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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