Comprehensive Physiotherapy Approach for Pneumonia After Angioplasty in an 83-Year-Old Hypertensive Male Patient: A Case Report

Abstract

Pneumonia is an infection that causes inflammation in the air sacs of the lungs. Coronary artery disease is a condition characterized by the buildup of plaque in the coronary arteries, which supply blood to the heart. This obstruction restricts blood flow, resulting in chest pain (angina) and, in extreme cases, heart attacks. An important part of successfully treating diseases like peripheral artery disease and coronary artery disease is balloon angioplasty, a commonly used medical procedure for treating narrowed or clogged arteries. An 83-year-old man who had pneumonia after angioplasty was the subject of this case study. The patient had pneumonia after angioplasty, which was managed by proper medications and cardio-respiratory physiotherapy. The patient was intubated and referred for cardio-respiratory physiotherapy. Physiotherapy treatments like mild chest vibrations, suctioning, and bed mobility exercises were given initially. After extubation, physiotherapy treatment continued with deep breathing exercises, coughing techniques, relaxation techniques, and mobility exercises for the upper limbs and lower limbs. Effective physical rehabilitation was necessary in order to minimize complications following angioplasty and allow him to resume his daily activities. Several outcome measures, like the ICU mobility scale, CURB-65 score, and chest X-ray grading scores, were used to monitor the patient's progress during rehabilitation. The benefits of pulmonary rehabilitation programs emphasize the need for tailored approaches in addressing individual patient needs for comprehensive recovery.

Introduction

Pneumonia is a common acute respiratory infection that affects the lung's alveoli and distant airways. It can cause serious illness and death in all age groups, both in the short and long term. The inflammation of one or both lungs, frequently brought on by bacterial, viral, or fungal invaders, is what distinguishes it. Community-acquired pneumonia and hospital-acquired pneumonia, which include ventilation-associated pneumonia, are the two main categories into which the illness falls [1]. As a subtype of ICU-acquired pneumonia, ventilator-associated pneumonia (VAP) is characterized by infection of the pulmonary parenchyma in patients subjected to invasive mechanical ventilation for at least 48 hours. When a patient needs invasive mechanical ventilation, one of the most frequent infections is still VAP. Bacteria, viruses, or fungi can bring on lung infections such as pneumonia. It is characterized by inflammation of the air sacs in the lungs, causing symptoms like coughing, breathing problems, and chest pain [2].

Coronary artery disease (CAD) is an artery disease where a buildup of cholesterol and other fats causes the coronary arteries to narrow or become obstructed. This may impede the heart's ability to receive blood, which could lead to potentially fatal consequences like heart attacks and chest pain [3]. When community-acquired pneumonia was present, cardiovascular problems affected 2.1% of outpatients and 26.7% of inpatients [4].

Balloon angioplasty, a widely used medical technique for treating constricted or obstructed arteries, is critical in effectively managing conditions such as coronary artery disease and peripheral artery disease. When performing this procedure on older adults, while performing this procedure in the elderly population that is 65 years old and above, it is critical to carefully assess their unique health needs and potential obstacles [5]. Balloon angioplasty in geriatric patients necessitates a cautious and personalized approach. Because of the high prevalence of other health conditions in this population, it is critical to conduct a thorough assessment of conditions such as diabetes, hypertension, and renal impairment prior to the procedure in order to manage them effectively. The selection of an appropriate site for vascular access, often using the radial or femoral approach, is critical because it accounts for potential difficulties related to vessel size and calcification. Proper medication management, including anticoagulant and anti-platelet therapy adjustments, is critical in balancing the risk of bleeding and clotting [6].

Cardio-respiratory physiotherapy is a method that aims to improve a patient's respiratory status and hasten their recovery by teaching cough and breathing techniques, using manual vibrations on the chest wall, improving airway clearance in lung diseases associated with reduced airway resistance, and improving patient positioning [7]. Though its application of manual chest clearance techniques varies, evidence-based practice consistently encourages early mobilization [8]. The physiotherapy protocol included deep breathing exercises, incentive spirometry, and mobilization techniques and exercises. It has been demonstrated that the recommended exercises increase strength, mobility, range of motion, and fitness [9].

We are presenting a case of an 83-year-old hypertensive male who has undergone angioplasty, requiring efficient physical rehabilitation to speed up recovery by preventing or resolving post-respiratory and cardiovascular complications and providing physical rehabilitation to restore their functional ability. Key outcome measures include the ICU mobility scale, CURB-65 score, and chest X-ray grading scores.

Case presentation

An 83-year-old male hypertensive patient resident of Sawangi visited the emergency care department with a complaint of cough with whitish expectoration, shortness of breath which was slow onset and continuous throughout the day, continuous low-grade fever, and chest pain for 15 days. He also gave a history of identical concerns experienced 17 years ago on 21st May 2006; he visited a government hospital (Nagpur), where he was suggested diagnostic tests like 2D-echo and color Doppler and diagnosed as left anterior descending artery blockage and managed conservatively. The patient experienced the same symptoms on 14th October, for which he was suggested diagnostic tests like 2D-echocardiogram, radiography, arterial blood gas, and routing tests (liver function test, kidney function test, and complete blood count). 2D-echocardiogram revealed that the left ventricular ejection fraction is 60% and grade I mild concentric left ventricular mass. Thorax radiography showed homogeneous opacity on the left middle and lower lung fields. Arterial blood gas showed fully compensated respiratory alkalosis. He underwent balloon angioplasty of the left anterior descending artery on 15th October 2023. He shifted to the medicine intensive care unit and was diagnosed with pneumonia and referred for cardio-respiratory physiotherapy. Timeline with events mentioned in Table 1.

Clinical finding

For clinical examination, patient consent was taken. Clinical findings are mentioned in Table 2.

Diagnostic assessment

2D-echocardiogram revealed that the left ventricular ejection fraction is 60% and grade I mild concentric left ventricular mass. Coronary angiography revealed left anterior descending coronary artery blockage is shown in Figure 1. Thorax radiography showed homogeneous opacity on the left middle and lower lung field. The thorax radiological findings are mentioned in Figure 2. Complete blood count reduced hemoglobin (11%), and the total erythrocyte count was 3.75 million cells per microliter. Kidney function test-creatinine: 2.1 milligrams/deciliter; liver function test-alanine 152 international units per liter. Random blood 166 milligrams/deciliter. Arterial blood gas on day one, the arterial blood gas report showed fully compensated respiratory alkalosis, and after week two, the arterial blood gas report showed normal findings.

Post-angioplasty medications

Table 3 shows the pharmacological management of the patient.

Therapeutic interventions

Counseling and education for both patients and caregivers to lower the risk of integumentary complications following surgery, to reduce post-operative respiratory and circulatory systems, to improve bed mobility and prevent prolonged immobility, to promote airway clearance and alleviate dyspnea, to increase lung volumes and capacities, to avoid stiffness in the joints and maintain their mobility and structural integrity, and to get back to routine activity of daily living (ADLs).

Physiotherapy management

Table 4 shows physiotherapy management from day one to day three. The patient was intubated via an endotracheal tube.

Table 5 shows physiotherapy management from day three to week one. The patient was on nasal prongs.

Table 6 shows physiotherapy management from week one to week two. The patient was on room ventilation. Figure 3 shows Jacobson's relaxation techniques; Figure 4 shows dynamic quadriceps exercises; and Figure 5 shows thoracic expansion. All the exercises are performed by the patient, as mentioned in the figure.

Outcome measures

ICU mobility scale [10], CURB-65 score for pneumonia severity [11], and X-ray grading scores [12] were used to assess patient progression. Tables 7, 8 show the outcome measures of the patient. In the inpatient department, every week, follow-up was taken to monitor the patient's condition. After discharge, the patient continued exercising at home and came back after two weeks for follow-up. Figures 2, 6, 7 show the X-ray, which is mentioned in Table 8.

Discussion

A patient developed pneumonia after angioplasty, managed with proper medications and cardio-respiratory physiotherapy. The patient was intubated and referred for physical rehabilitation to minimize complications and resume daily activity. Intubated adults with pneumonia who are on mechanical ventilation may benefit from respiratory physiotherapy. Chest physiotherapy includes chest vibrations and suctioning initially [13-15]. Pattanshetty et al. proposed that chest physiotherapy is widely accepted as a beneficial adjuvant for airway clearance in mechanically ventilated patients with pneumonia or relapsing lung atelectasis, using body positioning, manual chest manipulation (vibration), and suctioning [14]. Achttien et al. suggest that patients' awareness of deep breathing and coughing exercises can prevent surgical complications, potentially leading to improved outcomes like reduced atelectasis and pneumonia [16]. Sadeghimoghaddam et al. suggest that relaxation and prayer therapy interventions can be beneficial for health in promoting hope and reducing anxiety in patients with CAD or pneumonia [17].

Moreover, physiotherapy protocol, which includes deep breathing exercises, incentive spirometry, and mobilization techniques, has been proven to enhance strength, mobility, range of motion, and fitness [18]. Monisha et al. suggest that active breathing techniques can improve coughing efficiency, clear secretions, and enhance ventilation by incorporating breathing exercises [19]. According to Kachpile et al., ICU mobility scores show a steady rise in mobility, indicating the effectiveness of physiotherapy interventions in improving patients' mobility. This improvement may be attributed to factors like physiotherapy, medical management, and the patient's response to treatment. Regular monitoring and adjustments to the physiotherapy plan may be necessary for ongoing rehabilitation [20]. So, we used this scale for ICU mobility scores to evaluate elderly patients' progress. The case report aims to expedite patient recovery by treating cardiovascular and respiratory complications. The patient took a two-week physical therapy program and continued the protocol up to four weeks, which significantly enhanced their condition, and they resumed daily activity.

Conclusions

A case report highlighted the importance of a comprehensive physiotherapy approach in managing pneumonia after angioplasty in an elderly hypertensive patient. The physiotherapy approach was mainly focused on respiratory, circulatory, and psychological aspects and relaxation in relation to optimizing patient recovery. The majority of therapeutic objectives were met after two weeks of intensive physical therapy and continued up to four weeks. Significant improvements in the ICU mobility scale, CURB-65 score, and X-ray grading scores were also observed. A study emphasized the benefits of pulmonary rehabilitation programs to ensure an adequate and early recovery in a patient.