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Evolve Student Resources for Main: Cardiorespiratory

Physiotherapy: Adults and Paediatrics, 5th Edition, include the following:

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Cardiorespiratory Physiotherapy

To Barbara, Jennifer and Ammani

Cardiorespiratory Physiotherapy

ADULTS AND PAEDIATRICS

Fifth Edition

EDITED BY

ELEANOR MAIN BSc BA MSc PhD FCSP

Professor of Physiotherapy and Director of UCL Postgraduate Physiotherapy Programme, UCL School of Life and Medical Sciences, University College London, London, UK

LINDA DENEHY BAppSc(Phty)

GradDipPhysio(Cardiothoracic Phty) PhD

Professor and Head, Department of Physiotherapy, Melbourne School of Health Sciences, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia

FOREWORD BY

BARBARA A WEBBER FCSP DSc(Hons)

Formerly Head of Physiotherapy, Royal Brompton Hospital, London, UK

JENNIFER A PRYOR PhD MBA MSc FNZSP MCSP

Formerly Senior Research Fellow in Physiotherapy, Royal Brompton & Hare eld NHS Trust; Honorary Lecturer, University College London and Imperial College London, London, UK

S AMMANI PRASAD GradDipPhys FCSP

Cystic Fibrosis Manager, Respiratory Unit, Great Ormond Street Hospital for Children NHS Trust, London, UK

Previous editions:

No part o this publication may be reproduced or transmitted in any orm or by any means, electronic or mechanical, including photocopying, recording, or any in ormation storage and retrieval system, without permission in writing rom the publisher. Details on how to seek permission, urther in ormation about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be ound at our website: www.elsevier.com/permissions This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

ISBN 978-0-7020-4731-2

Notices

Knowledge and best practice in this feld are constantly changing. As new research and experience broaden our understanding, changes in research methods, pro essional practices, or medical treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any in ormation, methods, compounds, or experiments described herein. In using such in ormation or methods they should be mind ul o their own sa ety and the sa ety o others, including parties or whom they have a pro essional responsibility.

With respect to any drug or pharmaceutical products identifed, readers are advised to check the most current in ormation provided (i) on procedures eatured or (ii) by the manu acturer o each product to be administered, to veri y the recommended dose or ormula, the method and duration o administration, and contraindications. It is the responsibility o practitioners, relying on their own experience and knowledge o their patients, to make diagnoses, to determine dosages and the best treatment or each individual patient, and to take all appropriate sa ety precautions.

To the ullest extent o the law, neither the Publisher nor the authors, contributors, or editors, assume any liability or any injury and/or damage to persons or property as a matter o products liability, negligence or otherwise, or rom any use or operation o any methods, products, instructions, or ideas contained in the material herein.

For Elsevier

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To access your Evolve Resources visit:

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OUTCOME MEASUREMENT IN CARDIORESPIRATORY PHYSIOTHERAPY PRACTICE .................195

SELINA M PARRY ■ LINDA DENEHY WITH CONTRIBUTIONS FROM CLAIRE E BALDWIN, BRONWEN CONNOLLY, ELIZABETH H SKINNER, SALLY J SINGH, SARAH RAND, CRAIG A WILLIAMS

7 PHYSIOTHERAPY INTERVENTIONS ......248

ELEANOR MAIN WITH CONTRIBUTIONS FROM SUE BERNEY, LINDA DENEHY, MICHELLE CHATWIN, MARK R ELKINS, DANIEL FLUNT, AMANDA J PIPER, ANNEMARIE L LEE, BREDGE MCCARREN, HARRIET SHANNON, SARAH RAND, ROSEMARY MOORE, BARBARA A WEBBER, MARIE T WILLIAMS

8 OPTIMIZING ENGAGEMENT AND ADHERENCE WITH THERAPEUTIC INTERVENTIONS ..................................402

MANDY BRYON

9 ADULT INTENSIVE CARE......................415

JENNIFER PARATZ ■ GEORGE NTOUMENOPOULOS ■ ALICE Y M JONES ■ CLAIRE FITZGERALD 10 PAEDIATRIC INTENSIVE CARE .............455

Paediatric Mechanical Support .........................456

STEWART REID ■ MARK J PETERS

Physiotherapy Management of Ventilated Infants and Children ........................................473

ELEANOR MAIN ■ ALICIA J SPITTLE

11 UPPER ABDOMINAL AND CARDIOTHORACIC SURGERY FOR ADULTS........................................513

DOA EL-ANSARY ■ JULIE C REEVE ■ LINDA DENEHY WITH CONTRIBUTIONS FROM SULAKSHANA BALACHANDRAN, MICHELLE MULLIGAN

12 PHYSICAL ACTIVITY AND REHABILITATION .................................579

Physical Activity and Physical Fitness in Health and Disease ......................................580

CHRIS BURTIN ■ VASILEIOS ANDRIANOPOULOS ■ MARTIJN A SPRUIT

Pulmonary Rehabilitation .................................586

KATY MITCHELL ■ FABIO PITTA ■ ANNE E HOLLAND ■ ANNEMARIE L LEE ■ LINDA DENEHY

Cardiac Rehabilitation .....................................597

JULIE REDFERN ■ JENNIFER JONES

CARDIORESPIRATORY MANAGEMENT OF SPECIAL POPULATIONS .................639

LINDA DENEHY ■ ELEANOR MAIN

WITH CONTRIBUTIONS FROM SARAH SMAILES, ANITA PLAZA, JENNIFER PARATZ, LEANNE WILLIAMS, CLAIRE BRADLEY, JACQUELINE L LUKE, JACQUELINE ROSS, BROOKE WADSWORTH, KATE J HAYES, PRUE E MUNRO, PAUL AURORA, HELENA VAN ASWEGEN, CRAIG A WILLIAMS, SARAH RAND, CATHERINE L GRANGER, SUE BERNEY, AMY NORDON-CRAFT, LINDA DENEHY

APPENDIX – NORMAL VALUES, CONVERSION TABLE AND ABBREVIATIONS................757

Index ................................................................. 767

EVOLVE RESOURCES (evolve.elsevier.com/Main/cardiorespiratory): ■ bank of 350 images

FOREWORD

As previous editors of this textbook we feel very fortunate to have two remarkably busy professors of physiotherapy who have carried forward the editorship of this book. They are both actively involved in leading cardiorespiratory physiotherapy research and in teaching under- and postgraduate physiotherapists – Eleanor Main in London and Linda Denehy in Melbourne.

The editors have brought together a wealth of knowledge and evidence-based practice in respiratory and cardiac medicine, physiotherapy and assessment techniques. Expert clinicians have contributed important new material in cardiorespiratory care. This international collaboration will facilitate further progress for the bene t of both physiotherapists and patients. Despite improvements in the design, quality and rigour of allied healthcare research, there remains a paucity of evidence and a lack of clarity for best practice in some clinical areas. In physiotherapy research the ‘gold-standard’ randomized controlled trial is often fraught with dif culty because of the inability to conceal treatment allocation from participants. This can create uncontrollable bias resulting from patient preference, particularly in studies which involve a long-term burdensome intervention. Therefore clinical expertise currently remains an important element of evidence-based practice.

There have been many changes in healthcare provision and we have come a long way since the early days of ‘chest physiotherapy’ and ‘postural drainage’ prescribed by medical practitioners. This edition recognizes physiotherapists as highly skilled independent practitioners who are integral members of the multidisciplinary team. Their considerable depth of knowledge and ability to interpret the many and everincreasing investigative tests enable them to identify appropriate treatments, exercise or education programmes which meet the needs of individual patients. This comprehensive new edition will be a great asset to both undergraduate and postgraduate physiotherapists and other health professionals interested in respiratory and cardiac problems. The increase in research and improvements in clinical practice, undertaken during the 23-year lifetime of this textbook, are in part due to imaginative methods, advances in technology and education by enthusiastic clinicians and academics such as our two new editors. We believe that this edition will inspire another generation of physiotherapists to advance our profession.

JENNIFER A PRYOR

S AMMANI PRASAD

2016

BARBARA A WEBBER

ABOUT THE EDITORS

ELEANOR MAIN

Eleanor Main has been involved with clinical physiotherapy, teaching and research at Great Ormond Street Hospital for Children and the Institute of Child Health at University College London for almost 24 years. She quali ed as a physiotherapist at the University of the Witwatersrand, South Africa (1988) and worked as a paediatric physiotherapist at both the Red Cross

Children’s Hospital in Cape Town and then Great Ormond Street Hospital in London. She completed a BA (English and Psychology) at UNISA in South Africa (1991), an MSc in research methods from King’s College, London (1995) and a PhD in paediatric respiratory physiology from University College London (2001).

She was appointed as Lecturer in Children’s Physiotherapy Research at UCL in 2001, promoted to Senior Lecturer in 2007 and to Professor of Physiotherapy in 2015. She has been programme director for the UCL postgraduate Certi cate, Diploma and MSc in physiotherapy at UCL since 2005 and has supervised ve PhD students and 79 MSc project dissertations to date. In 2011 she was awarded a Fellowship of the Chartered Society of Physiotherapy in London for her ‘signicant contribution to education, teaching and learning in the eld of cardiorespiratory and paediatric physiotherapy’. Eleanor’s primary research interests relate to outcome measurement and clinical ef cacy studies in physiotherapy. This research, resulting in more than 80 peer-reviewed publications, and attracting over £2.8 million in project grant funding so far, has resulted in substantive advances in the understanding of assessment and treatment of children who require physiotherapy.

LINDA DENEHY

Linda Denehy is a PhD-quali ed physiotherapist who is Head of the Department of Physiotherapy at the University of Melbourne, Australia. Linda graduated in physiotherapy in Melbourne and spent 20 years as a clinician managing respiratory medicine, thoracic surgery and ICU patients both in Melbourne and at the Brompton Hospital in London. She has been a teaching and research academic for nearly 20 years and obtained her PhD in 2002 in the management of patients having upper abdominal surgery. Linda developed curricula in cardiorespiratory physiotherapy both for undergraduate and for postgraduate

students and led the implementation of the new threeyear doctor of physiotherapy entry to practice course at the University of Melbourne. She has supervised 30 higher degree research students to completion and has extensive research expertise in the area of cardiorespiratory physiotherapy, particularly in patient populations who are acutely unwell, including patients after major surgery and critically ill patients. She has published more than 100 research publications in peer-reviewed journals and 15 invited editorials or book chapters and has been invited to more than 25 national and international meetings as a keynote speaker. These include the European Respiratory Society in 2014 and the American Thoracic Society in 2014 and 2016. She is currently involved in developing international guidelines for ICU mobility and outcome measures in ICU. Linda has been successful in obtaining funding from more than 30 applications of over $6 million Australian dollars for research into physiotherapy and rehabilitation, including as a chief investigator on ve nationally competitive grants in rehabilitation after critical illness, lung cancer and breathlessness in COPD. She reviews for national and international competitive granting bodies and for several international scienti c journals including Lung Cancer, Intensive Care Medicine, Critical Care Medicine and Thorax . Her research has contributed to evidence-led practice, clinical guidelines and improved patient-centred outcomes.

PREFACE

It has been a real privilege to be invited to co-edit the fth edition of this core international cardiorespiratory textbook. It has always been an important text for undergraduate students around the world but is also an enduringly valuable reference text for both experienced and novice practitioners involved with cardiorespiratory care.

There have been some interesting and important advances in cardiorespiratory physiotherapy in the nine years since the rst printing of the fourth edition, and we have tried hard to include as many of the new ideas and new pieces of evidence as possible. Having said that, we acknowledge without reserve that we ‘stand on the shoulders of giants’, and many of the essential timeless features of the earlier editions remain intact.

Before we started, we asked clinical and university staff and students what they most wanted to see in this new edition and, as a result, we have made changes that we think will enhance the book. Some of the changes involved updating information or reorganizing where it is found in the text, and some are entirely new chapters. For example, the new rst chapter is an overview of cardiorespiratory anatomy and physiology essentials, with wonderful new illustrations, which we hope will be an outstanding clinical reference. Similarly, the assessment chapter, now doubled in length, provides an expanded and structured systematic approach to clinical cardiorespiratory assessment. Other new chapters include two dedicated to cardiac and respiratory problems or pathology, an outcome measures chapter,

a chapter on the principles of exercise and physical activity in cardiorespiratory populations and a chapter on cardiorespiratory rehabilitation of special populations, for example, children or those with obesity, cancer, liver disease or burns. Also new is the structure of the Physiotherapy Interventions chapter (previously Techniques), which is now problem-based rather than alphabetical, and which hopefully will facilitate a clearer clinical reasoning pathway for students or novice practitioners.

In general, topics related to the care of children with cardiorespiratory problems have now been incorporated into appropriate sections of text throughout the book, either because there is signi cant overlap in approach or care between adults and children, or because understanding children with cardiorespiratory problems facilitates better care of individuals through the lifespan: problems in childhood frequently continue into adulthood. An exception is the division between the adult and paediatric ICU chapters, because differences in the reasons for hospital admission and clinical and physiotherapy management of these populations remain substantial.

We are excited about and proud of the new edition and hope that it continues to serve physiotherapy professionals in cardiorespiratory care around the world for many years to come.

London and Melbourne 2016

ACKNOWLEDGEMENTS

We are indebted to all the expert contributors to this edition for the many tireless hours of work they have surrendered to the cause. Many of the contributors were new and, on the whole, represent a truly international perspective on cardiorespiratory physiotherapy. A few chapters involve collaborative writing partnerships between countries, and this enriches the text and assures that physiotherapy practice can ultimately aim to reach consensus about best practice internationally.

We are also so very grateful to Barbara Webber, Jennifer Pryor and Ammani Prasad (the ‘giants’ referred to in the Preface – although not in actual size!), for their extraordinary dedication over several decades to the clinical and academic advancement of cardiorespiratory physiotherapy care. The continued and growing appeal of this textbook over the past 23 years is testament to their work, the high quality of the book’s content and its ongoing usefulness in clinical practice.

It has been a pleasure working with Elsevier on this text and all the members of the editorial and production team: Rita Demetriou-Swanwick, Sally Davies, Julie Taylor, Nicola Lally, Brett MacNaughton, Miles Hitchen, Jo Collett, Kirsty Guest, Tharangini Sakthivel and Rupa Rai. Thank you also to the Elsevier illustrators for doing such a lovely job.

Finally we are eternally thankful to our colleagues, families and friends who helped us choose the front cover design and have tolerated neglect during this production, largely, but not exclusively without complaint! Colin, Daniel, Callum, the Shire folk, Gabrielle, Andrew and Lara, when you read your signed copies carefully, you’ll know it was worth it!

CONTRIBUTORS

Jennifer A Alison MSc Ph D D ip Phty

Professor of Respiratory Physiotherapy, University of Sydney; Clinical Specialist, Pulmonary Rehabilitation, Royal Prince Alfred Hospital, Sydney, Australia

Vasileios Andrianopoulos MSc

Clinical Exercise Physiologist, CIRO + Research and Development, Horn, Netherlands

Paul Aurora MRCP Ph D

Consultant in Paediatric Respiratory Medicine and Paediatric Lung Transplantation, Great Ormond Street Hospital for Children NHS Foundation Trust; Honorary Senior Lecturer, UCL Institute of Child Health, London, UK

Sulakshana Balachandran Ph D

BPhysio (Hons )

Senior Physiotherapist, Epworth HealthCare, Melbourne, Australia

Claire E Baldwin Ph D BPhysio (Hons )

Lecturer in Physiotherapy, Acute Care, University of South Australia, Adelaide; Physiotherapist, Flinders Medical Centre, South Australia, Australia

Joy L Barber MBBS MA FRCR

Radiology Registrar, St George’s University Hospitals NHS Foundation Trust, London, UK

Sue Berney BPhysio Ph D

Associate Professor, Manager of Physiotherapy Department, Austin Health, Melbourne, Australia

Claire Bradley BSc MSc

Senior Physiotherapist, King’s College Hospital NHS Foundation Trust, London, UK

Mandy Bryon Ph D

Consultant Clinical Psychologist, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK

Chris Burtin MSc Ph D

Clinical Researcher in Respiratory Physiotherapy, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium

Michelle Chatwin Ph D BSc (Hons ) Physiotherapy

Consultant Physiotherapist in Respiratory Support, Royal Brompton Hospital, London, UK

Conor D Collins FRCPI FRCR

Consultant Radiologist, St Vincent’s University Hospital, Dublin, Ireland; Associate Clinical Professor, University College, Dublin, Ireland

Bronwen Connolly BSc (Hons ) MSc Ph D

Consultant Clinical Research Physiotherapist, Critical Care, Guy’s & St Thomas’ NHS Foundation Trust, London, UK

Susan J Copley MB BS MD FRCR FRCP

Consultant Radiologist and Reader in Thoracic Imaging, Imperial College Healthcare NHS Trust, London, UK

Linda D enehy BApp Sc (Phty )

Grad D ip Physio (Cardiothoracic Phty ) Ph D

Professor and Head, Department of Physiotherapy, Melbourne School of Health Sciences, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia

D oa El -Ansary BApp Sc (Phty ) Int Cert OMT

Ph D APAM

Senior Lecturer, Lead: Engagement, Faculty of Medicine, Dentistry and Health Sciences, Physiotherapy Department, University of Melbourne, Melbourne, Australia; Research Fellow, HeartWeb, Melbourne; Research Fellow, Clinical Research Institute, Westmead, Sydney, Australia

Mark R Elkins BA BPhty MHSc Ph D

Clinical Associate Professor, Sydney Medical School, University of Sydney; Research Education Consultant, Centre for Education and Workforce Development, Sydney Local Health District, Sydney, Australia

Claire Fitzgerald BSc (Hons ) MSc MCSP

Clinical Specialist Respiratory Physiotherapist, London North West Healthcare NHS Trust; Senior Teaching Fellow, MSc Advanced Physiotherapy, University College London, London, UK

D aniel Flunt BApp Sc (Phty , Hons )

Senior Physiotherapist, Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, Australia

Christopher D George FAcad MEd FRCS FRCR

Consultant Radiologist, Epsom and St Helier University Hospitals NHS Trust; Examiner, Royal College of Radiologists; Honorary Senior Lecturer, St George’s University of London, London, UK

Catherine L Granger BPhysio (Hons ) Ph D Lecturer, Department of Physiotherapy, Melbourne School of Health Sciences, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia; Research Lead, Department of Physiotherapy, Royal Melbourne Hospital, Melbourne, Australia

Alex Harvey BSc (Hons ) MSc MCSP SRP Physiotherapy Lecturer, Brunel University, Middlesex; Senior Teaching Fellow, University College London, London, UK

Kate J Hayes BPhysio MPhysio (Cardio ) Senior Clinician Physiotherapist, Cardiothoracic Unit, Alfred Health, Melbourne, Australia

Andrew D Hirschhorn BApp Sc (Phty ) Ph D Senior Associate Physiotherapist, Westmead Private Physiotherapy Services; Research Fellow, Clinical Research Institute, Westmead; Honorary Research Fellow, Department of Physiotherapy, University of Melbourne, Melbourne, Australia

Anne E Holland BApp Sc (Physio ) Ph D Professor of Physiotherapy, Alfred Health and La Trobe University, Melbourne, Australia

Alice Y M Jones Ph D FACP Honorary Professor, Faculty of Health Sciences, University of Sydney, Sydney; Adjunct Professor, School of Allied Health, Grif th University, South East Queensland, Australia

Jennifer Jones Ph D MSc BSc (Hons ) PGCert Ed Director of Croí Prevention Programmes, Training and Education, Croi Cardiac Foundation, Galway, Ireland; Adjunct Senior Lecturer, Discipline of Health Promotion, National University of Ireland, Galway, Ireland; Reader in Physiotherapy, Brunel University; Honorary Research and Teaching Associate, Imperial College London, London, UK

Mandy Jones Ph D MSc MCSP SRP Course Director MSc (pre-registration) Physiotherapy, Brunel University, Middlesex, UK

Sarah Keilty MSc MCSP

Consultant Physiotherapist, Respiratory and Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, London, UK

Annemarie L Lee BPhysio MPhysio Ph D

Senior Lecturer, Physiotherapy, University of Melbourne, Melbourne, Australia

Jacqueline L Luke BSc (Physio , Hons )

Senior Clinician, Victoria Liver Transplant Unit, Austin Health, Melbourne, Australia

Eleanor Main BSc BA MSc Ph D FCSP

Professor of Physiotherapy and Director of UCL

Postgraduate Physiotherapy Programme, UCL School of Life and Medical Sciences, University College London, London, UK

Lyndal J Maxwell BApp Sc (Phty )

Grad D ip (Cardiothoracic Phty )

MApp Sc (Cardiopulmonary Phty ) Ph D

Senior Lecturer in Physiotherapy, School of Physiotherapy, Faculty of Health Sciences, Australian Catholic University, North Sydney, Australia

Bredge Mccarren BSc MApp Sc (Phty )

Grad D ip Physio (Cardiothoracic ) Ph D

Senior Lecturer, Western Sydney University, Penrith, Australia

Katy Mitchell MSCP Ph D

Research Associate, University Hospitals of Leicester NHS Trust, Leicester, UK

Rosemary Moore BApp Sc (Phty )

Grad D ip Physio (Cardiothoracic )

MPhysio (Research ) Ph D

Physiotherapist/Research Fellow, Institute for Breathing and Sleep, Austin Health, Heidelberg, Australia

Michelle Mulligan BMed MBA AFRACMA

FAICD FANZCA

Specialist Anaesthetist, Sydney, Australia

Sean F Mungovan BApp Sc (Phty ) MPhil

Principal Physiotherapist, Westmead Private Physiotherapy Services, Westmead Private Hospital, Sydney, Australia; Director, The Clinical Research Institute, Sydney, Australia; Honorary Fellow, Department of Physiotherapy, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia

Prue E Munro BPhysio Grad D ip Hlth Mgt

Senior Clinician Physiotherapist, Alfred Health, Melbourne, Australia

Amy N ordon -Craft PT DSc

Assistant Professor, Physical Therapy Program, University of Colorado, Anschutz Medical Campus, Denver, USA

George N toumenopoulos BApp Sc BSc

Grad D ip Clin Epid Ph D

Associate Professor of Physiotherapy, Australian Catholic University, North Sydney; Consultant Physiotherapist, Physiotherapy Department, St Vincent’s Hospital, Darlinghurst, Australia; Honorary Consultant Physiotherapist, Physiotherapy Department, Guy’s and St Thomas’ NHS Foundation Trust, London, UK

Jennifer Paratz MPhty Ph D FACP

Principal Research Fellow, Grif th University; Senior Research Fellow, School of Medicine, University of Queensland, Brisbane, Australia

Selina M Parry BPhysio (Hons ) Grad Cert

Uni Teaching Ph D Lecturer, Department of Physiotherapy, Melbourne School of Health Sciences, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia

Mark J Peters Ph D MBCh B MRCP FRCPCH Professor of Paediatric Intensive Care, Institute of Child Health, University College London; Consultant Paediatric and Neonatal Intensivist, Great Ormond Street Hospital NHS Foundation Trust, London, UK

Amanda J Piper BApp Sc (Phty ) MEd Ph D

Senior Physiotherapist, Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital; Clinical Senior Lecturer, Faculty of Medicine, University of Sydney, Sydney, Australia

Fabio Pitta PT Ph D

Professor of Physiotherapy, Universidade Estadual de Londrina, Londrina, Brazil

Anita Plaza BPhty (Hons )

Consultant Physiotherapist, Professor Stuart Pegg Adult Burn Centre, Royal Brisbane and Women’s Hospital, Brisbane, Australia

Sarah Rand BA BSc MSc

Senior Teaching Fellow, University College London Institute of Child Health, London, UK

Julie Redfern BApp Sc (Phty , Hons ) BSc Ph D

Associate Professor, Sydney Medical School, University of Sydney; Head of Cardiovascular Health Services and Public Health Program, The George Institute for Global Health, Sydney, Australia

Julie C Reeve Grad D ip Phys MSc Ph D

Senior Lecturer in Physiotherapy, Faculty of Health and Environmental Studies, Auckland University of Technology, Auckland, New Zealand

Stewart Reid MA(O xon ) MB BCh FRCA

Consultant, Paediatric Anaesthesia and Paediatric Intensive Care Medicine, Royal Belfast Hospital for Sick Children, Belfast, UK

D avid A B Richards OAM BSc (Med ) MBBS

MD FRACP FCSANZ FACC

Cardiologist, Westmead Private Hospital, Sydney, Australia; Cardiologist, Liverpool Hospital, Liverpool, UK; Honorary Associate Professor, Department of Medicine, University of Sydney, Australia; Conjoint Associate Professor, Department of Medicine, University of New South Wales, Sydney, Australia

Jacqueline Ross BApp Sc (Phty ) Grad D ip N euroscience

Senior Clinician Physiotherapist, Victorian Spinal Cord Service, Austin Health, Melbourne, Australia

Harriet Shannon BSc (Hons ) MA Ph D MCSP

Senior Teaching Fellow, University College London, Institute of Child Health, UK

Sally J Singh Ph D FCSP

Professor of Pulmonary and Cardiac Rehabilitation, Centre of Exercise and Rehabilitation Science, University Hospitals of Leicester NHS Trust and Leicester University, Leicester, UK

Elizabeth H Skinner BPhysio (Hons ) Ph D

Director, Physiotherapy Research, Western Health; Senior Intensive Care Unit Physiotherapist, Western Health; Honorary Research Fellow, University of Melbourne; Honorary Research Fellow, Monash University, Melbourne, Australia

Sarah Smailes BSc (Hons ) MCSP Ph D

Physiotherapy Consultant, St Andrew’s Centre for Plastic Surgery and Burns, Broom eld Hospital; Visiting Clinical Fellow, Postgraduate Medical Institute, Anglia Ruskin University, Chelmsford, UK

Alicia J Spittle Ph D Mp hysio , Bp hysio

Associate Professor, University of Melbourne; Principal Research Fellow, Murdoch Childrens Research Institute; Senior Physiotherapist, Royal Women’s Hospital, Parkville, Australia

Martijn A Spruit PT Ph D

Scienti c Advisor, Department of Research and Education, CIRO + Center of Expertise for Chronic Organ Failure, Horn, Netherlands; Associate Professor in Cardiopulmonary Rehabilitation at REVAL – Rehabilitation Research Center, BIOMED – Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium

Amanda Thomas MApp Sc (Ex & Sp Sc )

BApp Sc (Phys ) MCSP

Clinical Specialist Physiotherapist, Critical Care Outreach, The Royal London Hospital, Barts Health NHS Trust, London, UK; Vice President, International Confederation of Cardiorespiratory Physical Therapy, Clinical Advisor, United Kingdom Con dential Enquiry into Patient Outcome and Death, London, UK

Helena Van Aswegen BSc (Hons ) MSc Ph D

Associate Professor, Department of Physiotherapy, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Brooke Wadsworth BSc Phty (Hons )

MPhil

Advanced Physiotherapist, Princess Alexandra Hospital, Brisbane, Australia

Barbara A Webber FCSP DSc (Hons )

Former Head of Physiotherapy, Royal Brompton Hospital, London, UK

Craig A Williams BEd (Hons ) MSc Ph D FACSM FBASES

Professor of Paediatric Physiology and Health, University of Exeter, Exeter, UK

Leanne Williams BSc MCSP

Clinical Specialist Physiotherapist, London, UK

Marie T Williams Ph D

Grad Cert (Cardiorespiratory Phyty ) BApp Sc (Phyty )

Associate Professor and Associate Head of School: Research, School of Health Sciences, University of South Australia, Adelaide, Australia

ANATOMYANDPHYSIOLOGY

OFTHERESPIRATORYAND CARDLACSYSTEMS

MANDYJONES-AIEXHARVEYIELEANORMAIN

CHAPTEROUTLINE

INTRODUCTIONTORESPIRATION2

UPPERRESPIRATORYTRACT3

THEBRONCHIALTREE4

THEllJNGSANDPlEURAE5

SURFACEMARKINGSOFTHElUNGS8

TheRightlung8

Theleftlung8

ThePleura9

THETHORACICCAGE9

MovementsoftheRibs9

MUSClESOFRESPIRATION11

Diaphragm11

Intercostals13

AccessoryMusclesofInspirati

MusclesofForcedExpiration1

RESPIRATORYMECHANICO

RespiratoryPressures1

Ventilation14

MUCOCIIIARY S

Cilia15

Aqueous(Sol)layer15

Vlscous(Gel)layer15

COLlATERALVENTIlATIONl5

AIRWAYSRESISTANCEl6

AirwayInnervation16

SiteofHighestResistance16

Poiseuille’slaw16

ClinicalRelevanceofPoiseuille’slaw16

ConsequencesofIncreasedAirwayResistance17

ClinicalSignsofAirfowlimitation17

ProblemsAssociatedwithAirfowlimitation17

ReversalofAirfowlimitation17

RESPIRATORYCOMPHANCE18

FactorsAffectinglungCompliance18

AlteredlungCompliancel8

ClosingVolume18

PulmonarySurfaantl8

oreathing19

ryControlCentres(RCCs)19

eedullaryControlCentres19 ePontineControlCentres20

HigherBrainCentres20

ClinicalFailureoftheRespiratoryControl Centres20

Ondine’sCurse2O

RespiratoryControlFeedbackMechanism20

ClinicalFailureoftheEffectors20

RespiratorySystemSensors21

Mechanoreceptors21

IrritantReceptors21

Juxta-CapillaryReceptors21

Proprioceptors21

SpinalCordRefexes21

NasopulminaryRefexes21

Chemoreceptors21

PeripheralChemoreceptors22

CentralChemoreceptors22

StimulationoftheCentralChemoreceptors22

CentralChemoreceptorsandCOPD22

ClinicalRelevanceofHypercapnicCOPD23 lossofHypoxicDrive23

IncreasedV/OMismatch23

HaldaneEffect23

lUNGVOlUMES&VENTIlATION23

lungVolumes23

lungCapacities23

Factors A ecting Lung Volumes 23

Clinical Relevance o Lung Volumes and Capacities 24

Measuring Lung Volumes and Capacities 25

Why Assess Spirometry? 25

Ventilation Terminology 25

Anatomical Dead Space 25

Alveolar Dead Space 25

Physiological Dead Space 25

Alveolar Ventilation 25

Clinical Relevance o Alveolar Ventilation 26

Alteration o Alveolar Ventilation 26

GAS EXCHANGE 26

Fick’s Law and Gas Exchange 27

Concentration Gradient and Gas Solubility 27

Transit Time o Red Blood Cell (RBC) 28

Thickness o the Alveolar Membrane 28

Sur ace Area o Alveolar Membrane 28

Ventilation and Per usion Matching ( V/Q ) 28

Distribution o Ventilation in Healthy Lung 28

Distribution o Per usion in Healthy Lung 29

V/ Q Matching in the Sel -Ventilating Adult 29

Maintaining V/ Q Matching 30

Hypoxic Pulmonary Vasoconstriction (HPV) 30

Pulmonary Capillary Recruitment 30

Diagnosis o V/Q Mismatch 30

Bronchiole Response 30

Transport o Oxygen and Carbon Dioxide 31

Oxygen Transport 31

Oxygen and Haemoglobin 31

Haemoglobin’s A nity or Oxygen 32

The Oxygen Dissociation Curve 32

Why Does O 2 Need to Dissociate? 32

Factors A ecting Hb A nity or O 2 32

Diphosphoglycerate (DPG) 32

INTRODUCTION TO RESPIRATION

Carbon Dioxide Transport 33

Carbon Dioxide and Haemoglobin 33

Carbon Dioxide as Bicarbonate 33

Carriage From Tissue to Lungs 33

THE EFFECT OF GROWTH AND AGEING ON RESPIRATION 34

Embryonic Period (Weeks 3–5) 34

Pseudoglandular Period (Weeks 6–16) 34

Canalicular Period (Weeks 17–24) 34

Terminal Sac Period (Week 24–Term) 34

RESPIRATORY SYSTEM: ANATOMICAL AND PHYSIOLOGICAL DIFFERENCES BETWEEN CHILDREN AND ADULTS 35

Anatomical Di erences in the Respiratory System between Children and Adults 35

Physiological Di erences in the Respiratory System between Children and Adults 38

INTRODUCTION TO CARDIAC ANATOMY AND PHYSIOLOGY 40

Layers o the Heart Wall 41

Heart Valves 41

Coronary Circulation 41

Cardiac Cycle 41

Heart Sounds 42

Electrical Conductivity o the Heart 42

Electrical Conductivity and Electrocardiogram (ECG) 43

Autonomic Regulation o Heart Rate 44

Blood Pressure 44

Stroke Volume 44

Total Peripheral Resistance 45

Renal System 45

Auto Regulation o Blood Pressure 45

REFERENCES AND FURTHER READING 46

The supply of oxygen to body tissues is essential to life. As well as nutrients, cells require oxygen in order to release energy as part of tissue metabolism. As the cells use oxygen, they produce carbon dioxide, which is a metabolic waste product and is toxic if allowed to accumulate.

The primary function of the respiratory system is to supply the body with oxygen taken from atmospheric air, and to dispose of carbon dioxide. This complex process is known as respiration and is com-

prised of four stages: ventilation, external respiration, gas transport and internal respiration ( Marieb and Hoehn 2013).

The respiratory system is responsible for two of these stages: ventilation and external respiration. Ventilation is the movement of air in and out of the lungs, and external respiration (pulmonary gas exchange) is the diffusion of oxygen from the lungs to the blood, and carbon dioxide from the blood to the lungs. To achieve this, air is drawn by conductive ow into the alveoli and presented to the gas-exchanging surface where the process of exchange occurs by diffusion. The