Key Takeaways
- Cardiac rehabilitation has 4 phases: Phase I (inpatient/acute), Phase II (outpatient/supervised, 4-12 weeks), Phase III (community/maintenance, 6-12 months), Phase IV (lifelong maintenance)
- Exercise prescription follows the FITT principle: Frequency, Intensity, Time, Type — for cardiac patients: 3-5x/week, 40-80% HRR or RPE 12-16, 20-60 min, aerobic exercise
- Target heart rate calculation using Karvonen formula: THR = [(HRmax - HRrest) x % intensity] + HRrest; estimated HRmax = 220 - age
- Airway clearance techniques include postural drainage, percussion, vibration, active cycle of breathing, autogenic drainage, and PEP therapy
- Supplemental oxygen delivery: nasal cannula (1-6 L/min, 24-44% FiO2), simple mask (6-10 L/min, 35-60%), non-rebreather (10-15 L/min, 60-90%)
- Energy conservation techniques include pacing activities, using assistive devices, modifying task method, prioritizing activities, and diaphragmatic breathing
- Pursed-lip breathing decreases respiratory rate, increases tidal volume, and prevents airway collapse in COPD by maintaining positive pressure during exhalation
- Phase I cardiac rehab begins 24-48 hours post-event and progresses from 1-2 METs (self-care) to 3-4 METs (hallway walking) before discharge
Cardiopulmonary Interventions
Physical therapy interventions for cardiovascular and pulmonary conditions include cardiac rehabilitation, exercise prescription, airway clearance, and breathing retraining. The NPTE tests your ability to apply these interventions safely and effectively.
Cardiac Rehabilitation Phases
| Phase | Setting | Duration | Activities | MET Level |
|---|---|---|---|---|
| Phase I | Inpatient (hospital) | Duration of hospital stay | Self-care, bed exercises, progressive ambulation, education | 1-4 METs |
| Phase II | Outpatient (supervised) | 4-12 weeks (36 sessions typical) | Monitored exercise, risk factor modification, education | 4-7 METs |
| Phase III | Community/transitional | 6-12 months | Gym-based exercise, independent monitoring, lifestyle changes | 7-10 METs |
| Phase IV | Maintenance (lifelong) | Ongoing | Independent exercise program, continued risk management | Per individual capacity |
Phase I Details (Inpatient)
- Begins 24-48 hours after cardiac event (MI, CABG, PCI)
- Day 1-2: Seated ADLs, ankle pumps, bed-to-chair transfers (1-2 METs)
- Day 3-4: Hallway ambulation, stair negotiation (2-3 METs)
- Discharge criteria: Tolerates 3-4 METs without symptoms, understands activity guidelines
- Patient education: Signs/symptoms to report, activity modification, risk factor management
Exercise Prescription: FITT Principle
| Component | Cardiac Rehab (Phase II) | General Aerobic Fitness |
|---|---|---|
| Frequency | 3-5 days/week | 3-5 days/week |
| Intensity | 40-80% HRR or RPE 12-16 | 55-90% HRmax or 40-85% HRR |
| Time | 20-60 minutes | 20-60 minutes |
| Type | Walking, cycling, rowing, arm ergometry | Any rhythmic, continuous aerobic activity |
Target Heart Rate Calculation
Karvonen Formula (Heart Rate Reserve Method)
THR = [(HRmax - HRrest) x % intensity] + HRrest
- HRmax (estimated) = 220 - age
- Heart Rate Reserve (HRR) = HRmax - HRrest
Example: 60-year-old patient, resting HR 72 bpm, prescribed 60-80% intensity:
- HRmax = 220 - 60 = 160 bpm
- HRR = 160 - 72 = 88 bpm
- Lower target: (88 x 0.60) + 72 = 52.8 + 72 = 125 bpm
- Upper target: (88 x 0.80) + 72 = 70.4 + 72 = 142 bpm
- Target HR zone: 125-142 bpm
Note: The Karvonen formula is preferred over the straight percentage method (% of HRmax) because it accounts for resting heart rate, providing a more individualized prescription. For patients on beta-blockers, use RPE instead.
Airway Clearance Techniques
| Technique | Description | Indications |
|---|---|---|
| Postural drainage | Positioning to use gravity to drain secretions from specific lung segments | Excessive secretions, cystic fibrosis, bronchiectasis |
| Percussion | Rhythmic clapping on chest wall over involved segment | Combined with postural drainage |
| Vibration | Fine oscillatory pressure applied during exhalation | Combined with postural drainage |
| Active cycle of breathing (ACBT) | Breathing control → thoracic expansion → forced expiratory technique (huff) | Independent airway clearance |
| Autogenic drainage | Three phases of breathing at different lung volumes to mobilize and collect secretions | Independent technique, cystic fibrosis |
| PEP (Positive Expiratory Pressure) | Breathing against resistance to splint airways open | COPD, cystic fibrosis, post-surgical atelectasis |
| Flutter/Acapella device | Oscillating PEP device combines positive pressure with vibration | Mucus mobilization, COPD |
Contraindications to postural drainage positions:
- Head-down positioning is contraindicated in: increased intracranial pressure (ICP), uncontrolled hypertension, recent esophageal surgery, and GERD
Breathing Exercises
Diaphragmatic Breathing
- Patient places one hand on chest, one on abdomen
- Inhale through the nose — abdomen rises, chest remains relatively still
- Exhale slowly through pursed lips — abdomen falls
- Strengthens the diaphragm, reduces accessory muscle use, improves ventilation efficiency
Pursed-Lip Breathing (PLB)
- Inhale through the nose for 2 counts
- Exhale slowly through pursed lips for 4 counts (2:1 exhale-to-inhale ratio)
- Mechanism: Creates back-pressure that prevents airway collapse during exhalation
- Benefits: Decreases respiratory rate, increases tidal volume, improves gas exchange
- Primary use: COPD patients (prevents air trapping)
Energy Conservation
Energy conservation techniques are critical for patients with limited cardiopulmonary reserve:
- Pacing: Alternate activity and rest periods; avoid rushing
- Planning: Schedule demanding tasks during peak energy periods; plan ahead
- Prioritizing: Focus on essential tasks first; delegate when possible
- Positioning: Use sitting instead of standing when possible; avoid unnecessary bending/reaching
- Problem-solving: Modify tasks to reduce energy demands (slide objects instead of lifting, use wheeled carts)
Dyspnea Management: Teach patients to exhale during the exertion phase of activities (e.g., exhale while lifting, inhale during rest).
A 55-year-old patient with a resting HR of 70 bpm is prescribed exercise at 60% intensity using the Karvonen formula. What is the target heart rate?
Phase I cardiac rehabilitation typically begins:
Pursed-lip breathing is MOST beneficial for patients with:
Which of the following is a contraindication to head-down (Trendelenburg) postural drainage positioning?
Which of the following are criteria for STOPPING exercise during a cardiac rehabilitation session? (Select all that apply)
Select all that apply
Using the Karvonen formula, a 50-year-old patient with a resting HR of 60 bpm is prescribed exercise at 70% intensity. What is the target heart rate?
Diaphragmatic breathing is performed correctly when:
One MET equals the resting metabolic rate, which is _____ mL O2/kg/min.
Type your answer below
Which cardiac rehabilitation phase involves supervised, ECG-monitored exercise in an outpatient setting?