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OMM 12/10/03 3pm
Ventilated Patient
Gustowski
Nathan Seaman
Pg 1 of 5
Osteopathic Manipulation for the Ventilated Patient
“The Ostopath resaons if he reasons at all, that order andhealth are inseparable, and
that when order in all parts is found, desease cannot prevailk, and if order is complete
and desease should be found, there is no use for order.”
A.T. Still
Case 1
78 y/o WF with a PMHx of COPD and HTN is admitted from the ED for bilateral
lower lobe pneumonia. While you are doing your H & P, the patient begins having
difficulty breathing. You auscultate her lungs and find bilateral rales, expiratory wheezes
and decreased breath sounds. Respiratory is called, and when they arrive, the patient has
become canotic and her O2 sats drop to 60%. You quickly intubate the patient and
transfer to the ICU. In the unit, the patient remains stable for 24 hours and is alert. You
decide to do OMT to improve the function of the ribs and diaphragm and to assist in
extubation.
Note: Bedfast ptnts have increased stasis of fluids-contributing to decreased
venous and lymphatic return... Think about why?...(DVT, headache, nausea, vomiting,
ileus, urinary retention, poor renal output, edema atelectasis)
Mechanical venitlator “takes over” the work of the diaphragm, so it becomes
“lazy”
I.
II.
Rational treatment Based on Osteopathic Principles
a. Find and encourage Health
i. Remove obsturctions to allow the return of homeostasis
ii. Structure and Function are reciprocally interrelated
b. Autonomic nervous system
i. Sympathetic nervous system
ii. Parasympathetic nervous system
c. Lymphatic system
d. Respiratory mechanics
Sympathetic Nervous System
a. Cell bodies of sympathetic nerves to lungs are from T1-6
i. Paravertebral chain ganglia
b. Hypersympathetonia
i. Facilitation in the thoracic spine
ii. Decreased exursions
iii. Bronchodilation
iv. Vasoconstriction
v. Increased mucous production
c. Treatment goals
i. Increase sympathetic tone i.e. bronchodilation, vasoconstriction
ii. Decrease sympathetic tone....decrease vasoconstriction
iii. IMPROVE SYMPATHETIC FUNCTION
III.
IV.
V.
VI.
OMM 12/10/03 3pm
Ventilated Patient
Gustowski
Nathan Seaman
Pg 2 of 5
iv. Suggested treatments – rib raising, indirect or myofascial release to
thoracic spine
Parasympathetic Nervous System
a. Vagus n.
i. Exits skull at jugular foramen
ii. Ganglion nodosum of vagus lies in fascias on anterior surface of
OA and AA (also helps treat the brainstem)
b. Increase parasympathetic tone
i. Bronchoconstriction
ii. Vasodilation
c. Treatment Goals
i. Normalize vagal tone
1. prevent bronchoconstriction, decrease mucous production
ii. Decrease congestion to the vagus nerve and jugular foramen
1. prevent venous back pressure to the vagus nerve /
brainstem centers
iii. Suggested treatment – OA decompression, release, C1-2 release
Lymphatics
a. Heart and lung primarily drain through right lymphatic duct
b. Right and lef main lymph ducts pass though Sibson’s fascia
c. Lymph is mobilized with the use of skeletal muscle and the body’s pumps
(diaphragms)
d. Immobility causes decreased movement of lymph and fluids
e. Lymphatic treatment goals
i. Encourage lymphatic drainage of the thorax
ii. Improve removal of inflammatory waste products, congestion in te
bronchial tree
iii. Improve function of respiratory “toilet”
iv. Promote healing and improve immunity by increasing antigen
presentation in the lymph nodes
f. Suggested treatment – lymphatic pumps, release Sibson’s fascia, indirect
to clavicles / 1st rib
Respiratory Mechanics
a. Muscles of respiration
i. Diaphragm, intercostals, scalenes
b. Ventilated patients lose the action of the diaphragm because a machine is
doing the work
c. The sternum is intimately associated with the diaphragm via the central
tendon of the diaphragm
d. Suggested treatments – myofascial release of the sternum , diaphragm
release, coronary and falciform ligament release
Osteopathic Treatment Goals
a. Autonomic Nervous System
VII.
VIII.
IX.
X.
OMM 12/10/03 3pm
Ventilated Patient
Gustowski
Nathan Seaman
Pg 3 of 5
i. Decrease facilitation and viscero-somatic reflexes to improve
blood flow, delivery of oxygen and nutrients to diseased organs
ii. Restore balance to the nervous system
b. Lymphatic drainage
i. Facilitate removal of inflammatory waste products, decrease fluid
stasis
c. Respiratory mechanics
i. Improve the function of the diaphragm which is necessary for
breathing lymphatic drainage
d. Decrease venous back pressure to avoid congestion at the respiratory and
vagal centers
e. Decrease facilitation to the phrenic n.
f. Directly stimulate the diaphragm
g. Encourage lymphatic drainage of the thorax
h. Increase ribcage and spinal mobility to improve thoracic motion
diaphragm excursion, ventilatory efficiency
Structure and function are reciprocally interrelated
a. Target areas
i. Cervical spine – OA C3-5
ii. Thoracic spine
iii. Ribs
iv. Diaphragm
v. Sternum
vi. Sibson’s fascia – clavicle 1st rib
Treatment strategy
a. Release the cranial base/ occipitoatlanto joint
b. Treat cervical spine dysfunction
c. Release sternum
d. Release sibson’s fascia – clavicles, myofascial
e. Improve ribcage function – rib raising, walking, springing
f. Decrease facilitation (viscero-somatic reflexes) thoracic release
g. Rib raising
h. Release the thoracoabdominal diaphragm
Manipulative techniques (don’t compromise the saftey of the patient to do
OMT i.e. knocking out a central line, you may have to modify the technics by
moving to the side of the bed)
a. Ligamentous articular strain – ribs, coronary and falciform ligaments
b. Sternal mobilization
Ligament Articular Strain
a. Method of treating somatic dysfunction that occurs in ligamentous
structures
b. Ligament “balance” joint through their tension
c. Injury causes strain in the ligaments
d. Goal- balance the tension in ligament until the body recenters
OMM 12/10/03 3pm
Ventilated Patient
Gustowski
Nathan Seaman
Pg 4 of 5
e. Remember that ligament require 3 months to heal
Rib Articulations
a. Costotransverse ligaments go superior and lateral and superior and medial
XII. LAS – Ribs 2-12, Supine, Indirect
a. Run hands under patients ribcage and feel for a “tight spot” or symmetry,
it’s a quick scan. Find the rib that is dysfunctional
b. From the side of the table, grab the rib head and pull superiorly and
laterally to disengage the rib
c. Use as much force as you feel coming back to you from the tissue, match
the tension and the release should be pretty quick, requires “quite a bit of
force.”
d. Remember to use elbow as fulcrum
XIII. LAS – Coronary Ligament
a. Coronary ligament – reflection of peritoneum from liver to the diaphragm
at the margins of the bare area of the liver. Posterior right lobe of liver is
connected to the diaphragm via right triangular lig. Left lobe of the liver
is connected to the diaphragm via the left triangular ligament and is
continuous with the falciform ligament.
b. Coronary ligament is contacted through extraperitoneal fascia just below
left costal margin. You are treating the coronary ligament though the skin,
subcutatneous fat, abdominal muscles.
i. Start with pad of thumb at xyphoid and slide down costal margin
inferior laterally about 2 inches and feel for a strand of tightness or
hardness.
ii. Often a pulsating cardia tug is felt, it will disappear after release
iii. Balance the tension by pressing into the tightest point, match the
tension of the tissue. Force is superior, posterior and lateral
iv. Should release quickly by softening and heart beat will disappear.
XIV. Falciform Ligament – Double layer of peritoneum. Contacts the peritoneum
dorsal to the right rectus muscle and diaphragm. Free edge contains the round
ligament and parumbilical veins.
a. Place the pad of your thumb parallel to the right lower costal margin,
about ½-1 inch below the xyphoid process, just right of midline. Press
with balanced tension in a posterior, lateral, and superior direction
b. Maintain balanced pressure until the tension is released
c. Force is superior, posterior, lateral
XV. Sternum
a. Operator at head of the table
b. Physician’s caudad hand contacts the sternum and manubrium and the
palm of their cephalad hand is placed posteriorly across the spinous
processes (t1-6)
c. Move the sternum in it’s six motions – superior, inferior, lateral to the
right, lateral to the left, clockwise and counterclockwise rotation
d. The posterior hand will move in the opposite direction
XI.
OMM 12/10/03 3pm
Ventilated Patient
Gustowski
Nathan Seaman
Pg 5 of 5
e. Hold at barrier until release in all motions
XVI. Remember...
a. Rind the HEALTH in your patient
b. Remove restrictions / barriers to health
c. Know your anatomy and your treatment goals