Essentials of

Cardiopulmonary Physical

Therapy

FOURTH EDITION

Ellen Hillegass, PT, EdD, CCS,

FAACVPR, FAPTA

President, Cardiopulmonary Specialists, Inc, A Consulting

Corporation, Partner in PT CARDIOPULMONARY

EDUCATORS, LLC, A webinar-based continuing education

company, http://www.ptcardiopulmonaryeducators.com

Adjunct Professor, Department of Physical Therapy, Mercer

University, Atlanta, Georgia

Adjunct Professor, Department of Physical Therapy,

Western Carolina University, Cullowhee, North Carolina

Table of Contents

Cover image

Title page

Copyright

Dedication

Contributors

Preface

Acknowledgments

Section 1. Anatomy and Physiology

1. Anatomy of the cardiovascular and pulmonary systems

Thorax

The Respiratory System

The Cardiovascular System

Cardiac and Pulmonary Vessels

Systemic Circulation

Summary

2. Physiology of the cardiovascular and pulmonary systems

The Pulmonary System

The Cardiovascular System

Summary

Section 2. Pathophysiology

3. Ischemic cardiovascular conditions and other vascular

pathologies

Anatomy of the Coronary Arteries

Myocardial Perfusion

Atherosclerosis

Hypertension

Cerebrovascular Disease

Peripheral Arterial Disease

Other Vascular Disorders

Summary

4. Cardiac muscle dysfunction and failure

Causes and Types of Cardiac Muscle Dysfunction

Cardiac Muscle

Specific Pathophysiologic Conditions Associated with Congestive Heart

Failure

Clinical Manifestations of Congestive Heart Failure

Medical Management

Mechanical Management

Surgical Management

Prognosis

Physical Therapy Assessment

Physical Therapy Interventions

Ventilation

Summary

5. Restrictive lung dysfunction

Etiology

Pathogenesis

Clinical Manifestation

Maturational Causes of Restrictive Lung Dysfunction

Interstitial Causes

Environmental/Occupational Causes

Asbestosis

Infectious Causes

Neoplastic Causes

Pleural Diseases

Cardiovascular Causes

Neuromuscular Causes

Musculoskeletal Causes

Connective Tissue Causes of RLD

Immunologic Causes

Pregnancy as Cause

Nutritional and Metabolic Causes

Traumatic Causes

Therapeutic Causes

Pharmaceutical Causes

Radiologic Causes

Summary

6. Chronic obstructive pulmonary diseases

Overall Etiology, Pathology, and Pathophysiology of COPD

Lung Function in Obstructive Lung Diseases

Symptoms Associated with Obstructive Lung Diseases

Physical and Psychological Impairments Associated with Obstructive Lung

Diseases

Quantification of Impairment in Obstructive Lung Diseases

Disease-Specific Obstructive Lung Conditions

Pediatric Obstructive Lung Conditions

7. Cardiopulmonary implications of specific diseases

Obesity

Diabetes Mellitus

Clinical Implications for Physical Therapy

Chronic Kidney Disease and Failure

Other Specific Diseases and Disorders

Cardiopulmonary Toxicity of Cancer Treatment

Summary

Section 3. Diagnostic Tests and

Procedures

8. Cardiovascular diagnostic tests and procedures

Diagnostic Test Interpretation and Probability of Disease

Sensitivity/Specificity of Testing

Clinical Laboratory Studies

Other Noninvasive Diagnostic Tests

Other Imaging Modalities

Exercise Testing

Pharmacologic Stress Testing

Cardiac Catheterization: Coronary Angiography and Ventriculography

Digital Subtraction Angiography

Endocardial Biopsy

Vascular Diagnostic Testing for Aortic, Peripheral, and Carotid Disease

Peripheral Arterial Disease and Dysfunction and Diagnosis

Carotid Artery Disease and Diagnosis

Summary

9. Electrocardiography

Basic Electrophysiologic Principles

Heart Rhythm: Assessment of Single-Lead Electrocardiogram

Heart Blocks

Ventricular Arrhythmias

Other Findings on a 12-Lead Electrocardiogram

Summary

10. Pulmonary diagnostic tests and procedures

Chest Imaging

Bronchoscopy

Pulmonary Function Testing

Blood Gas Analysis

Oximetry

Cytologic and Hematologic Tests

Summary

Section 4. Surgical Interventions,

Monitoring, and Support

11. Cardiovascular and thoracic interventions

Cardiovascular and Thoracic Surgical Procedures

Gene Therapy for the Stimulation of Angiogenesis

Radiation

Chest Tube Placement

Pacemaker Implantation

Implantable Cardioverter Defibrillator

Summary

12. Thoracic organ transplantation: Heart and lung

History

Evaluation

Preoperative Rehabilitation

Alternative Therapies to Transplantation

Donor Selection and Matching Criteria

Surgical Techniques

Medications

Postoperative Treatment

Lung Transplantation

Future Trends in Transplantation Care161

Summary

13. Monitoring and life support

Monitoring Equipment

Temperature Monitoring

Intracranial Pressure Monitoring

Life Support Equipment

Summary

Section 5. Pharmacology

14. Cardiovascular medications

Pharmacokinetics

Pharmacodynamics

General Considerations of Pharmacologic Management

Cardiac Drugs Used in Critical Care

Cardiac Pharmacology in the Geriatric Population

Cardiac Pharmacology in the Neonate and Pediatric Populations

Pharmacologic Management of Diabetes

Heart Transplantation

Vascular Pharmacology

Summary

15. Pulmonary medications

Physiology

Bronchomotor Tone

Rationale for Bronchodilators

Bronchodilators

New Drug Development

New Antifibrotic Medications (for the Treatment of Idiopathic Pulmonary

Fibrosis)

Pulmonary Arterial Hypertension Medications

Ancillary Pulmonary Medications

Summary

Section 6. Cardiopulmonary

Assessment and Intervention

16. Examination and assessment procedures

Elements of Patient Management

Patient History

Medical Chart Review

Interview with the Patient and the Family

Systems Review

Physical Examination

Evaluation

Summary

17. Interventions for acute cardiopulmonary conditions

Airway Clearance Techniques

Breathing Strategies, Positioning, and Facilitation

Breathing Exercises

Special Considerations for Mechanically Ventilated Patients

Exercise

Injury Prevention and Equipment Provision

Patient Education

Discharge Planning

Pediatric Considerations

Summary

18. Interventions and prevention measures for individuals

with cardiovascular disease, or risk of disease

Primary Prevention

Rehabilitation of Patients with Documented Cardiovascular Disease

Management and Evaluation of Patients during the Acute Phase

Postacute Phase Rehabilitation

Candidacy

Home-Based Cardiac Rehabilitation

Rehabilitation/Secondary Prevention in the Outpatient Setting

Secondary Prevention: Management of Risk Factors

Administrative Considerations

Summary

19. Pulmonary rehabilitation

Choosing Goals and Outcomes in Pulmonary Rehabilitation

Structure of the Pulmonary Rehabilitation Program

Physical Therapy Management

Patient Evaluation Procedures

Treatment Intervention

Physical Conditioning

Summary

20. Pediatric cardiopulmonary physical therapy

Respiratory System Development

Cardiac Development

Congenital Heart Defects

Respiratory Conditions of Infancy

Pediatric Conditions with Secondary Cardiopulmonary Issues

Pediatric Conditions with Decreased Activity Levels and/or Altered Posture

Physical Therapy Examination

Physical Therapy Evaluation, Diagnosis, and Prognosis

Physical Therapy Intervention

Summary

21. The lymphatic system

Anatomy and Physiology

Pathophysiology

The Role of the Lymphatic System in the Cardiovascular System and in

Cardiovascular Disease

Medical Management

Lipedema

Summary

22. Outcome measures: A guide for the evidence-based

practice of cardiopulmonary physical therapy

Outcomes Defined

Importance of Measuring Outcomes

Selection of Data to Measure

Functional Performance Measures

Quality-of-Life Measures

Summary

Index

Copyright

3251 Riverport Lane St. Louis, Missouri 63043

ESSENTIALS OF CARDIOPULMONARY PHYSICAL

THERAPY, FOURTH EDITION ISBN: 978-0-323-43054-8

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Notices Knowledge and best practice in this field are

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Practitioners and researchers must always rely on their

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Previous editions copyrighted 2011, 2001, and 1994.

Library of Congress Cataloging-in-Publication Data

Names: Hillegass, Ellen A., editor.

Title: Essentials of cardiopulmonary physical therapy /

[edited by] Ellen Hillegass.

Other titles: Cardiopulmonary physical therapy Description:

Fourth edition. | St. Louis, Missouri : Elsevier, [2017] |

Includes bibliographical references and index.

Identifiers: LCCN 2016002395 | ISBN 9780323430548

(hardcover : alk. paper) Subjects: | MESH: Cardiovascular

Diseases–physiopathology | Cardiovascular Diseases–

rehabilitation | Lung Diseases–physiopathology | Lung

Diseases–rehabilitation | Physical Therapy Modalities

Classification: LCC RC702 | NLM WG 166 | DDC 616.1/062-

-dc23 LC record available at http://lccn.loc.gov/2016002395

Executive Content Strategist: Kathy Falk Content

Development Manager: Jolynn Gower Senior Content

Development Specialist: Brian Loehr Publishing Services

Manager: Julie Eddy Project Manager: Abigail Bradberry

Design Direction: Miles Hitchen Printed in China Last digit

is the print number: 9 8 7 6 5 4 3 2 1

Dedication

This book is dedicated to my beloved family for

all their love and support as well as their

understanding during my endless hours of

working on this edition:

To my husband Dan, who is my rock and my

constant support whom I could not live without;

To my three wonderful children: Patrick, Jamie,

and Christi who give me moral support, make

me laugh, and who constantly try to keep me up

to date on all the modern technologies that

have helped me communicate with them,

communicate with my colleagues, and write this

book. They keep me young with their ideas and

assistance; they constantly have a “joie de

vivre”;

To my two dogs: Sparky and Bear who kept my

feet warm while I sat for hours at the computer

working on this edition but demanded daily

play, and provided a wonderful mental break

from writing;

To my brother-in-law George, who was an

inspiration to everyone he knew and met with

his positive attitude and fighting spirit that he

had up until the day he died from pancreatic

cancer.

And,

In loving memory of my parents, John and

Norma, who kept me busy as their daughter and

caregiver while they were alive, and were always

proud of everything I did.

In addition, I dedicate this edition:

To my colleagues who keep me informed, give

me moral and intellectual support, and who

keep me inspired to maintain my passion for

the field of cardiovascular and pulmonary

physical therapy. I have enjoyed being a mentor

to many rising cardiopulmonary specialists as

well as all my students, and have especially

enjoyed being a resident mentor to my first

resident, Erica Colclough, and my current

residents Tiffany Haney and Stephen Ramsey. I

also especially rely on the support and

inspiration of some very dear friends/colleagues

including Dianne Jewell, Andrew Ries, Claire

Rice, and Joanne Watchie.

And finally, I can never forget my very special

friends/mentors to whom I am forever grateful

and whose memories and teachings are with me

always: Michael Pollock (1937–1998), Linda

Crane (1951–1999), and Gary Dudley (1952–

2006).

Contributors

Erinn Barker, DPT, Cardiovascular and Pulmonary

Physical Therapist Resident, Department of Physical

Therapy, Duke University Hospital, Durham, North Carolina

Pamela Bartlo, PT, DPT, CCS

Clinical Associate Professor, Physical Therapy, D’Youville

College, Buffalo, New York Staff PT in Cardiac and

Pulmonary Rehabilitation, Rehabilitation Department,

Mount St. Mary’s Hospital, Lewiston, New York Traci

Tiemann Betts, PT, DPT, CCS, Physical Therapist –

Cardiopulmonary Clinical Specialist, Physical Medicine and

Rehabilitation, Baylor Institute for Rehabilitation – Baylor

University Medical Center – Baylor Scott & White

Healthcare, Dallas, Texas Tamara L. Burlis, PT, DPT,

CCS, Associate Director of Clinical Education, Assistant

Professor, Program in Physical Therapy and Internal

Medicine, Washington University, St. Louis, Missouri

Rohini K. Chandrashekar, PT, MS, CCS

Guest Lecturer, Physical Therapy, Texas Woman’s

University, Houston, Texas Physical Therapist,

Rehabilitation, Triumph Hospital Clear Lake, Webster,

Texas Meryl Cohen, DPT, MS, CCS

Assistant Professor, Department of Physical Therapy, Miller

School of Medicine, University of Miami, Coral Gables,

Florida Adjunct Instructor, Massachusetts General

Hospital, Institute of Health Professions, Boston,

Massachusetts Kelley Crawford, DPT, Level III Clinician,

Rehabilitation, Medicine, Maine Medical Center, Portland,

Maine Rebecca Crouch, PT, DPT, CCS

Adjunct Faculty, Doctoral Program in Physical Therapy,

Duke University, Durham, North Carolina Coordinator of

Pulmonary Rehabilitation, PT/OT Duke University Medical

Center, Durham, North Carolina Nicole DeLuca, DPT,

CCS, Program Coordinator, Cardiopulmonary

Rehabilitation, Physical Medicine and Rehabilitation, Miami

VA Healthcare System, Miami, Florida Konrad J. Dias, PT,

DPT, CCS, Associate Professor, Physical Therapy Program,

Maryville University, St. Louis, Missouri Christen

DiPerna, PT, DPT, Physical Therapist, Indiana University

Health Methodist Hospital, Indianapolis, Indiana Anne

Mejia-Downs, PT, CCS

Assistant Professor, Krannert School of Physical Therapy,

University of Indianapolis, Indianapolis, Indiana Physical

Therapist, Department of Rehabilitation Services, Clarian

Health Partners, Indianapolis, Indiana Jennifer

Edelschick, PT, DPT, Coordinator of Pediatric Acute

PT/OT Services Physical and Occupational Therapy, Duke

Medicine, Durham, North Carolina Tara Marie Dickinson

Fahrner, PT, DPT, CCS, Physical Therapist, Physical

Medicine, Sacred Heart Hospital, Pensacola, Florida Ann

Winkel Fick, PT, DPT, MS, CCS

Director of Clinical Education Associate Professor, Physical

Therapy, Maryville University, St. Louis, Missouri PRN

Physical Therapist, Physical Therapy, Barnes-Jewish

Hospital, St. Louis, Missouri Danielle L. Fioriello, PT,

MPT, CCS, Physical Therapist, Cardiac and Pulmonary

Rehabilitation, Mount Sinai Beth Israel, New York, New

York Courtney Frankel, PT, MS, CCS, Clinical Research

Coordinator II, Department of Medicine, Duke University,

Durham, North Carolina Susan L. Garritan, PT, PhD,

CCS, Clinical Assistant Professor, Rehabilitation Medicine,

Acute Care Physical Therapy Coordinator, Tisch Hospital,

New York University, Langone Medical Center, New York,

New York

Natalie M. Goldberg, PT, DPT, CCS

Adjunct Professor, Department of Physical Therapy,

University of Hartford, Hartford, Connecticut Physical

Therapist, Department of Rehabilitation, Hartford Hospital,

Hartford, Connecticut Kate Grimes, MS, PT, CCS,

Clinical Assistant Professor, Massachusetts General

Hospital, Institute of Health Professions, Boston,

Massachusetts Ellen Hillegass, PT, EdD, CCS,

FAACVPR, FAPTA

President, Cardiopulmonary Specialists, Inc, A Consulting

Corporation, Partner in PT CARDIOPULMONARY

EDUCATORS, LLC, A webinar-based continuing education

company, http://www.ptcardiopulmonaryeducators.com

Adjunct Professor, Department of Physical Therapy, Mercer

University, Atlanta, Georgia Adjunct Professor, Department

of Physical Therapy, Western Carolina University,

Cullowhee, North Carolina Morgan Johanson, PT, MSPT,

CCS

Coordinator of Inpatient and Outpatient, Cardiac and

Pulmonary Physical Therapy Co-Director, Cardiovascular

and Pulmonary Physical Therapy Residency Program,

Physical Medicine and Rehabilitation, Ann Arbor VA

Healthcare System, Ann Arbor, Michigan Tamara

Klintwork-Kirk, PT, CCS, Clinical Services Coordinator,

Department of Physical and Occupational Therapy, Duke

University Hospital, Durham, North Carolina Meghan

Lahart, PT, DPT, CCS, Physical Therapist II,

Rehabilitation Services, Advocate Christ Medical Center,

Oak Lawn, Illinois Kristin M. Lefebvre, PT, PhD, CCS,

Assistant Professor, Institute for Physical Therapy

Education, Widener University, Chester, Pennsylvania Ana

Lotshaw, PT, PhD, CCS, Rehabilitation Supervisor,

Physical Medicine and Rehabilitation, Baylor University

Medical Center, Dallas, Texas Sean T. Lowers, PT, DPT,

CCS, Senior Physical Therapist, Department of Physical

Therapy and Occupational Therapy, Duke University Health

System, Durham, North Carolina Kate MacPhedran, PT,

PhDc, CCS

Instructor, Doctor of Physical Therapy, Gannon University,

Erie, Pennsylvania Frailty Consultant, Consultants in

Cardiovascular Diseases, Inc., Saint Vincent Hospital, Erie,

Pennsylvania Susan Butler McNamara, MMSc, PT, CCS,

Team Leader, Division of Rehabilitation Medicine, Maine

Medical Center, Portland, Maine Harold Merriman, PT,

PhD, CLT, Associate Professor, Department of Physical

Therapy, University of Dayton, Dayton, Ohio Andrew Mills,

PT, DPT, Assistant Professor, School of Physical Therapy,

Touro University Nevada, Henderson, Nevada Amy Pawlik,

PT, DPT, CCS, Program Coordinator, Cardiopulmonary

Rehabilitation Therapy Services The University of Chicago

Hospitals, Chicago, Illinois Christiane Perme, PT, CCS,

Senior Physical Therapist, Department of Physical Therapy

and Occupational Therapy, The Methodist Hospital,

Houston, Texas Karlyn J. Schiltgen, PT, DPT, OCS, CCS,

Physical Therapist, Department of Inpatient PT/OT, Duke

University Hospital, Durham, North Carolina Alexandra

Sciaky, PT, DPT, MS, CCS

Adjunct Faculty, Department of Physical Therapy,

University of Michigan-Flint, Flint, Michigan Senior

Physical Therapist, Coordinator of Clinical Education,

Physical Medicine and Rehabilitation, Physical Therapy

Section, Veterans Affairs Ann Arbor Healthcare System Ann

Arbor, Michigan Debra Seal, PT, DPT, Senior Pediatric

Physical Therapist, Acute Therapy, Cedars-Sinai Medical

Center, Los Angeles, California Joanne Watchie, MA, PT,

CCS, Owner, Joanne’s Wellness Ways, Pasadena, California

Preface

Originally this text was developed to meet the needs of the

physical therapy community, as cardiopulmonary was

identified as one of the four clinical science components in

a physical therapy education program as well as in clinical

practice. Those aspects of physical therapy commonly

referred to as “cardiovascular and pulmonary physical

therapy” are recognized as fundamental components of the

knowledge base and practice base of all entry-level physical

therapists. Therefore this text was developed for entry-level

physical therapists, as well as individuals in practice who

need more in-depth knowledge of cardiopulmonary content.

This text is also utilized by many clinicians studying for

advanced practice board certification as well as those

involved in residency programs. Although intended

primarily for physical therapists, this text has been useful

to practitioners in various disciplines who teach students or

who work with patients who suffer from primary and

secondary cardiopulmonary dysfunction. This fourth edition

can also be used by all practitioners who teach entry-level

clinicians, work with residents as well as to help in clinical

practice of patients with cardiopulmonary dysfunction.

This fourth edition has gone through update and revision

from the third edition to make the text more user friendly

and provide more interactive learning. The same six

sections exist: Anatomy and Physiology; Pathophysiology;

Diagnostic Tests and Procedures; Surgical Interventions,

Monitoring and Support; Pharmacology; and

Cardiopulmonary Assessment and Intervention. The six

sections were kept as they facilitate the progression of

understanding of the material in order to be able to

perform a thorough assessment and provide an optimal

intervention as well as provide measurable outcomes to

assess change.

The revisions you should notice include both major and

minor changes. All chapters have been revised as well as

supplemented with many figures and tables and some

videos to help the learner visualize the written information.

Additional figures, case studies, and resource material can

also be found on the Evolve website that accompanies this

text. The number of clinical notes was increased to help

clinicians and students understand certain clinical findings

and help them relate them to the pathophysiology of

cardiovascular and pulmonary disease. All chapters were

updated with new information, technology, and research.

Each chapter had specific revisions that should be

highlighted. Chapters 1 and 2, which explain anatomy and

physiology, increased the number of figures to help the

learner relate the pathophysiology to the normal anatomy

and physiology. In addition, the developmental and

maturational anatomy was moved to the pediatrics chapter

(Chapter 20) to help the learner compare the

pathophysiology to the normal in this population. Chapter

3, Ischemic Cardiovascular Conditions and Other Vascular

Pathologies, underwent revision particularly in areas that

were lacking such as venous dysfunction including deep

vein thrombosis. New material was added, so that you will

now find hypertension, peripheral arterial disease,

cerebrovascular disease, renal disease, and aortic

aneurysm in this chapter, in addition to ischemic disease.

Chapter 4, Cardiac Muscle Dysfunction and Failure, was

restructured and revised to improve the flow and

understanding of this important pathologic condition as

well as all new figures and tables to help understand heart

dysfunction and failure.

Due to the complexities and number of conditions of

restrictive lung dysfunction many more tables were created

in Chapter 5 to separate the material and assist the learner

to identify key information quickly. Chapter 6, Chronic

Obstructive Pulmonary Diseases, was updated and revised

to emphasize the importance of this disease and the fact

that COPD is the third leading cause of death. Revisions in

Chapter 7, Cardiopulmonary Implications of Specific

Diseases, emphasize information on obesity, diabetes, and

metabolic syndrome, as well as cancer and neuromuscular

diseases.

New technologies and advancements in diagnostic tests

and surgical procedures were added to Chapters 8, 9, 10,

and 11. Chapter 11, Cardiovascular and Thoracic

Interventions underwent major overhaul with many new

figures and text. The advances in transplantation were

discussed in Chapter 12 and Monitoring and Life Support

(Chapter 13) was revised to increase the depth of

information on ventilators as well as other monitoring

equipment found in intensive care units and used by PTs

when mobilizing patients earlier.

As advances in health care and diagnostics occur, so do

improvements and changes in medications, so both

Cardiovascular Medications (Chapter 14) and Pulmonary

Medications (Chapter 15) required updating. Chapter 16

(Examination and Assessment Procedures) was revised with

addition of new tables to help organize assessments and

improve the understanding of this material. Chapter 17,

Interventions for Acute Cardiopulmonary Conditions added

a greater emphasis on early mobility and Chapter 18,

Interventions and Prevention Measures for Individuals with

Cardiovascular Disease, or Risk of Disease had major

updating and revision, new clinical notes and many new

figures and tables. Chapter 19, Pulmonary rehabilitation

was revised to correspond with changes in the new

pulmonary rehabilitation (PR) definition and in the

changing practice since Medicare revised payment for PR.

Chapter 20, Pediatric Cardiopulmonary Physical Therapy

and Chapter 21, The Lymphatic System were two

won