators (ICD) may
also be used to treat cardiac arrhythmias. An ICD can both pace the heart
muscle and deliver a high-energy impulse to reset the heart muscle if certain
dangerous arrhythmias develop.
When the hearts pumping ability has become too comprised by CHF or
cardiomyopathy, a heart transplant or heart-lung transplant may be
considered. After the healthy tissue of a recently deceased person is
harvested, the patients diseased organ (or organs) is removed and the
harvested tissue is transplanted into the patients body. Transplant decrease
the risk for organ rejection. Nearly 50% of all heart transplant recipients
survive for 10 years. Most recipients resume normal lifestyles, but only about
40% return to work.
COMMON CARDIAC MEDICATIONS
It is important for the professional occupational therapy practitioner to
know the purpose & side effects of cardiac medications that are prescribed to
his clients so that he may be able to maximize client activity performance
during intervention.
The following table lists the common cardiac medications to patients
who have experienced recent cardiac distress.
CATEGORY

COMMON NAMES

Angiotensin II
receptor blockers

Losartan (Cozaar)
Irbestan (Avopro)

PURPOSE &
USES
Keep blood
pressure from

REASON
PRESCRIBED
Control high blood
pressure & heart

(or inhibitors)

blockers

Calcium channel
blockers

Diuretics (water
pills)

Vasodilators

Digitalis
preparations

Statins

Anticoagulants

Antiplatelet agents

rising by
preventing
angiotensin II from
having an effect
on the heart
Atenolol (Tenormin)
Decrease heart
Propanolol (Inderal)
rate & cardiac
output, lower
blood pressure an
make heart beat
more slowly &
with less force
Amlodipine (Norvasc,
Interrupt
Lotrel)
movement of
Diltiazem (Cardizem,
calcium into cells
Tiazac)
of the heart &
blood vessels
Furosemide (Lasix)
Cause loss of
Hydrochlorothiazide
excess water &
(Esidrix, HydroDIURIL)
sodium by
urination
Nitroglycerin
Relax blood
Minodixil
vessels, increase
supply of blood &
oxygen to the
heart while
reducing its
workload
Digoxin (Lanoxin)
Increase the force
of cardiac
contractions
Statins
Resins
Nicotinic acid (niacin)
Warfarin (Coumadin)

Lower blood
cholesterol levels

Aspirin
Dipyridamole

Prevent clots by
preventing
platelets from

Decrease blood
clotting time

failure

Treatment of
abnormal cardiac
rhythms & chest
pain

Treat high blood

pressure, angina &
some arrhythmias

Lower blood
pressure, reduce
edema in lungs &
extremities
Ease chest pain

Treatment of heart
failure &
arrhythmias, atrial
fibrillation
Lower LDL, raise
HDL & lower
triglyceride levels
Prevent clots from
forming & prevent
clots
Prevent clots after
MI; with unstable
angina, ischemic

ACE inhibitors

Fosinopril (Monopril)

sticking together
Expand blood
vessels, lower
levels of
angiotensin II;
make heart work
easily

stroke, plaque
Treat high blood
pressure & heart
failure

PSYCHOSOCIAL CONSIDERATIONS
Clients who have experience recent myocardial infarctions usually go
through phases of adjustment to their disability. They go through fear &
anxiety when they are forced to confront their mortality. Sedatives reduce
stress in these patients & allow rest for healing. However, once they are
stabilized, the clients must face the reality of their physical limitations.
Once the clients are able to ambulate within the hospital & thus start to
resume their normal activities, their feelings of helplessness start to subside.
The clients feel more secure when familiar coping mechanisms allow them to
respond to stress. However, some of these coping mechanisms are harmful &
should be discouraged. This is where newly learned coping mechanisms are
reinforced on the client, which will be taught by the intervention team.
Feelings such as denial are common with patients with cardiac disease.
Clients exhibiting signs of this attitude need close monitoring during the
recovery phase. The individual may ignore all precautions & could therefore
stress & further damage their cardiovascular systems.
CARDIAC REHABILITATION
During the first one to three days after the myocardial infarction, the
clients condition is stabilized. This acute phase is then followed by a period of
early mobilization. During the Phase 1 of treatment (inpatient cardiac
rehabilitation), clients are allowed to do low-level physical activities such as
self-care. Cardiac & postsurgical precautions, instruction in energy
conversation & graded activities, establishment for appropriate activity level at
discharge are also done at this phase.
During the Phase 2 (outpatient cardiac rehabilitation), which begins at
discharge, exercise can be advanced but client is closely monitored. Phase 3
consists of community-based exercise programs. However, some individuals
require home treatment because they are not strong enough to tolerate
outpatient therapy.
Implementation of cardiac rehabilitation induces benefits for clients.
These include reduction of health care costs, & positive health effects.
Reduced mortality according to some researches are also shown to result

from cardiac rehabilitation. Patients with left ventricular dysfunction are also
giving good feedbacks by improving physical work capacity. In addition,
patients who acquired skills in relaxation & control of breathing were found to
require fewer hospitalizations.
Early & accurate identification of signs & symptoms of cardiac distress
are imperative to the well-being of the client. When signs of cardiac distress
are manifested during activity, the activity should be stopped, patient should
be allowed to rest, & emergency medical help should be sought if symptoms
dont resolve. The symptoms exhibited should be reported afterward to the
team & future activity must be modified to decrease workload.
The Borg Rate of Perceived Exertion Scale is a tool used to measure
perceived exertion. After a given activity, the client will be asked to appraise
his/her feelings of exertion after the activity & give the activity a rating. The
scale starts at 6 which shows no exertion at all, until 19, which is extremely
strenuous activity, equal to the most strenuous activity the patient has ever
performed.
Clients perception of their illness can have an impact on their ability to
make the changes in lifestyle necessary for healthy living after an acute
coronary event. Individualized intervention plans that address the unique
physical, social &psychologic concerns of client improve the integration of
lifestyle changes & functional improvement.

Signs & Symptoms of Cardiac Distress

Sign/Symptom
Angina

Dyspnea

Orthopnea

What to Look For

Look for chest pain that may be described
as squeezing, tightness, aching, burning
or choking. Pain is generally substernal&
may radiate to the arms, jaw, neck or
back. More intense or longer-lasting pain
forewarns of greater ischemia.
Look for shortness of breath with activity
or at rest. Note the activity that brought on
the dyspnea & the amount of time that it
takes to resolve. Dyspnea at rest with a
resting respiratory of greater then 30 bpm
is a sign of acute congestive failure. The
patient may require emergency medical
help.
Look for dyspnea brought on by lying
supine. Count the number of pillows that

Nausea/Emesis
Diaphoresis
Fatigue

Orthostatic [hypotension]

the patient needs to breathe comfortably

during sleep.
Look for vomiting or signs that the patient
feels sick to the stomach
Look for cold, clammy sweat
Look for a generalized feeling of
exhaustion. See: Borg Rate of Perceived
Exertion Scale in previous discussions
Look for a drop in systolic blood pressure
& hypotension of greater than 10 mmHg
with a change in position from supine to
sitting or sitting to standing.

MONITORING RESPONSE TO ACTIVITY

When the patients response to an activity is being assessed, symptoms
provide one indication that the patient is or is not tolerating the activity. HR,
BP, rate-pressure product (RPP), and ECG readings are other measures that
may be used to evaluate the cardiovascular systems response to work.
Heart Rate
HR, or the number of beats per minute, can be monitored by feeling the
patients pulse at the radial, brachial, or carotid sites. The radial pulse is
located on the volar surface of the wrist, just lateral to the head of the radius.
The brachial pulse is found in the antecubital fossa, slightly medial to the
midline of the forearm. The carotid pulse, located on the neck lateral to the
Adams apple, should be palpated gently; if overstimulated, it can cause the
HR to drop below 60 beats per minute (bradycardia).
To determine HR, the clinician applies the second and third fingers (flat, not
with the tips) to the pulse site. If the pulse is even (regular), the clinician
counts the number of beats in 10 seconds and multiplies the finding by 6. The
thumb should never be used to take a pulse because it has its own pulse. All
clinicians who assess HR, as well as patients, should be able to note the
evenness (regularity) of the heartbeat. HR can be regular or irregular. An
irregular heartbeat may be described as regularly irregular, which means that
there is a consistent irregular pattern (e.g., every third beat is premature), or it
may be described as irregularly irregular, which means that there is no pattern
to the premature or skipped beats. HR irregularities include skipped beats,
delayed beats, premature beats, and beats originating from outside the
normal conduction pathway in the heart. Although an irregular HR is not
normal, many individuals function quite well with an irregular rate.

Blood Pressure
BP is the pressure that the blood exerts against the walls of any vessel as the
heart beats. It is highest in the left ventricle during systole and decreases in
the arterial system with distance from the heart. A stethoscope and BP cuff
(sphygmomanometer) are used to indirectly determine BP. The BP cuff is
placed snugly (but not tightly) around the upper part of the patients arm just
above the elbow, with the bladder of the cuff centered above the brachial
artery. The examiner inflates the cuff while palpating the brachial artery to 20
mm Hg above the point at which the brachial pulse is last fel.t with the
earpieces of the stethoscope angled forward in the examiners ears, the dome
of the stethoscope is placed over the patients brachial artery. Supporting the
patients arm in extension with the pulse point of the brachial artery and the
gauge of the stethoscope at the patients heart level, the examiner deflates
the cuff at a rate of approximately 2 mmHg per second.
Rate Pressure Product is the product of HR and systolic BP. It is usually a
five-digit number but is reported in three digits by dropping the last two.
During any activity, the RPP should rise at peak and return to base line in
recovery after five to ten minutes of rest.
ANATOMY AND PHYSIOLOGY OF RESPIRATION
The respiratory system consists of an upper respiratory tract (nose to larynx)
and a lower respiratory tract (trachea onwards).The conducting portion
transports air and includes the nose, nasal cavity, pharynx, larynx, trachea,
and progressively smaller airways, from the primary bronchi to the terminal
bronchioles. The respiratory portion carries out gas exchange and is
composed of small airways called respiratory bronchioles and alveolar ducts
as well as air sacs called alveoli
The respiratory system supplies the body with oxygen and disposes of carbon
dioxide, filters inspired air, produces sound, contains receptors for smell, rids
the body of some excess water and heat and helps regulate blood pH.
Breathing (pulmonary ventilation) consists of two cyclic phases: (a) inhalation,
also called inspiration, draws gases into the lungs and (b) exhalation, also
called expiration, forces gases out of the lungs.
The upper respiratory tract is composed of the nose and nasal cavity,
paranasal sinuses, pharynx (throat), larynx and is composed of all parts of the
conducting portion of the respiratory system.
Respiratory mucosa is a layer of pseudostratified ciliated columnar epithelial
cells that secrete mucus and is found in nose, sinuses, pharynx, larynx and

trachea. Mucus can trap contaminants while cilia move mucus up towards
mouth.
A. Upper Respiratory Tract
The nose is composed of (a) Internal nares which has an opening to the
exterior, (b) External nares which has an opening to the pharynx, and (c)
Nasal conchae which has folds in the mucous membrane that increase air
turbulence and ensures that most air contacts the mucous membranes.
The nose has a rich supply of capillaries and warms the inspired air. It is
composed of an olfactory mucosa where the mucous membranes contain
smell receptors, respiratory mucosapseudostratified ciliated columnar
epithelium containing goblet cells that secrete mucus which traps inhaled
particles. Lysozyme kills bacteria and lymphocytes and IgA antibodies protect
against bacteria.
The nose provides and airway for respiration, moistens and warms entering
air, filters and cleans inspired air, a resonating chamber for speech, detects
odors in the air stream. Rhinoplasty is the surgery to change shape of
external nose
The paranasalsinuses is composed of four bones of the skull containing
paired air spaces - frontal, ethmoidal, sphenoidal, and maxillary. It decreases
skull bone weight, warms, moistens and filters incoming air, adds resonance
to voice, communicates with the nasal cavity by ducts and is lined
bypseudostratified ciliated columnar epithelium.
The pharynx is a common space used by both the respiratory and digestive
systems. It is commonly called the throat and originates posterior to the nasal
and oral cavities and extends inferiorly near the level of the bifurcation of the
larynx and esophagus. It is a common pathway for both air and food. Its walls
are lined by a mucosa and contain skeletal muscles that are primarily used for
swallowing. Its flexible lateral walls are distensible in order to force swallowed
food into the esophagus. The pharynx is partitioned into three adjoining
regions: nasopharynx, oropharynx, and laryngopharynx.
The nasopharynx is the superior-most region of the pharynx. It is covered with
pseudostratified ciliated columnar epithelium and is located directly posterior
to the nasal cavity and superior to the soft palate, which separates the oral
cavity. Normally, only air passes through. Material from the oral cavity and
oropharynx is typically blocked from entering the nasopharynx by the uvula of
soft palate, which elevates when we swallow. In the lateral walls of the
nasopharynx, paired auditory/eustachian tubes connect the nasopharynx to

the middle ear. The posterior nasopharynx wall also houses a single
pharyngeal tonsil (commonly called the adenoids).
The oropharynx is the middle pharyngeal region. It is immediately posterior to
the oral cavity and is bounded by the edge of the soft palate superiorly and
the hyoid bone inferiorly. It is the common respiratory and digestive pathway
through which both air and swallowed food and drink pass. It contains
nonkeratinized stratified squamous epithelim. The lymphatic organs here
provide the first line of defense against ingested or inhaled foreign materials.
Palatine tonsils are on the lateral wall between the arches, and the lingual
tonsils are at the base of the tongue.
The laryngopharynx is the inferior, narrowed region of the pharynx. It extends
inferiorly from the hyoid bone to the larynx and esophagus and terminates at
the superior border of the esophagus and the epiglottis of the larynx. It is lined
with a nonkeratinized stratified squamous epithelium and permits passage of
both food and air.
B. Lower Respiratory Tract
The conducting airways are composed of the trachea, bronchi, up to terminal
bronchioles while the respiratory portion of the respiratory system is
composed of the respiratory bronchioles, alveolar ducts, and alveoli.
The larynx, the voice box, is a short, somewhat cylindrical airway ends in the
trachea. It prevents swallowed materials from entering the lower respiratory
tract, conducts air into the lower respiratory tract and produces sounds. It is
supported by a framework of nine pieces of cartilage (three individual pieces
and three cartilage pairs) that are held in place by ligaments and muscles.
Nine c-rings of cartilage form the framework of the larynx
thyroid cartilage (1) Adams apple, hyaline, anterior attachment of
vocal folds, testosterone increases size after puberty
cricoid cartilage (1) ring-shaped, hyaline
arytenoid cartilages (2) hyaline, posterior attachment of vocal folds,
hyaline
cuneiform cartilages - (2) hyaline
corniculatecartlages - (2) hyaline
epiglottis (1) elastic cartilage
The muscular walls of the larynx aid in voice production and the swallowing
reflex. The glottis is the superior opening of the larynx,epiglottis prevents food
and drink from entering airway when swallowing. The larynx is composed of
pseudostratified ciliated columnar epithelium.

In sound production, the larynxs inferior ligaments are called the vocal folds.
These are the true vocal cordsbecause they produce sound when air passes
between them while the superior ligaments are called the vestibular folds.
These are the false vocal cordsbecause they have no function in sound
production, but protect the vocal folds. The tension, length, and position of
the vocal folds determine the quality of the sound.
There is intermittent release of exhaled air through the vocal folds. The
loudness depends on the force with which air is exhaled through the cords.
The pharynx, oral cavity, nasal cavity, paranasal sinuses act as resonating
chambers that add quality to the sound and the muscles of the face, tongue,
and lips help with the enunciation of words.
The trachea is a flexible tube also called windpipe that is 10 cm long. It
extends through the mediastinum and lies anterior to the esophagus and
inferior to the larynx. The anterior and lateral walls of the trachea supported
by 15 to 20 C-shaped tracheal cartilages. The cartilage rings reinforce and
provide rigidity to the tracheal wall to ensure that the trachea remains open at
all times. The posterior part of tube lined by trachealis muscle and is lined by
ciliated pseudostratified columnar epithelium.
At the level of the sternal angle, the trachea bifurcates into two smaller tubes,
called the right and left primary bronchi. Each primary bronchus projects
laterally toward each lung. The most inferior tracheal cartilage separates the
primary bronchi at their origin and forms an internal ridge called the carina.
When the trachea/pharynx becomes blocked, a small incision may be made
in the trachea to allow air to pass freely into the lungs, the surgeon performs a
tracheotomy.
The bronchial tree is highly branched system of air-conducting passages that
originate from the left and right primary bronchi. It progressively branches into
narrower tubes as they diverge throughout the lungs before terminating in
terminal bronchioles. The incomplete rings of hyaline cartilage support the
walls of the primary bronchi to ensure that they remain open. The right
primary bronchus is shorter, wider, and more vertically oriented than the left
primary bronchus and foreign particles are more likely to lodge in the right
primary bronchus. The primary bronchi enter the hilus of each lung together
with the pulmonary vessels, lymphatic vessels, and nerves. Each primary
bronchus branches into several secondary bronchi (or lobar bronchi). The left
lung has two secondary bronchi. The right lung has three secondary bronchi.
They further divide into tertiary bronchi. Each tertiary bronchus is called a
segmental bronchus because it supplies a part of the lung called a
bronchopulmonary segment. With successive branching amount of cartilage
decreases and amount of smooth muscle increases, this allows for variation

in airway diameter. During exertion and when sympathetic division active the
blood vessels undergo bronchodilation while mediators of allergic reactions
like histamine cause bronchoconstriction. Epithelium gradually changes from
ciliated pseudostratified columnar epithelium to simple cuboidal epithelium in
terminal bronchioles
RESPIRATORY ZONE OF LOWER RESPIRATORY TRACT
Most of the tubing in the lungs makes up conduction zone and consists of
nasal cavity to terminal bronchioles. The respiratory zone is where gas is
exchanged and consists of alveoli, alveolar sacs, alveolar ducts and
respiratory bronchioles
The lungs contain small saccularoutpocketings called alveoli. They have a
thin wall specialized to promote diffusion of gases between the alveolus and
the blood in the pulmonary capillaries. Gas exchange can take place in the
respiratory bronchioles and alveolar ducts as well as in the alveoli, each lung
contains approximately 300 to 400 million alveoli. The spongy nature of the
lung is due to the packing of millions of alveoli together.
The respiratory membrane is composed of squamous cells of alveoli,
basement membrane of alveoli, basement membrane of capillaries and the
simple squamous cells of capillaries about .5 in thickness
CELLS IN ALVEOLUS
Type I cells : simple squamous cells forming lining
Type II cells : or septal cells secrete surfactant
Alveolar macrophages
GROSS ANATOMY OF THE LUNGS
Each lung has a conical shape. Its wide, concave base rests upon the
muscular diaphragm. Its superior region called the apex projects superiorly to
a point that is slightly superior and posterior to the clavicle. Both lungs are
bordered by the thoracic wall anteriorly, laterally, and posteriorly, and
supported by the rib cage. Toward the midline, the lungs are separated from
each other by the mediastinum. The relatively broad, rounded surface in
contact with the thoracic wall is called the costal surface of the lung.
Left lung is divided into 2 lobes by oblique fissure and is smaller than the right
lung. The cardiac notch accommodates the heart. Right lung is divided into 3
lobes by oblique and horizontal fissure and is located more superiorly in the
body due to liver on right side.
PLEURA AND PLEURAL CAVITIES

The outer surface of each lung and the adjacent internal thoracic wall are
lined by a serous membrane called pleura. The outer surface of each lung is
tightly covered by the visceral pleura while the internal thoracic walls, the
lateral surfaces of the mediastinum, and the superior surface of the
diaphragm are lined by the parietal pleura. The parietal and visceral pleural
layers are continuous at the hilus of each lung.
The potential space between the serous membrane layers is a pleural cavity.
The pleural membranes produce a thin, serous pleural fluid that circulates in
the pleural cavity and acts as a lubricant, ensuring minimal friction during
breathing. Pleural effusion is pleuritis with too much fluid
BLOOD SUPPLY OF LUNGS
pulmonary circulation
bronchial circulation bronchial arteries supply oxygenated blood to
lungs, bronchial veins carry away deoxygenated blood from lung tissue
superior vena cava
Response of two systems to hypoxia
Pulmonary vessels undergo vasoconstriction
Bronchial vessels like all other systemic vessels undergo vasodilation
RESPIRATORY EVENTS
Pulmonary ventilation is the exchange of gases between lungs and
atmosphere. External respiration is the exchange of gases between alveoli
and pulmonary capillaries. Internal respiration is the exchange of gases
between systemic capillaries and tissue cells
There are two phases of pulmonary ventilation:
a. Inspiration, or inhalationis a very active process that requires input of
energy. The diaphragm, contracts, moving downward and flattening,
when stimulated by phrenic nerves.
b. Expiration, or exhalation is a passive process that takes advantage of
the recoil properties of elastic fiber. The diaphragm relaxes. The
elasticity of the lungs and the thoracic cage allows them to return to
their normal size and shape. Forced expiration requires active
contraction of abdominal muscles to compress the viscera and
squeeze the diaphragm upward in the thorax and further enforced by
flexing torso forward and pressing with the arm on the chest or
abdomen
MUSCLES THAT ASSIST WITH RESPIRATION
The scalenes help increase thoracic cavity dimensions by elevating the first
and second ribs during forced inhalation. The ribs elevate upon contraction of
the external intercostals, thereby increasing the transverse dimensions of the

thoracic cavity during inhalation. Contraction of the internal intercostals

depresses the ribs, but this only occurs during forced exhalation. Normal
exhalation requires no active muscular effort.
Other accessory muscles assist with respiratory activities. The pectoralis
minor, serratus anterior, and sternocleidomastoid help with forced inhalation,
while the abdominal muscles (external and internal obliques,
transversusabdominis, and rectus abdominis) assist in active exhalation.
BOYLES LAW
The pressure of a gas decreases if the volume of the container increases,
and vice versa.When the volume of the thoracic cavity increases even slightly
during inhalation, the intrapulmonary pressure decreases slightly, and air
flows into the lungs through the conducting airways. Air flows into the lungs
from a region of higher pressure (the atmosphere) into a region of lower
pressure (the intrapulmonary region).When the volume of the thoracic cavity
decreases during exhalation, the intrapulmonary pressure increases and
forces air out of the lungs into the atmosphere.
VENTILATION CONTROL BY RESPIRATORY CENTERS OF THE BRAIN
The trachea, bronchial tree, and lungs are innervated by the autonomic
nervous system. The autonomic nerve fibers that innervate the heart also
send branches to the respiratory structures. The involuntary, rhythmic
activities that deliver and remove respiratory gases are regulated in the
brainstem within the reticular formation through both the medulla oblongata
and pons.
RESPIRATORY VALUES
A normal adult averages 12 breathes per minute = respiratory rate (RR). The
respiratory volumes are determined by using a spirometer.
LUNG VOLUMES
TIDAL VOLUME (TV): Volume inspired or expired with each normal
breath. = 500 ml
INSPIRATORY RESERVE VOLUME (IRV): Maximum volume that can
be inspired over the inspiration of a tidal volume/normal breath. Used
during exercise/exertion.=3100 ml
EXPIRAT0RY RESERVE VOLUME (ERV): Maximal volume that can
be expired after the expiration of a tidal volume/normal breath. = 1200
ml
RESIDUAL VOLUME (RV): Volume that remains in the lungs after a
maximal expiration CANNOT be measured by spirometry.=1200 ml
LUNG CAPACITIES

INSPIRATORY CAPACITY ( IC): Volume of maximal inspiration: IRV +

TV = 3600 ml
FUNCTIONAL RESIDUAL CAPACITY (FRC): Volume of gas
remaining in lung after normal expiration, cannot be measured by
spirometry because it includes residual volume: ERV + RV = 2400 ml
VITAL CAPACITY (VC): Volume of maximal inspiration and expiration:
IRV + TV + ERV = IC + ERV = 4800 ml
TOTAL LUNG CAPACITY (TLC): The volume of the lung after
maximal inspiration. The sum of all four lung volumes, cannot be
measured by spirometry because it includes residual volume: IRV+ TV
+ ERV + RV = IC + FRC = 6000 ml

INNERVATION OF RESPIRATION
The trachea, bronchial tree and lungs are innervated by the autonomic
nervous system. The autonomic nerve fibers that innervate the heart also
send branches to the respiratory structures. The pulmonary plexus is
composed of the sympathetic innervation which causes bronchodilation and
parasympathetic innervation which causes bronchoconstriction. The
involuntary, rhythmic activities that deliver and remove respiratory gases are
regulated in the brainstem.
CHRONIC LUNG DISEASE
o Common chronic disorders of the lungs for which pulmonary
rehabilitation is typically prescribed include chronic obstructive
pulmonary disease (COPD) and asthma.
o COPD is characterized by:
Damage to the alveolar wall
Inflammation of the conducting airway
Includes emphysema, peripheral airway disease, chronic
bronchitis
o Emphysema condition in which alveoli becomes enlarged or
ruptured, usually because of a restriction during expiration or a
decrease in elasticity of the lungs.
o Chronic emphysema
Men; ages 45 -65 yo who have a history of chronic
bronchitis, smoking, working in areas of high levels of air
pollution, or exposure to cold
Progresses = becomes dyspnea which occurs at rest
o Physiologic changes that occur with peripheral airway disease
Inflammation

Fibrosis
Narrowing of terminal airways of lungs
o Common clinical manifestations
Coughing
Spitting up mucus
o May develop into emphysema or evolve in to a full-fledged
COPD
o Chronic bronchitis is diagnose after a 2yr period of repeated
episodes, lasting longer than 3mos of mucus producing cough
of unknown origin
o Cigarette smoking has a direct relationship with the
development of the disease
Clinical manifestations increases aNd the pack-year
history increases
Pack year = no. of packs of cigarettes per day X no.
ofyrs smoking
o Asthma
Irritability of the bronchotracheal tree
Onset: episodic
Experience wheezing, shortness of breath
Some have a genetic predisposition
Allergic causes: pollens, respiratory irritants (perfume,
dust, cleaning agents)
First clinical manifestation: BRONCHOSPASM due to
exposure to cold air/exercise
Irritation of the airways leads to narrowing of the air
passages and interferes with ventilation o the alveolar
sacs.
If obstruction of the airway is significant enough, a
reduction in oxygen levels in the bloodstreams will result
in HYPOXIA
Untreated= death
PULMONARY RISK FACTORS
o SMOKING
o Other environmental irritants
Air pollution
Chemical exposure
Dust
MEDICAL MANAGEMENT
o COPD is a progressive, chronic disease
o Onset insidious

o Evaluate patients medical history and perform a physical

examination
o Assess history of smoking and occupational exposure to
respiratory irritants
o Blood work and x-ray examination to further asses clinical
status
o Medications:
Anti-inflammatory
Bronchodilators
Expectorants
o Flu shots and pneumonococcal vaccines are recommended
o Oxygen therapy may also be prescribed at a low rate
SIGNS AND SYMPTOMS OF RESPIRATORY DISTRESS
o DYSPNEA - most obvious sign of breathing difficulty
o Shortness of breath even at rest
o Unable to utter a short phrase without grasping for air
o Extreme fatigue
o Nonproductive cough
o Confusion
o Impaired judgment
o Cyanosis

Pulmonary Rehabilitation
The goal of pulmonary rehabilitation is to stabilize or reverse the disease
process and return the patients function and participation in
activity/occupation to the highest capacity. A multidisciplinary rehabilitation
team working with the patient can design an individualized intervention
program to meet this end. Accurate diagnosis, medical man- agement,
therapy, education, and emotional support are components of a pulmonary
rehabilitation program. OT personnel are frequently part of the patients team,
which is headed by the patient and also includes the physician, nurse, and
the patients family and social supports. Respira- tory therapists, dietitians,
physical therapists, social workers, and psychologists may also be team
members. Roles of team members vary slightly among facilities. Knowledge
of spe- cialized pulmonary treatment techniques is imperative for each team
member when treating persons with pulmonary disease.
Intervention Techniques
1. Dyspnea Control Postures

Adopting certain postures can reduce breathlessness. In a seated position,

the patient bends forward slightly at the waist while supporting the upper part
of the body by leaning the forearms on a table or the thighs. In a standing
position, relief may be obtained by leaning forward and propping oneself on a
counter or shopping cart.
2. Pursed-Lip Breathing
Pursed-lip breathing (PLB) is thought to prevent tightness in the airway by
providing resistance to expiration. This technique has been shown to increase
use of the diaphragm and decrease accessory muscle recruitment.5 Persons
with COPD sometimes instinctively adopt this technique, whereas others may
need to be taught it. Instructions for PLB are as follows:
3. Diaphragmatic Breathing
Another breathing pattern, which calls for increased use of the diaphragm to
improve chest volume, is diaphragmatic breathing. Many persons learn this
technique by placing a small paperback novel on the abdomen just below the
xiphoid process (base of the sternum or breastbone). The novel provides a
visual cue for diaphragmatic movement. The patient lies supine and is
instructed to inhale slowly and make the book rise. Exhalation through pursed
lips should cause the book to fall.
4. Relaxation
Progressive muscle relaxation in conjunctions with breathing exercises can
be effective in decreasing anxiety and controlling shortness of breath. One
technique involves tensing muscle groups while slowly inhaling and then
exhaling twice as slowly through the lips. It is helpful to teach the patient a
sequence of muscle groups to tense and relax. One common sequence
involves tensing and relaxing first the face; followed by the face and neck;
then the face, neck, and shoulders; and so on, down the body to the toes. A
calm, quiet, and comfortable environment is important for the novice in
learning any relaxation technique. Biofeedback in conjunctions with relaxation
therapy promotes more timely masterly of relaxation skills.

5. Other Treatment and Considerations

Physical therapists are generally called on to instruct patients in chest
expansion exercises, a series of exercises intended to increase the flexibility
of the chest. Percussion and postural drainage use gravity and gentle
drumming on the patients back to loosen secretions and help drain the

secretions from the lungs. By isometrically contracting the arms and hands
while they are placed on the patients thorax, the therapist may transmit
vibration to the patient. Vibration is performed during the expiratory phase of
breathing ad helps loosen secretions. Percussion and postural drainage,
however, be contraindicated on acutely ill patients and those who are
medically unstable
Humidity, pollution, extremes of temperature, and stagnant air have
deleterious effects on persons with respiratory ailments. The therapist and
patient should take these factors into consideration when planning activity.
EVALUATION
I.

REVIEW OF MEDICAL RECORDS

A review of the medical record will identify the patients medical history,
social history, test results, medications, and precautions.

II.

PATIENT INTERVIEW
Thoughtful, probing questions will help the patient and the therapist
identify areas of concern and lay the groundwork for establishing
mutually agreeable goals. The therapist should observe the patient for
signs of anxiety, SOB, confusion, difficulty comprehending, fatigue,
abnormal posture, reduced endurance, reduced ability to move, and
stressful family dynamics. Clarification of symptoms before treatment
can prove invaluable should symptoms arise. Asking patients to
describe a typical day will reveal problems that are meaningful and
relevant to the patient. Also patients cognitive and psychosocial status
will become apparent.
CLINICAL EVALUATION
Its purpose is to establish the patients present functional ability and
limitations. Clients with impairments in the cardiovascular system will
require monitoring of HR, BP, signs and symptoms of cardiac distress,
and possibly ECG readings during an assessment of tolerance to
postural changes and during a functional task.

III.

CARDIOVASCULAR RESPONSE TO ACTIVITY

HEART RATE

BLOOD PRESSURE

APPROPRIATE
Increases with ax to no
more than 20 beats/min
above the resting heart rate
(avg: 60-100 beats/min)
Systolic blood pressure rise

INAPPROPRIATE
HR >20beats/min above
RHR with ax; RHR >120
drops or does not rise

SBP >220 mm Hg postu

with ax

SIGNS AND SYMPTOMS

Absence of adverse
symptoms

hypotension (>10-20 mm
drop in SBP; decrease i
SBP
Excessive SOB; angina
nausea and vomiting;
excessive sweating; ext
fatigue; cerebral sx

Individuals with disorders involving the reparatory systems should be

monitored closely for signs and symptoms of respiratory distress.
Example: (1) an increased awareness of normal breathing such as
during an anxiety attack, (2) an increase in the work of breathing (3) an
abnormality in the ventilatory system (4) SOB (5) cyanosis (6) nasal
flaring (7) increased/decreased breathing rate (8) increased/decreased
O2 saturation.

SOURCE:
PEDRETTIS OT PRACTICE SKILLS FOR PHYSICAL DYSFUNCTION, 7 TH
ED., EDITED BY HEIDI PENDELTON, WINIFRED SCHULTZ-KROHN