Welcome everyone. So just some housekeeping. As you know, CME is available through this lecture. So the way that you can get that is once the lecture is uploaded by AAPMNR, which usually takes a few days, you can go on the online learning portal and complete the survey and then you will get credited for that CME. This is a recurring monthly lecture series. So we are hosting it every second Tuesday at 1pm Eastern Standard Time. And you can reach out to me if you have any interest in volunteering. And then as a reminder, we also have a trainee series and a journal club. We send out advertisements through FizzForum, through the unofficial Facebook group, and then we also have calendar invites. So if you are not on the listserv and would like to be, please just email me or any other members of the community. I'm just going to let our speaker share their slides. Okay, great. So it's 12.05, so we can get started. So today we have Marlee Owen. Marlee is a senior therapist here where I work as well at the Shirley Ryan Ability Lab. She treats on the inpatient pediatric floor as well as in the pediatric cardiopulmonary lab. Marlee received her doctorate in physical therapy from Ithaca College in 2017. After graduating there, she began her career in outpatient pediatrics within the Spalding Rehabilitation Network and then moved to Chicago in January of 2019 to take a position on the inpatient needs floor at Shirley Ryan Ability Lab. She began to realize her passion for cardiopulmonary PT around 2020 in the midst of the pandemic. She pursued those interests via several continuing education courses and in-person mentoring opportunities and gained knowledge and grew her passion in that area. She began to treat as a cardiopulmonary lab therapist in 2020, where she sees patients on inpatient feeds with cardiovascular and or pulmonary impairments, generally in addition to their main admitting diagnosis. Her passions and research interests include infant and toddler cardiorespiratory care as well as ventilator liberation in the pediatric population. Today she hopes to use her knowledge and experience in cardiopulmonary physical therapy as well as her work in an interdisciplinary team to inspire you to think about your patients breathing as so much more than the ability to sustain life. I actually invited Marlee to give this lecture after working with her as an attending here at the Shirley Ryan Ability Lab, where we have a vent weaning program. I have personally learned a lot from her, so I wanted everyone else to have the opportunity to as well. I will hand it over to Marlee. Thanks Emily. I'm Marlee Owen. I am a physical therapist here on pediatrics at the Shirley Ryan Ability Lab. I'm going to talk to you today a little bit about the specialty of cardiovascular and pulmonary physical therapy. You'll hear it talked about as cardiovascular and pulmonary physical therapy and cardiopulmonary physical therapy, so I might use those words sort of interchangeably. So objectives for this time are to help you understand what a CVP PT is or what a cardiopulmonary PT is, understand how we are able to integrate cardiopulmonary systems into our physical therapy evaluation and how this so strongly correlates to motor function and motor dysfunction, how to identify patient populations that would benefit from cardiopulmonary or cardiovascular physical therapy, and then to understand how cardiopulmonary physical therapy can assist with some specialized clinical decisions on specialized populations. First, some people probably have and some people probably haven't heard of cardiovascular and pulmonary physical therapy. The Academy of Cardiovascular and Pulmonary Physical Therapy is a section or an academy of the APTA, the American Physical Therapy Association, just the same as the pediatric section or the neurology section or the geriatric section, and in the website it says that we focus on health, wellness, prevention, and or rehabilitative services in a variety of practice settings to individuals of all ages at risk for or diagnosed with cardiovascular or pulmonary impairments. So for my specific setting, like Emily said, this is usually in conjunction with additional diagnoses such as traumatic brain injury, spinal cord injury, cerebral palsy, spinal muscular atrophy, the list goes on. So PTs are able to utilize this examination and evaluation of the cardiac and the pulmonary systems, but within a lens of improved independence and function within rehabilitation. So the most popular and probably the most well-known is cardiac rehabilitation. So you think of cardiac rehab as somebody with heart failure or after a heart transplant or in pediatrics, a lot of our single ventricle pathology kiddos end up in cardiac rehab. However, for the purposes of this talk, I'm actually going to be focusing on more on the pulmonary side of things and talking about how breathing and timing of breathing and using breathing for so many other things other than breathing to just sustain your life, especially as we can talk about it in context of improved independence and function in the rehabilitation world. So breathing is not just breathing. It has such a direct impact on every single thing that we do. And I hope that by going through this lecture, I can show you that it's maybe a disservice to our kiddos and adults to not include cardiopulmonary care in their rehabilitation. So in order to sort of understand what we do, we have to kind of back it up just a little bit. For those, you'll see Mary Masary's name a lot on a couple of these slides. She's a physical therapist actually in Glenview in the Chicagoland area. And she is sort of the driver of this field, specifically pediatric cardiopulmonary care. But she worked with Christopher Reeves, trying to get him to take some breaths off his ventilator. And she holds many courses in both adult and pediatric cardiopulmonary therapy. So I'm going to be using a bit of her information here. So the basis for cardiopulmonary rehabilitation is the relationship between breathing and postural control. So the relationship between postural control and respiratory mechanics is completely dependent upon the regulation of pressure in our thorax and abdomen. So if we have impaired neuromuscular function, like all or most of our patients, we see impaired posture, and then we can see impaired breathing and function. So she uses this sort of soda pop can model of postural control or a soda can model of postural control. So if you think about the strength of a soda can, and you think about what gives it its strength, it's the pressure and the fact that it's a closed system. So if the system, or the positive pressure, excuse me, within the system is greater than the atmospheric pressure that's exerted onto the system from the outside. If the system opens, or we open the top of the soda can, the pressure control and the stability of the can is lost. So it's a lot easier to squeeze a can that is open than one that's closed. So we can think about our sort of anatomical soda can in different components. So our vocal folds and our other sort of superior glottal structures are what regulates the airflow and is essentially the top of our soda can. Our pelvic floor helps us regulate the pressure from the bottom of our soda can. And everything in between the vocal folds and the pelvic floor is our soda can. With our diaphragm as sort of this major mover and regulator between more intrathoracic pressure or more intra-abdominal pressure and how we can exchange those. But if the system opens, like we said, our pressure control is lost. And without an ability to control our pressure, we're unable to maintain a strong core. And then we can't at all expect our patients to be able to be functional and for sure can't expect them to move their limbs on this base that's not stable. So during inhalation, for example, our diaphragm is sitting in the middle of our soda can, it lowers. And so therefore the thoracic pressure decreases and it creates this vacuum into our thorax in order to bring our air in. We don't have the pressure control between our thorax and our abdomen for our diaphragm to lower and pull in that vacuum. Regular breathing is going to be really, really difficult. So our patients often have what we call a breach in the system or have significant postural and pressure regulation implications. So I think the easiest one to think about is the tracheostomy. So it really is literally like popping open the top of the soda can. It's below the glottal structures. And so there's no close to the top of the system, especially if you don't have a PMV or a cap on. If it's just open with an HME or a trach collar or something like that, we are unable to maintain our intrathoracic pressures when the system is just open. If you think about intercostal muscle weakness, we often see that anterior chest collapse, especially in patients with spinal muscular atrophy or spinal cord injuries. And if we collapse in our upper chest, it makes the vacuum from the diaphragm really difficult to achieve so that we can get regular spontaneous breathing. So we're just collapsing here instead of being able to hold open to pull in our air. Diaphragmatic weakness is the decreased ability control. Our limb helps us control our limbs because if we are unable to maintain, like we said, that strong diaphragmatic contraction to regulate our pressures, then we don't have that distal limb support. It also significantly impairs our breathing mechanics and strength if we don't have a strong diaphragm. Abdominal muscles are what keep our abdominal viscera where they're supposed to be up against our diaphragm. So if we have abdominal weakness, we can see excessive sort of anterior and inferior excursion or displacement of those abdominal viscera. And then that's causing inadequate positive intra-abdominal pressure for postural control. So you can often see this in patients that have a diagnosis of quadriplegia, how they have their abdominal viscera sort of low and protruding. This also decreases our breathing mechanics. The diaphragm doesn't have anything really strong and supportive to work off of. And it also significantly impacts our GI motility. Paraspinals are similar. There's a possible compromise of breathing. Think about the postural implications of paraspinal muscle weakness or paralysis. Also can contribute to internal organ dysfunction. And then lastly, our pelvic floor. So if the pelvic floor is unable to support our positive intra-abdominal pressure, we're at high risk for incontinence and prolapse. But additionally, if you think about somebody with an indwelling catheter, that causes a breach to the system, causing decreased postural stability. So how can I work with the physical medicine and rehab doctors to clinically control the pressure? So that's what we need to do, right? We need to help our patients control their pressure so that they can have support. So as a physician, you can assist us in providing a PMV or a Passy-Muir valve to a patient, even if a cap is intolerated. So that allows us to at least close the top of that system a little bit. And the research is showing us that a PMV can provide significantly improved postural stability. You know, a lot of places, if you only use a cap, a lot of places only use a PMV. And if you have patients that only are able to do PMV, but, or aren't able to tolerate a cap, but maybe they could tolerate a PMV, we're really able to give them a significant increase in their postural stability just from a PMV. Also moving from an independent catheter to an intermittent catheter to improve the intra-abdominal pressure support. And then we're always looking for clearance to make sure we can give these patients an abdominal binder. And then as a PT, I can fit them for that abdominal binder that will give them that postural support from the outside that their abdominal muscles aren't giving them, moving their abdominal viscera back to where it belongs to give their diaphragm something to work off of. And then we have a whole host of exercises that we can do as physical therapists to improve pressure regulation. And one of them is utilization of counting. So research is showing us that mid-range glottal closure during phonation mostly is the most stable position. So not a closed off glottis and not a wide open one. So utilizing coughing or talking during exercises will help clinically control their pressure as well. So once we understand the theory of pressure control, I have to assess how a patient is breathing. So we utilize several assessments, including our regular PT evaluation, as well as chest wall excursion or inspiratory excursion measurements, which you can see on the first picture there. Respiratory measurements such as peak cough flow, peak expiratory flow, and respiratory measurements such as chest wall excursion. I'm gonna look at manual muscle tests. I'm gonna look at the mobility of the shoulder girdle and the rib cage. And then I'm gonna look at their cough strength and breathing strength and things like that. And then as a physician, you can assist us in looking at things like diaphragmatic ultrasounds to give us a much more in-depth look at what the diaphragm is doing. This is specifically helpful in our patients that may have a paralyzed diaphragm or may have a phrenic nerve involvement or may have a hemidiaphragm. So that's that last picture that you see there. So once we figure out exactly what muscles are available to the patient and which muscles they're currently using, we can take that information and facilitate improved breathing strength and efficiency with those muscles that are available. So if a patient is having trouble with breathing, essentially all their energy and their muscles are gonna allocate there. Breathing wins. So as a physical therapist, I'm able to help maximize the efficiency of their breathing and improve their therapy participation. For those of you who work in an inpatient rehab setting, they have to participate in three hours of therapy. And sometimes if they're having trouble breathing, just bringing them to the gym and getting them transitioned onto a mat is as much as they can participate in if I'm unable to efficiently maximize or maximize the efficiency of their breathing so that they can then focus on things like head control, limb control, because all of those things are less effective and a lot harder for a patient if we don't back it up and first look at what they're doing with their breathing. So who benefits from cardiovascular or cardiopulmonary physical therapy? I mean, essentially every patient is a cardiovascular or cardiopulmonary patient because we all have a heart and we all have lungs and we all need to sustain life. However, some patients, specifically any patient with a neuromuscular injury or a neuromuscular disease will benefit more from a cardiovascular or pulmonary assessment. So I've listed here essentially all the diagnoses I could think of. I'm sure there are more, but these are the diagnoses that I mostly work with, including but not limited to spinal cord injury, traumatic brain injury, cerebral palsy, spina bifida, SMA, which is becoming a really interesting thing to work with in cardiopulmonary sense. But these patients would really benefit from someone with a cardiopulmonary lens taking a peek at them to make sure that their breathing is maximized. So what are these specialized clinical decisions that I talk about? So as a physical medicine and rehab doctor, you have to make a lot of decisions and some of them as a PT, I can give you some additional information and we can help make these decisions together. So one of those things is decannulation. So as a cardiopulmonary PT, I can assess with the assistance of speech therapy, RT, pulmonology to assess their readiness for the occlusion itself. But then in order to, research is showing us that if they don't get to a peak expiratory flow of about 160 liters per minute, assisted or unassisted, that they have a decreased success rate for decannulation. So I can work to support them muscularly and functionally to help them get towards that safe decannulation level or to test them and tell you, yes, they are at that safe decannulation level. We can be more sure that this is going to be a good next step for them. And then as well on the other side, if they don't get to those levels, despite specified cardiovascular and pulmonary interventions, helping them strengthen, improve their coordination, et cetera, we can know with better certainty that decannulation is maybe not the safest move for them at this time. They can move on to outpatient cardiopulmonary PT, continue their strengthening and reassess at a later date if decannulation is a safe option for them. Additionally, cough assist or airway clearance is a hot topic right now. So as a cardiopulmonary PT, I can both assist in family education to provide manual cough assist, as well as we can start to assess the need for mechanical cough assist. So there's emerging research for recommendations based on diagnosis. There's not as clear cut as the decannulation numbers, at least right now, but hopefully it's coming. For example, we do have numbers for Duchenne's muscular dystrophy. So the research is showing that once they hit around 270 liters per minute, and they're in the progressive end, so they're likely going to get lower and lower, we know that they need cough assist. And the first person to possibly test or notice this might be during a bout of PT or a PM&R visit. And the easiest thing we can do is just test their peak expiratory flow and see if they need to participate in cardiopulmonary PT and to see if they need cough assist or airway clearance assistance at home to hopefully decrease the amount of time that they need to spend in the hospital, or hopefully improve the amount of time that they can spend at home between hospitalizations. And then the next or the last kind of clinical decision I'm going to talk a little bit more about today is ventilator liberation. So at the Shirley Ryan Ability Lab, as of around 2021, we started this large interdisciplinary team for our ventilator liberation. So this includes the pulmonologist, the respiratory therapist, the physical medicine and rehab doctor, and the cardiopulmonary PT. And we all do our own assessments to gain information about this patient. So I'm going to do all the assessments I talked about in some of the previous slides. I'm going to look at their muscles. I'm going to look at their innervation levels. I'm going to look at what their biceps are doing, what their shoulders are doing, what their neck is doing. I'm going to look at their posture. I'm going to look at their chest wall excursion. And then I'm going to ask the physical medicine and rehab doctors to look at their diaphragm specifically. I can get some information by palpating and those sorts of things, but really nice information from a diaphragmatic ultrasound. Our team is then able to take all of that information from these specific assessments and really run with it. We can develop specialized therapy plans focused on providing targeted strengthening to the muscles within each patient that we know are working and are receiving messages from the spinal cord in relationship to spinal cord injuries or just those that are the most effective and the most functional. We also know that the diaphragm can be strengthened. So just like any other muscle, the diaphragm is shown to weaken without use. And so just research is showing that just after about 48 hours on a ventilator, our diaphragm starts to weaken. So it doesn't make any sense to try to pull a patient off of a ventilator or decannulate a patient without improving their diaphragmatic strength. So here at the Shirley Ryan Ability Lab, since about November of 2021, we've progressed 13 patients through our ventilator weaning program, all who actually failed ventilator weaning at their previous settings, which was an ICU or an LTAC. And we're weaning patients who are appropriate to be weaned about 57% faster than previous to when we introduced this interdisciplinary team model. And our success really is due to working as a team. As the cardiovascular and pulmonary PT, I can take information from all of those other specialties and integrate it for a patient-specific centered plan of care. All of our patients present differently and have different innervations, different coordination levels, different strengths. So they all deserve to be treated that way and get specialized treatment plans to help them succeed. I wouldn't be able to do that without the assistance of the interdisciplinary team. And then the exercises wouldn't be able to get done without the cardiopulmonary PT. Okay, so, sorry. So I have a couple of case studies just to show how we have been working in our interdisciplinary teams and sort of to show you what cardiopulmonary therapy has done with these different cases. So our first case is actually the case that I worked with Emily on. And this is a 14-year-old girl with a spinal cord injury. And she was diagnosed as a C to Asia A when she came to us. We are getting diaphragmatic ultrasounds on all of our new airway or ventilator patients. And she had no activation or ability to breathe with or over the ventilator. All her experts, the RT, the pulmonologist, her neurologist were saying that she would require a ventilator for life. And it did look that way on initial exam. So initially as the cardiopulmonary PT, my goal was to help her tolerate leaked speech. So my goal was to help with the assistance of speech therapy to help her tolerate coordinating her breath with the ventilator and allowing her to tolerate leaked speech. Then, because I am consistently assessing as I go, we started to see tiny little bits of return and really a ton of improvement to tolerance to leaked speech. So I asked our PM and our doctors to get an additional diaphragmatic ultrasound. I said, there's something going on in there. I can feel it. I can see it. What's going on? And it revealed hemidiaphragmatic activation. And so then I had this glimmer of hope that maybe we can get her off the vent for five minutes. Maybe we can get her off the vent for 45 minutes. Maybe her parents are gonna be able to shower her as a single person shower instead of on a ventilator, which requires at least two people for a shower. We provided her with specialized interventions for her specific presentation. And we were actually able to discharge her on only nocturnal ventilation. So she had so much improvement and so much recovery that she didn't need her ventilator at all during the waking hours. And she actually was able to be off her ventilator for over 120 hours before I noticed that she was getting fatigued and that I thought that we might need to place her back on the ventilator. After some discussion with the interdisciplinary team, it became clear that discharging her on nocturnal ventilation was gonna be the best for her long-term. But we were able to get her off the vent for an entire, for her entire day. And I just followed up with her and she still is off the ventilator all the time during the day. So this is just a, next is just a little video of that patient with myself and Emily makes a cameo as well, just to show you some of the things that we were doing with her from a cardiopulmonary standpoint. So this is breath stacking to try to improve chest wall mobility. Diaphragmatic facilitation, lateral costal facilitation, assisted cough, measuring her peak expiratory flow. So another population that we work with a lot in rehabilitation is kiddos with, or kids with cerebral palsy. So this is just a short case study on a patient that we recently admitted, GMFCS5, four years old. He admitted after multiple pneumonias, and he required tracheostomy, but he was not requiring ventilator support when he got to us. He also had a history of neuromuscular scoliosis, as we know a lot of GMFCS5 level patients do. And I met with family, or we met with family as a cardiopulmonary physical therapy team to really just give family the tools to improve his pulmonary hygiene at home. Giving them tools for ribcage mobility to improve his ribcage expansion and get more air, to give him an, we gave him an abdominal binder for support in order to assist him with his cough, assist him with support and regulating his pressures. He was not a candidate at that time for transition from an HME. So supporting him externally with an abdominal binder was what we did. And then introducing both manual and mechanical cough assist to him and his family. And just to allow him to stay out of the hospital for just a little bit longer. And arming parents with something that they can do to assist their child in clearing their airway. And thinking about kind of cough assist for more than just a spinal cord injury patient. There are patients who really benefit from cough assist that just go into the hospital as they're starting to get a cold to obtain cough assist and clear their airway. So as a cardiopulmonary PT, if a patient is able to, I'm able to work on cough strength, but I'm also able to teach family members manual cough assist and then recommend mechanical cough assist if we feel like that is going to be beneficial for the patient. So why cardiovascular and pulmonary PT? I hope that through this time I was able to show you that there are allied health clinicians that are specialists in breathing for more than just breathing. And we're excited to partner with you to help support our patients' breathing and their function. Emily and Marlee, this is Didem Inanoglu from Boston. Hi, how are you? I am very excited about this wonderful talk, so thank you, Marlee. Yes, you're welcome. This is a huge gap in our practices, in our best practices, and I'm working currently out of Franciscan with all this vent or respiratory babies, toddlers, and kids at all ages. So I put it in the chat too, I have two questions in terms of the wonderful approaches that you mentioned and the research behind it. How about our really young ones? Because we get babies, newborns, right out of NICU on vents, and of course our goal is to give it our best try to get them off the vent. So any age-matched or developmentally-matched protocols that you have or any references that you can share, I would definitely appreciate it. And then the other thing is when we talk about strengthening for any other skeletal muscle, we, you know, there's always modalities we would like to think about and throw in. So like I like my therapist using eSTEM a lot, we see good results. Is that a modality potentially available or beneficial for these respiratory muscles? I can definitely speak to the eSTEM for the respiratory muscles. So there actually is quite a bit of research coming out about the utilization of eSTEM specifically on the obliques to help target those muscles to then give sort of like that internal abdominal binder sort of effect, where if we strengthen those muscles, we're able to pull the rib cage down, give the diaphragm a good base to work off of, and then strengthen again those obliques to really pull the pressure regulation for those muscles. So yes, there is eSTEM for little ones, bigger people. I've also had, there's some research going on around utilization of eSTEM through like for cough assist and things like that. So there's lots of research in the eSTEM, in the eSTEM world. Yes. So if you can share some of those references through email, I'm happy to put my email, but Emily should have it too, I guess my email, hopefully. Yeah, and mine's here up on the screen. Okay, perfect. I will send you a reminder if that's okay. No, that would be great. And I do have a references slide here that does have some of the references specifically for this talk. I'll put my email back up. But, and then from a infant toddler standpoint, Mary Mazury has a really nice course called I Survived Now What? And it's about patients who are babies who have spent time in the NICU and they had all these cardiovascular or cardiopulmonary compromises. And then, you know, what do we do now? You know, they survived, but now we have to help them thrive and live and move past that. So that course is a nice one as well. Wonderful. And one last request. Is it okay if I reach out to you about joining the Complex Care Committee, AAC PDM, or also do some e-services for my therapy team here at Franciscan and Boston Children's? Yes, you can reach out to me about whatever you'd like. I'd love to help. Appreciate that. Thank you guys. Yes, of course. Thank you. I think one thing that we're lucky to have here is Dr. Franz, who is so comfortable and competent in diaphragmatic ultrasound. But I just wanted to ask how you, if you could share a little bit of how you use those measures and what information you get from that that's helpful for your plan. Yeah. So I think, you know, I've, maybe much to Dr. Franz's demise, I've been requesting a lot of diaphragmatic ultrasounds from him. And I've been trying to go in and see what they, like, see what he's seeing firsthand, because I feel like that's really helpful, as well as he writes up a really lovely report for me. But essentially what we're looking at is thickening ratios of the diaphragm during both quiet breathing and then vital capacity breathing. So what is that diaphragm doing and how is it thickening during contraction? So there are norms for the diaphragm thickening ratios. So for ventilator weaning, 1.2 millimeters is our sort of our 1.2 thickening ratio is showing, is starting to show us that that may be the successful ventilator weaning candidate. But, you know, for the specific patient that we shared, her diaphragm was doing less than nothing on her initial exam with her request, us requesting with her to breathe on the, you know, with the ventilator, her diaphragm was not contracting. It was not showing us any sort of thickening. And then when we moved to our second one, her one side was not really showing any movement, but the other side was showing a really nice thickening. So I'm really looking for, is their diaphragm moving when they essentially ask it to move? And then what is that thickening ratio? Cause that gives me a little bit of an idea of prognostically how they're going to do. Yeah. I think it's such a great point to remember, to think about progress in physical therapy, you know, with like classic physical therapy that we see in motor recovery and then remembering to think, Oh, maybe this changes their their respiratory status. So I think that was such a cool way that we ended up readdressing and looking and finding in somebody who we wouldn't expect to have recovery. You never know everybody's different. Yeah, for sure. And I think that's one of the really nice things about inpatient rehab is that I was able to see her most every day. And so those tiny changes were really evident to me. And then I could bring those to you guys and you know, ask, you know, I, I know that we had a not so great ultrasound, but let's get another one. And I think I'm ready to pull this girl off her ventilator and, and having the support to do that and everybody's sort of working together is really great. I don't see any more questions right now. I'm seeing if any more pop up, but that was great. I hope that everyone enjoyed that lecture and it should be uploaded for anyone who couldn't make it to watch it and get CME credits later.

Marlee Owen

cardiopulmonary physical therapy

postural control

case studies

core strength

ventilator liberation

rehabilitation