Cardiorespiratory physiotherapy

In short

Cardiorespiratory (cardiopulmonary) physiotherapy is the branch of clinical physiotherapy that assesses and treats impairments of ventilation, gas exchange, airway clearance and cardiovascular exercise capacity — in ICUs, wards, operation theatres, OPDs and community rehabilitation. It prevents and treats post-operative pulmonary complications, clears secretions in COPD, bronchiectasis and cystic fibrosis, weans patients off ventilators, and delivers structured cardiac and pulmonary rehabilitation after myocardial infarction, CABG or COVID-19. It is examined in BPT third- and fourth-year "Cardiovascular and Pulmonary Physiotherapy" papers, in MPT entrance tests (AIIMS, PGIMER, MAHE, NEET-PG equivalents for allied health) and in practical/viva stations on auscultation, ABG interpretation and exercise prescription. Employers testing it include Apollo, Fortis, Manipal, Max, Narayana Health, AIIMS and state medical college hospitals, and CGHS/ESIC-empanelled rehabilitation centres. Practice in India is regulated under the National Commission for Allied and Healthcare Professions Act, 2021, which recognises physiotherapy as an allied and healthcare profession with state registration councils.

Explained

Applied anatomy and physiology the subject rests on

• Ventilation vs respiration: ventilation is bulk air movement into and out of alveoli; respiration is gas exchange across the alveolar-capillary membrane. Physiotherapy mainly improves ventilation, secretion clearance and oxygen transport, not the membrane itself.
• Lung volumes: tidal volume (TV ≈ 500 mL), inspiratory reserve (IRV ≈ 3,000 mL), expiratory reserve (ERV ≈ 1,100 mL), residual volume (RV ≈ 1,200 mL). Capacities: IC = TV + IRV; FRC = ERV + RV; VC = IRV + TV + ERV; TLC = VC + RV. RV and FRC cannot be measured by spirometry (need helium dilution, nitrogen washout or body plethysmography).
• Closing volume and FRC: supine posture and anaesthesia lower FRC towards closing volume, so dependent airways close, causing atelectasis and shunt — the physiological basis for upright positioning and deep breathing after surgery.
• Dead space: anatomical (~150 mL, conducting airways), alveolar (ventilated but not perfused) and physiological (sum). Rapid shallow breathing wastes a larger fraction on dead space.
• Ventilation-perfusion (V/Q): normal overall V/Q ≈ 0.8. In an upright lung, both ventilation and perfusion are greater at the base, but perfusion increases more, so V/Q is high at the apex and low at the base. Shunt = perfusion without ventilation (V/Q → 0, does not correct with oxygen); dead space = ventilation without perfusion (V/Q → ∞).
• Mucociliary clearance: cilia beating in a sol layer move a gel layer at roughly 5-15 mm/min; impaired by dehydration, smoking, high FiO₂, endotracheal tubes, anaesthesia and immobility.
• Oxygen transport chain: FiO₂ → airway patency → alveolar ventilation → diffusion → haemoglobin → cardiac output → peripheral extraction. Treatment is chosen by identifying which link is broken — the core reasoning model (Dean's oxygen transport pathway).
• Cardiac output = HR × stroke volume; oxygen delivery DO₂ = CaO₂ × cardiac output. Exercise raises VO₂ mainly by raising cardiac output and extraction (widened a-v O₂ difference).

Assessment

1. History: diagnosis, onset, smoking (pack-years), occupational exposure (bagassosis, silicosis, byssinosis, biomass smoke in rural India), cough and sputum character, haemoptysis, dyspnoea grade (mMRC 0-4), exercise tolerance, drugs, vaccination, home environment and stairs.
2. Observation: respiratory rate (normal 12-20/min adult), pattern (apnoea, Cheyne-Stokes, Kussmaul, paradoxical/abdominal), accessory muscle use, chest shape (barrel, pectus, kyphoscoliosis), clubbing, cyanosis, pursed-lip breathing, intercostal recession, surgical scars, drains, lines, oedema, JVP.
3. Palpation: tracheal position, chest expansion (upper, middle, lower zones; tape measure at axilla, nipple and xiphisternum), tactile vocal fremitus, crepitus (surgical emphysema), tenderness.
4. Percussion: resonant (normal), hyper-resonant (pneumothorax, emphysema), dull (consolidation, collapse), stony dull (pleural effusion).
5. Auscultation: normal vesicular; bronchial breathing over consolidation; reduced/absent over effusion, pneumothorax, collapse. Added sounds — crackles (coarse = secretions, fine late-inspiratory = fibrosis/oedema), wheeze (expiratory, airflow obstruction), pleural rub, stridor (upper airway, inspiratory).
6. Objective data: SpO₂ (target usually 94-98%; 88-92% in CO₂-retaining COPD), ABG, chest radiograph, spirometry, peak expiratory flow, ECG, echo ejection fraction, ventilator parameters, sputum culture, haemodynamics.
7. Exercise and function: 6-minute walk test (6MWT), incremental and endurance shuttle walk tests, 1-min sit-to-stand, Borg RPE 6-20 or modified Borg dyspnoea 0-10, MRC muscle grading, maximal inspiratory/expiratory pressure (MIP/MEP), handheld dynamometry.

Airway clearance and lung expansion techniques

• Postural drainage (PD): segment-specific gravity-assisted positions (e.g. head-down for basal segments, sitting upright for apical). Each position held 5-15 min. Modified PD avoids head-down tilt — used with raised intracranial pressure, severe hypertension, gastro-oesophageal reflux, recent haemoptysis, cardiac failure, obesity and in infants.
• Manual techniques: percussion (cupped hands, 100-480 bpm equivalent rhythm over affected segment), vibration and shaking on expiration, rib springing. Contraindicated over fractures, osteoporosis, flail chest, chest drains, skin grafts, low platelets, pulmonary haemorrhage, metastatic rib disease.
• Active cycle of breathing technique (ACBT): breathing control → 3-4 thoracic expansion exercises (with or without a 3-second end-inspiratory hold) → forced expiration technique (1-2 huffs) → breathing control; repeat. Independent, cheap, the mainstay for cooperative adults.
• Autogenic drainage: controlled tidal breathing at three successive lung volumes (unsticking at low volume, collecting at mid, evacuating at high) without coughing — used in cystic fibrosis and bronchiectasis.
• Huffing / forced expiration technique (FET): forced expiration with an open glottis from mid-lung volume; moves the equal pressure point peripherally and avoids the airway collapse caused by a hard cough.
• PEP and oscillating PEP: PEP mask/bottle PEP at 10-20 cm H₂O; flutter, Acapella and high-frequency chest wall oscillation add vibration to shear mucus. Bottle-blowing with a tube in water is the standard low-cost Indian substitute.
• Incentive spirometry: sustained maximal inspiration against a flow- or volume-oriented device, 5-10 breaths hourly while awake; prevents post-operative atelectasis by increasing transpulmonary pressure. Volume-type devices are preferred because flow devices encourage fast shallow breaths.
• IPPB, CPAP, BiPAP/NIV: mechanical lung expansion when the patient cannot generate volume; NIV reduces work of breathing and improves alveolar ventilation in type II respiratory failure and acute cardiogenic pulmonary oedema.
• Manual hyperinflation (bagging) and ventilator hyperinflation: slow large breath, inspiratory hold, quick release to mimic a cough, in intubated patients — typically volumes about 50% above tidal with pressure limited to ~40 cm H₂O. Contraindicated in undrained pneumothorax, severe bronchospasm and haemodynamic instability.
• Suctioning: nasopharyngeal, oropharyngeal or endotracheal; catheter diameter under half the tube's internal diameter, pressure typically 80-150 mmHg, each pass under 15 seconds, pre-oxygenate, sterile technique. Risks: hypoxaemia, arrhythmia, mucosal trauma, bronchospasm, raised intracranial pressure.
• Breathing re-education: diaphragmatic breathing, pursed-lip breathing (creates back-pressure that splints airways and reduces air trapping), segmental/localised expansion, inspiratory muscle training (threshold device at 30-50% MIP), relaxation and energy conservation, positioning for dyspnoea relief (forward lean with arms supported).

Medical and surgical conditions treated

• COPD: obstructive — FEV₁/FVC < 0.70 post-bronchodilator; GOLD grades 1-4 by FEV₁% predicted and ABCE groups by symptoms/exacerbations. Physiotherapy: pulmonary rehabilitation, pursed-lip breathing, airway clearance only if sputum-producing, IMT, energy conservation, smoking cessation support.
• Asthma: reversible obstruction; breathing retraining (Papworth/Buteyko-type pattern work), exercise-induced bronchospasm management, peak flow diary education, avoid treatment during acute severe bronchospasm.
• Bronchiectasis and cystic fibrosis: daily airway clearance, nebulised hypertonic saline before clearance, exercise training, postural correction. Bronchiectasis from childhood tuberculosis and measles is common in India.
• Pneumonia, lung abscess, empyema: positioning for V/Q, clearance once antibiotics started, mobilisation; post-decortication shoulder and expansion exercises.
• Pulmonary tuberculosis: physiotherapy for sequelae — fibrothorax, restrictive defect, deconditioning, post-TB bronchiectasis. Infection control under RNTCP/NTEP; N95 respirator, negative-pressure or well-ventilated rooms, treatment deferred in sputum-positive infectious phase where possible.
• Interstitial lung disease: restrictive — reduced TLC, FVC and DLCO with normal or high FEV₁/FVC ratio; exercise with supplemental oxygen, pacing, no benefit from secretion clearance.
• Pleural effusion and pneumothorax: expansion exercises after drainage, intercostal drain care, mobilisation with drain, shoulder range of motion to prevent frozen shoulder.
• Thoracic and cardiac surgery: pre-operative education and incentive spirometry; post-operative wound support during coughing, early sitting out of bed and ambulation, sternal precautions after median sternotomy (no pushing, pulling or lifting more than about 5 kg, no single-arm loading, for roughly 6-8 weeks — protocols vary by centre).
• Abdominal surgery: upper abdominal incisions cut FRC and VC sharply; the strongest evidence is for early mobilisation plus deep breathing to prevent post-operative pulmonary complications.
• Burns, trauma, flail chest, spinal cord injury: inhalation injury clearance; in tetraplegia above T6 the abdominal thrust ("quad/assisted cough") and abdominal binder support a weak expiratory effort.
• ICU: positioning (side-lying with the good lung down improves oxygenation in unilateral adult disease; prone positioning in ARDS), early mobilisation progression (bed exercises → sitting → standing → tilt table → walking with ventilator), passive and active limb exercise to limit ICU-acquired weakness, splinting, weaning support. Stop criteria: SpO₂ < 88-90%, HR outside 40-130/min or 20% change, systolic BP < 90 or > 180 mmHg, new arrhythmia, agitation, line or airway risk.
• Long COVID / post-COVID: graded, symptom-titrated aerobic and strength training, breathing pattern retraining, avoidance of over-exertion in post-exertional symptom exacerbation.

Cardiac rehabilitation and exercise prescription

• Indications: post-MI, post-PCI, post-CABG or valve surgery, stable angina, chronic heart failure, post-transplant, peripheral arterial disease.
• Phases: I in-patient (days 1-5: self-care, sitting, bed-to-chair, corridor walking, education, risk-factor counselling); II early out-patient supervised, monitored exercise, usually 6-12 weeks; III intermediate community/supervised maintenance; IV lifelong independent maintenance.
• FITT prescription: Frequency 3-5 days/week; Intensity 40-80% VO₂ reserve or heart-rate reserve, RPE 11-14/20; Time 20-60 min continuous or interval, plus warm-up and cool-down; Type large-muscle aerobic (walking, cycle ergometer) plus resistance at 30-50% 1-RM, 10-15 repetitions, 2-3 days/week.
• Risk stratification (low/moderate/high) by ejection fraction, ischaemia on testing, arrhythmia, functional capacity and symptoms — determines ECG monitoring need.
• Absolute contraindications to exercise testing/training: unstable angina, uncontrolled arrhythmia, decompensated heart failure, severe symptomatic aortic stenosis, acute myocarditis/pericarditis, acute pulmonary embolism, dissecting aneurysm, acute DVT, active endocarditis. Relative (not absolute) contraindications, where exercise proceeds only if benefit outweighs risk: resting systolic BP > 200 or diastolic > 110 mmHg, uncontrolled diabetes/metabolic disease, severe left main stenosis, tachy- or bradyarrhythmias, hypertrophic cardiomyopathy.
• Pulmonary rehabilitation: multidisciplinary 6-12 week programme — aerobic endurance, interval training for severe dyspnoea, upper and lower limb strengthening, IMT, education, nutrition, psychosocial support and self-management/action plans. Outcomes: 6MWT distance (minimal clinically important difference about 25-35 m), dyspnoea, quality of life (CRQ, SGRQ, CAT score), fewer admissions. It improves symptoms and function without necessarily changing FEV₁.

Standards, law and practice in India

• Regulation: National Commission for Allied and Healthcare Professions Act, 2021 — constitutes the national commission, professional councils and state councils; registration in the state register is required to practise, and recognised qualifications and standards of education are notified under it.
• Labour and workplace: the four Labour Codes are in force from 21 November 2025 and replaced the Factories Act, Minimum Wages Act, Industrial Disputes Act and BOCW Act; occupational health provisions relevant to dust- and fume-exposed workers (silicosis, byssinosis) now sit under the Occupational Safety, Health and Working Conditions Code.
• Infection control and waste: Bio-Medical Waste Management Rules, 2016 (as amended) govern disposal of suction catheters, filters and mouthpieces (yellow/red category bags as applicable); NABH standards cover hospital physiotherapy departments; NTEP airborne-infection-control guidance applies in TB wards.
• Devices and tax: medical devices are regulated under the Medical Devices Rules, 2017 by CDSCO; GST slabs since 22 September 2025 are 5%/18%/40%, with most medical devices and many health items in the lower slabs — confirm the current HSN rate before quoting, as rates are revised.
• Documentation: SOAP notes, ICF framework for goal-setting, consent, outcome measures recorded at admission and discharge; electronic records under ABDM/Ayushman Bharat Digital Mission in many hospitals.
• Service settings: CGHS and ESIC empanelment, Ayushman Bharat PM-JAY packages include some rehabilitation procedures; telerehabilitation is permitted following the Telemedicine Practice Guidelines (2020) framework adopted by allied professions.

Key points

• Oxygen transport pathway - the reasoning chain (FiO₂ → ventilation → diffusion → Hb → cardiac output → extraction) used to pick the right technique.
• Obstructive vs restrictive - obstruction lowers FEV₁/FVC below 0.70; restriction lowers FVC and TLC with a normal or raised ratio.
• FRC vs closing volume - supine posture and anaesthesia drop FRC, closing dependent airways: the reason for upright positioning.
• ACBT - breathing control + thoracic expansion + forced expiration; first-line, independent airway clearance for adults.
• Huff over cough - open-glottis forced expiration moves secretions without collapsing unstable airways.
• Pursed-lip breathing - adds back-pressure, splints airways, reduces air trapping and dyspnoea in COPD.
• Incentive spirometry - sustained maximal inspiration; volume-type devices preferred; prevents post-operative atelectasis.
• Modified postural drainage - no head-down tilt when there is raised ICP, hypertension, reflux, haemoptysis or cardiac failure.
• Suction limits - under 15 s per pass, 80-150 mmHg, catheter under half the tube's internal diameter.
• Good lung down - in unilateral adult lung disease, lying on the unaffected side improves oxygenation; the opposite is true in infants.
• Prone positioning - improves oxygenation in moderate-to-severe ARDS by recruiting dorsal lung and evening out V/Q.
• Early mobilisation - the strongest single ICU physiotherapy intervention; reduces ICU-acquired weakness, delirium and ventilator days.
• Borg scales - RPE 6-20 (target 11-14 in cardiac rehab) and modified dyspnoea 0-10 (target 3-4 in pulmonary rehab).
• 6MWT - the standard field test; 30 m straight corridor, standardised phrases, MCID about 25-35 m.
• Karvonen method - target HR = resting HR + % × (HR max − resting HR); preferred over percentage of HR max.
• MET - 1 MET = 3.5 mL O₂/kg/min; used to grade activities and plan return to work and sexual activity.
• Sternal precautions - no heavy push/pull/lift for roughly 6-8 weeks after median sternotomy; centre protocols vary.
• Shunt does not correct with oxygen - persistent hypoxaemia on high FiO₂ points to shunt (collapse, consolidation), needing recruitment, not more O₂.

Formulas and examples

Example 1 — Spirometry interpretation. A 58-year-old man, 25 pack-years, post-bronchodilator FEV₁ = 1.44 L (predicted 3.60 L), FVC = 2.70 L (predicted 4.50 L).

• Ratio = 1.44 ÷ 2.70 = 0.533 → below 0.70 → obstructive defect.
• FEV₁% predicted = 1.44 ÷ 3.60 × 100 = 40% → GOLD grade 3 (severe).
• FVC% predicted = 2.70 ÷ 4.50 × 100 = 60% — reduced by air trapping, not restriction (ratio is low).
• Plan: pulmonary rehabilitation, pursed-lip breathing, IMT, energy conservation, exacerbation action plan; airway clearance only if productive.

Example 2 — Ventilation and dead space. Patient A: TV 500 mL at 12/min. Patient B (same 60 kg body weight): TV 250 mL at 24/min. VD = 2.2 × 60 = 132 mL.

• A: V̇E = 0.500 × 12 = 6.0 L/min; V̇A = (500 − 132) × 12 = 4,416 mL/min = 4.42 L/min.
• B: V̇E = 0.250 × 24 = 6.0 L/min; V̇A = (250 − 132) × 24 = 2,832 mL/min = 2.83 L/min.
• Same minute ventilation, but B's alveolar ventilation is 36% lower — rapid shallow breathing wastes ventilation on dead space. Treat by slowing and deepening the breath.

Example 3 — Cardiac rehabilitation target heart rate. 54-year-old post-CABG, resting HR 72/min, on no beta-blocker, prescribed 50-70% heart-rate reserve.

• HRmax = 220 − 54 = 166/min; HR reserve = 166 − 72 = 94/min.
• Lower limit = 72 + 0.50 × 94 = 72 + 47 = 119/min; upper limit = 72 + 0.70 × 94 = 72 + 65.8 = 138/min.
• Prescription: treadmill/corridor walking 5 days/week, 30 min, HR 119-138/min, Borg RPE 11-14, warm-up and cool-down 5-10 min each, plus resistance training 2 days/week at 30-50% 1-RM (observe sternal precautions). If a beta-blocker is added, the age formula is invalid — use a symptom-limited test or RPE.

Example 4 — Oxygenation indices. ICU patient on FiO₂ 0.60, PaO₂ 78 mmHg, PaCO₂ 40 mmHg, Hb 12 g/dL, SaO₂ 0.95.

• P/F = 78 ÷ 0.60 = 130 → moderate ARDS range.
• PAO₂ = 0.60 × (760 − 47) − 40/0.8 = 0.60 × 713 − 50 = 427.8 − 50 = 377.8 mmHg.
• A-a gradient = 377.8 − 78 = 299.8 mmHg — grossly widened → shunt/collapse, not hypoventilation.
• CaO₂ = (1.34 × 12 × 0.95) + (0.003 × 78) = 15.28 + 0.234 = 15.51 mL/100 mL.
• Interpretation: more FiO₂ alone will not fix a shunt — use recruitment (positioning, prone, PEEP, secretion clearance) and treat the collapse.

Example 5 — Weaning index and functional capacity. Spontaneous breathing trial: f = 26/min, TV = 320 mL. 6MWT after rehabilitation: 300 m → 345 m.

• RSBI = 26 ÷ 0.320 = 81.3 → below 105, favourable for weaning (used with secretions, cough strength, haemodynamics, sedation, not alone).
• 6MWT gain = 345 − 300 = 45 m, above the MCID of about 25-35 m → clinically meaningful.
• Estimated walking VO₂ at 345 m in 6 min = 57.5 m/min on the level: VO₂ ≈ 3.5 + 0.1 × 57.5 = 9.25 mL/kg/min ≈ 9.25 ÷ 3.5 = 2.6 METs — enough for light household work, not yet for heavy lifting or stair-heavy labour.

(Normal values: pH 7.35-7.45, PaCO₂ 35-45 mmHg, PaO₂ 80-100 mmHg, HCO₃⁻ 22-26 mmol/L, SaO₂ 95-98%.)

Where it is used

• Tertiary hospital ICUs and HDUs: Apollo, Fortis, Max, Manipal, Narayana Health, AIIMS and medical college hospitals employ ICU physiotherapists for ventilator weaning support, positioning, early mobilisation and tracheostomy care.
• Cardiac surgery and cath-lab programmes: phase I and II cardiac rehabilitation units alongside CABG, valve and PCI services; roles as cardiac rehabilitation physiotherapist or exercise physiologist.
• Pulmonary rehabilitation and respiratory OPDs: COPD, post-TB sequelae, bronchiectasis, ILD and post-COVID clinics; district hospitals and NGO/charitable chest clinics.
• Paediatric and neonatal respiratory care: NICU/PICU support for cystic fibrosis, bronchiolitis and congenital heart surgery (shared with the paediatric note — here, the respiratory technique component).
• Occupational and public health: screening and rehabilitation of dust-exposed workers (stone-crushing, textiles, mining) under the Occupational Safety, Health and Working Conditions Code; corporate wellness and smoking-cessation programmes.
• Home care, telerehabilitation and devices: home-visit chest physiotherapy, portable oxygen and NIV training, sales/clinical-application roles with incentive spirometer, PEP device, NIV and oxygen-concentrator manufacturers, and insurance/CGHS-empanelled rehabilitation services.

Interview questions

• Q: How do you decide between an airway clearance technique and a lung expansion technique? A: By the problem identified on assessment — secretion retention with productive cough and coarse crackles calls for clearance; low volumes, atelectasis and reduced expansion without sputum call for expansion techniques such as incentive spirometry and thoracic expansion exercises.
• Q: Why is a huff preferred to a cough in COPD? A: A huff is a forced expiration with an open glottis, so intrathoracic pressure stays lower and the equal pressure point moves peripherally, clearing secretions without collapsing the already unstable airways.
• Q: When would you not use head-down postural drainage? A: With raised intracranial pressure, uncontrolled hypertension, severe gastro-oesophageal reflux or recent feeding, active haemoptysis, cardiac failure, severe dyspnoea or abdominal distension — use modified positions instead.
• Q: In an adult with unilateral right-lower-lobe consolidation, which side should the patient lie on and why? A: Left side-lying ("good lung down") — perfusion follows gravity to the dependent, better-ventilated lung, improving V/Q matching and oxygenation; in infants the reverse holds because of their compliant chest wall.
• Q: A ventilated patient has PaO₂ 60 mmHg on FiO₂ 0.8. What does that tell you? A: A P/F ratio of 75 with a wide A-a gradient indicates a large shunt from collapse or consolidation; it will not respond to more oxygen alone, so recruitment — positioning, prone, PEEP, secretion clearance — is needed.
• Q: What is RSBI and what is its limitation? A: Rapid shallow breathing index = respiratory rate ÷ tidal volume in litres; below about 105 favours successful weaning, but it must be read with cough strength, secretion load, haemodynamics, sedation and mental state rather than used alone.
• Q: How do you set exercise intensity for a post-MI patient on a beta-blocker? A: The age-based HRmax formula is invalid, so use a symptom-limited exercise test to set the target, or prescribe by Borg RPE 11-14 and the talk test, with HR used only as a relative guide.
• Q: What are the sternal precautions after a median sternotomy? A: Avoid pushing, pulling or lifting more than about 5 kg, single-arm loading and unsupported coughing for roughly six to eight weeks, support the sternum while coughing, and follow the operating centre's protocol as these vary.
• Q: Does pulmonary rehabilitation improve FEV₁? A: Usually not — it improves exercise capacity, dyspnoea, quality of life and admission rates without necessarily altering lung function, because it works on peripheral muscle, efficiency and self-management.
• Q: What is the target SpO₂ for a COPD patient who retains CO₂, and why? A: About 88-92% rather than 94-98%, because high oxygen in a chronic CO₂ retainer can worsen hypercapnia through loss of hypoxic pulmonary vasoconstriction and the Haldane effect.
• Q: When do you stop mobilising an ICU patient? A: If SpO₂ falls below about 88-90%, heart rate goes outside 40-130/min or changes by more than 20%, systolic BP falls below 90 or rises above 180 mmHg, a new arrhythmia or chest pain appears, or the patient becomes agitated or a line/airway is at risk.
• Q: What precautions apply to a sputum-positive tuberculosis patient needing chest physiotherapy? A: Treat in a well-ventilated or negative-pressure area, wear a fitted N95 respirator, schedule the session last, use disposable or disinfected equipment and dispose of waste as per Bio-Medical Waste Management Rules, 2016, following NTEP airborne-infection-control guidance.

Common mistakes

• Calling a reduced FVC "restriction" without checking FEV₁/FVC — air trapping in COPD also lowers FVC.
• Reporting minute ventilation as evidence of adequate ventilation, ignoring dead space and alveolar ventilation.
• Giving incentive spirometry for sputum clearance, or percussion for simple atelectasis — matching the wrong tool to the problem.
• Using the "good lung down" rule for infants, or forgetting that it is reversed in them.
• Raising FiO₂ for shunt-related hypoxaemia instead of recruiting collapsed lung, and giving high-flow oxygen to a CO₂-retaining COPD patient.
• Suctioning too long, with too large a catheter, or without pre-oxygenation — causing desaturation and arrhythmia.
• Using 220 − age targets in patients on beta-blockers or after a transplant, and skipping warm-up, cool-down and contraindication screening before exercise.
• Writing vague goals ("improve breathing") instead of measurable ICF-based goals with outcome measures recorded at admission and discharge.

Related topics

Neurological physiotherapy · Paediatric physiotherapy · Geriatric physiotherapy · Exercise physiology and electrotherapy · Intensive care monitoring and medical emergencies · Community-based rehabilitation and public health.