Ep 2: The Trifecta

[00:00:00] Welcome to Talking All Things Cardiopulm. I am your host, Dr. Rachele Burriesci, physical therapist and board certified Cardiopulmonary clinical specialist. This podcast is designed to discuss heart and lung conditions, treatment interventions, research, current trends, expert opinions, and patient experiences.

The goal is to learn, inspire, and bring cardio palm to the forefront of conversation. Thanks for joining me today, and let's get after it.

Hello, hello and welcome to episode two of Talking All Things Cardiopulm. I am your host, Rachele Burriesci. So today we're gonna call episode two, the Trifecta, and we're calling it the trifecta because there are three main components that I feel should be a part of every cardiopulmonary session. And I'm really [00:01:00] saying this across the board in a very generic sort of, There are three components that if included in your session, will maximize your patient's benefit, and pretty much this is a blanket statement to go across most cardiac and lung conditions, period.

I don't think there's one condition diagnosis that I would say, oh no, don't take this approach. Honestly, most of research in. Multiple diagnoses in the cardio home world support the trifecta, and it's something that I found that when I included with my patient population, whether it's in the icu, in the acute care setting, virtually on telehealth in the outpatient world, patients do better.

So what is the trifecta? It truly is the basics. Breathing, aerobic, training, and [00:02:00] strengthening. I'm gonna say it again. Breathing, aerobic training and strengthening are the three main components that should be included in every cardio palm session. And when you coordinate and prioritize those three components, your patients will do well.

So let's talk about it. I'm not gonna be able to tell you exactly how. To progress for every single patient, but we're gonna try to at least explain why this is so paramount. So let's start with breathing. It is a vital aspect of life. You physically cannot do anything else. If you cannot breathe, you require breathing to do any form of activity, of daily living, walking, strength, exercise.

Being alive. You have to be able to breathe and when [00:03:00] there are inefficiencies in your breathing, in your oxygenation, in your gas exchange, in your ventilatory pump, all words that are really nice to throw into your assessment or PT diagnosis, your patient is going to have more difficulty with aerobic training, strengthening everything.

So it's really important, first of all, that you are assessing breath, doing a chest exam, looking at diaphragm activation, chest wall mobility, osculating your patient, even just recognizing if your patient is on oxygen or not, and then checking respiratory rate and SPO two and what that looks like at rest.

Sometimes you might be surprised in either direction. It's super important to have a base and have an understanding of your patient's current status. In order to know what breathing [00:04:00] exercises to truly tackle, depending on what diagnosis that patient has, there is likely a breathing exercise that will suit them best.

But we're gonna keep this pretty generic today because honestly, we're gonna be talking about breathing for who knows how many episodes. It is so important that we understand that most people have some sort of breathing in efficiency or diaphragm weakness, and when you have a breathing in inefficiency and or weakness of the diaphragm, everything else is going to struggle.

Your body's goal is to stay alive, period. So first things first. See if that diaphragm can activate and then get it to activate more efficiently and then activate in different P positions. It's important that we are encouraging the patient to breathe appropriately, to think about their breathing and to incorporate it into [00:05:00] their session in some way, shape, or.

Okay. Breathing has so much benefit. We can talk about the cardiovascular benefit and the fact that it helps increase preload with a change in pressure. As we breathe, we can talk about how. diaphragmatic control and breathing control with exercising is super important, and even in the balance world to create stability.

At the core. There are so many aspects of breath control that we can touch upon and, and give its rationales to why we should be encouraging it, performing it, and incorporating it into any session. It also helps with lymph movement. It's going to help improve oxygenation at the avio line, at the Avilar capillary interface where it all starts, right?

If we're having an issue of getting oxygen across into the blood, we don't have oxygen available in the [00:06:00] blood, then it's gonna be hard. To utilize the oxygen at the tissue level. So if we can maximize breath control, chest wall mobility, gas exchange at the start, aerobic training, strengthening will be much more efficient.

So, Breathing is super important to incorporate, and we can talk about what types of breathing exercises we would do for each type of D, whether you had fluid at the aviola. Maybe we're gonna lean more towards the inspiratory hold. Maybe your patient is post surgery and has a thoracic incision, then maybe we're gonna be push pushing, stacked breath.

maybe your patient has emphysema and their primary problem is getting the air out. Well, then we're gonna encourage per lip breathing, even if there isn't pathology involved. Breathing control, breathing, efficiency, breath strengthening, [00:07:00] diaphragmatic strengthening. hold so much weight. There is improvement in peak VO two, improvement in a maximum inspiratory pressure and expiratory pressure.

Um, decrease sympathetic input, increase vagal tone. So many ways that breathing can affect the whole system. It should be incorporated. Period. And honestly, I would say across the board, we should be encouraging our patients to at least start to recognize their breath. Because especially older generations who maybe didn't grow up with, um, exercise training and yoga and breathing and Pilates and all of these things that are like commonplace now, they didn't have that.

They didn't have that encouragement or even the. of breath control. So no matter what age your patient is at breathing has benefit. [00:08:00] And if you actually have a pathology related to the cardiac or pulmonary system, we have to be encouraging breathing, period. I can talk about breathing exercises and all the benefits for hours, but I wanna get to the second component and that is aerobic.

Aerobic training is gonna look different across the spectrum. It's gonna look different pending what setting you're in. It's gonna look different even within one setting. For instance, you're in the acute care setting. We can have a patient in the icu and we might have a patient out on the floors. The aerobic training that is gonna be involved in those two different patients on those two separate floors is going to look different.

It might look different from patient embed A and patient. B in ICU as well. You have to meet your patient where they're at, and regardless if we're starting at a super low [00:09:00] level in the ICU or at a on a regular floor in the acute care setting, or your patients in cardiac outpatient phase two rehab, there is benefit to encouraging aerobic.

So much research around, um, incorporating aerobic training and improving heart rate recovery, improving resting heart rate, improving resting systolic and diastolic blood pressure, improving autonomic nervous system control, improve quality of life and, and exertion, the ability to actually do. But in order to perform aerobic training, there is a very key word that we need to think about aerobic, which means we need oxygen to perform, said work.

And if we don't have oxygen as a priority with breathing, aerobic training is gonna be [00:10:00] much more difficult. So aerobic training can look like using a peddler in the supine position. In intervals of 30 seconds, five seconds, 10 seconds, two minutes, five minutes, whatever it is. That is aerobic training. And what I wanna kind of just say out, uh, right at the start is interval training is where it's at.

Interval training is the key to unlocking aerobic conditioning. Regardless of your setting, you have to start in a sequence that's gonna actually allow for an appropriate vital sign. We shouldn't be tanking every time we perform activity. When we have an inappropriate blood pressure response, it should tell us something.

So when we are exercising, the goal is to have our vital signs moving in the correct direction. If I was to assess heart rate or blood pressure with activity, it should respond appropriately to. met level that I'm [00:11:00] performing. So for every one met level of activity, my heart rate should increase about 10 to 12 beats per minute.

For every one met level of activity, my systolic blood pressure should increase somewhere between eight and 12 millimeters of mercury per met. If my blood pressure is not moving and staying flat, we call that a blunted response, and that could be for many reasons. It could be the activity isn't hard enough.

It could be because a person's on beta blockers, or it could be because the patient's capacity is not up to par, are if the patient's blood pressure, heart rate. Drop with activity, that's a sign of failure. So the goal is never to push your patient into failure because all you're doing is training in failure, failure, and you're basically just sucking up your reserve.

It's gonna take longer to recover, it's gonna put the patient at higher risk for [00:12:00] potentially switching into an arrhythmia. It's not training. The body for success, right? I, I tell all my students, all my patients, we have to set you up for success. And in order to do that, you need to be looking at the response.

This is where the skill comes in. When you are performing aerobic training with your patient, whether it's in the ICU or on the floors in the hospital, you should be assessing blood pressure, heart rate, SPO two. Two set activity. If you're not, then you don't truly know. If your patient is responding appropriately, they might feel okay.

They might be asymptomatic, but are they truly getting an appropriate response? You don't know unless you check, so I really encourage that if you're incorporating aerobic training, that you're taking that neck. Step and assessing the response because the goal is to train in a good response. So if I'm in the ICU [00:13:00] and my patient can use the peddler for 30 seconds and they have an appropriate response, great.

Stop, rest. Do it again. Repeat response. It's good. Do it again. It's too easy. We're looking at rpe. We're looking at the response as not quite 10 beats per. Well, maybe you can actually up that interval, but I highly recommend that you increase the number of intervals before you increase the time in your interval and make sure that you're truly getting an appropriate response.

And I'm not gonna lie, this can be very boring for your patients, especially if you're at those really lower. Patients with heart failure in the hospital setting might only be able to tolerate 10 feet. Well, if they have a good response at 10 feet and they can handle 10 feet, 10 feet rest, do it again. 10 feet rest.

Do it again. You do that 5, [00:14:00] 6, 7, maybe even 10. Now you're at a hundred. You're not just walking 10 feet, you're walking 50 feet. Pay attention to time and distance. You can use either as a way to gauge how far, how long your patient went, but I highly encourage you to pay attention to the response because as you start improving, that response is going to get better.

If you have, um, an extraordinarily increased response. We call that e. , an exaggerated response. Very common in patients who are deconditioned to have an exaggerated response with exercise. So I'm gonna stay in the acute care setting just for a second. And I just wanna kind of bring another piece to this puzzle of the trifecta.

If your patient is in the hospital setting, they are likely. In a bedrest position, and I'm gonna say that really loosely because those, that term itself is [00:15:00] just wildly misconstrued. In healthcare, the word bedrest technically means from an order perspective that the patient cannot get up, that it would be against medical advice to get up.

What I'm saying is that when a patient is in the hospital, they're in the. So they're gonna have effects of bedrest just from being in the hospital, not being on a order that says I cannot get up. There is a article written in like 2017 that actually said that patients spend 90% of their awake hours in bed during a hospital stay, even if they're independent with walking.

We know this. If you work in the hospital setting, you know your patient is in. Maybe sitting for prolonged periods of time. The amount, the amount of bouts of walking that is actually occurring is minimal. So you can expect just from being in the hospital, not even saying the patient's in the icu, not even saying that the patient is [00:16:00] sedated and on event and like literally on bedrest, I am just saying your patient is in the hospital period.

They're gonna start showing effects of bedrest and. That looks pretty profound in the cardiovascular system. In the muscle system, a little bit with skeletal, and you're also gonna see changes with breathing. So what does that actually mirror? That trifecta. So when you're just in bed, even if you put a healthy person in bed and they're on bedrest for a period of.

they're gonna have a decrease in their VO two max, decrease in their cardiac output, decrease in oxygen delivery, and capitalization at the muscle itself. You become inefficient, so you can really extrapolate that if you're a deconditioned and you know, household ambulator. You're probably experiencing a good number of these effects as well.

From a muscle [00:17:00] perspective. You literally start to atrophy. You lose size of your muscle, you lose efficiency of your muscle. You lose peripheral oxygenation at that tissue. The ability to actually obtain the oxygen that's available is decreas. Significant effects heart rate, resting heart rate increases just from being in a bedrest position.

So your resting rate becomes higher because you actually have decreased vagal tone. So going back to breathing, breathing helps increase vagal tone and decrease sympathetic input. So breathing can actually affect the vital sign response that you get. Being on bedrest or being deconditioned, or even just looking at changes that occur with aging.

So breathing aerobic training are two main components that should be included with your patients that have cardiac and pulmonary conditions. [00:18:00] The benefits are profound. Lastly, we have strengthen. And I really don't say that breathing is first, aerobic is second, strengthening is third. I really probably say breathing is first, and then aerobic and strengthening sort of happen together.

What I am saying is that they both should happen. It's not one or the other. And again, strengthening is gonna look different depending on your patient's functional level. So again, if we're in the ICU setting, that might be as significant. Moving your extremities through their range of motion against gravity versus someone who's maybe on general floors are functional, able to sit to stand, able to move their limbs against gravity, but are deconditioned, weakened, et cetera, versus your patient in the outpatient setting who probably [00:19:00] has four outta five strength is a community amator, but lacks.

Overall strength and conditioning. When we incorporate strength into the routine, we're gonna increase strength, size of muscle cross-sectional area, but we're also gonna improve. The cellular level, we're gonna become more efficient and actually be able to recruit more motor units. Motor units. So it's gonna be easier to perform set activity.

We're going to improve capillary density. This is huge. This is huge for so many patients with cardiac and pulmonary dysfunction. If we improve capillary density, then we're gonna have increased blood flow to the. We have increased blood flow to the tissue, we're gonna have increased oxygen available for that tissue to do work.

It's super important that we understand that this isn't one or the other. This is becoming more efficient in the three [00:20:00] most basic aspects of life. If you can't breathe, you can't function, you can't walk, you can't do daily stuff. If you lack aerobic conditioning, aerobic capacity. Likely you're symptomatic patients likely disc mic, maybe they get dizzy, maybe they have orthostatic hypotension, whatever their issue is, you have to start somewhere.

And if you start to incorporate purposeful aerobic training, they're going to be able to improve their aerobic capacity, and that might look like improve exertional dyspnea. They might be able to go further, longer, faster. Without getting shorter breath. If the patient starts working on strengthening and we're improving blood flow to the muscle tissue or improving strength, we're improving the ability to physically get up out of a chair.

That functional strength is important. They usually go hand in hand. If a patient becomes [00:21:00] atrophied, sedentary, they have decreased cross-sectional area. week overall. Maybe they had an inpatient admission, was on bedrest for a period of time. Well, they're probably doing less, and if they're not able to do a sit to stand independently, well they're not gonna be walking by themself.

So then their aerobic function follows behind. So they typical. Decondition together and they can improve together and I highly recommend that you don't get too hung up on. While I'm really working on strength and I'm really working on aerobic training, do it all. There's enough time breathing, aerobic training.

Strengthening is the trifecta that's gonna take that patient to the next level. All of the things that we do with breathing training, aerobic training, strength training is going to improve efficiency of oxygen delivery, efficiency of oxygen [00:22:00] use, improve blood flow, improve preload, improved overall quality of life for your patient when you start to inc.

These, these three things, you're gonna start to see change. And I really wanna reiterate that when you're including breathing, aerobic and strength training into your session, you're starting where your patient is at. It doesn't mean it's not cookie cutter, right? Like it can't be, everyone's different.

Even my patients in the ICU are different, like I said before, but you're meeting your patient where they're at, and you go from there. If. Breathing exercises without resistance is easy for your patient. Well, then it's time to add resistance. And quite frankly, the research that's, that supports resistance.

Um, breathing training is profound. Again, it affects every system, heart, lung, peripheral strength. It's super important to [00:23:00] encourage good control. The body is always going to choose being. Versus anything else. If your diaphragm is weakened, if it's fatigued and it feels like it's going to quit, there is a reflex that will occur that basically vaso constricts everything in the skeletal muscles periphery to stop sending blood flow to the legs, to their arms, whatever you're physically.

and shunt that blood to the diaphragm because it's gotta keep you alive. So it's super important that you are working on efficiency of breathing so that you can actually train aerobically, that you can actually string train. You don't want to be pushing into depletion every single time. You don't wanna be pulling from the reserve.

You wanna be doing this systematically. You wanna understand what is my patient's max heart. And you can do that with the simple two [00:24:00] 20 minus age, and then take a percent of that. You can look at heart rate reserve. You can use R P E, but use an intensity that makes sense and use an intensity that is going to have an appropriate response to whatever your patient is doing.

And the last component is strengthening. Strengthening is so important, especially just for the functionality of life. Being able to move your body against gravity at its simplest form, moving your extremities against gravity, performing a sit to stand, the most basic of strengthening is needed to perform.

Activities of daily living have a quality of. And quite frankly, if we lose strength and become de deconditioned and have atrophy, then we tend to be doing a less aerobic training as well. And so they tend to. Decondition together, one will affect the other. But we know strengthening has so much benefit to multiple [00:25:00] aspects.

Obviously the strength component, the ability to increase muscle size, the increase in skeletal muscle oxygenation that occurs when we perform strength training. We increase capillary density, which is so important to. Blood flow, oxygen to the tissue, but also to remove waste. It's more efficient. Um, strengthening helps with the efficiency at the cellular level.

As we atrophy, we lose the, the motor unit capacity. We have, we need more motor units to perform the same level of work. They become inefficient and so strengthening, the first thing that happens before size improvement is actually neural efficiency. And if it becomes more, Efficient or easier to perform, it becomes less work.

So everything kind of works hand in. But strengthening has to be a component and it's going to help a number of cardiac and lung conditions. [00:26:00] One specific diagnosis that's sticking out in my mind right now is the peripheral arterial disease. Patient needs to be performing, strengthening. We need to encourage increased capillary density, improvement of efficiency.

That is how they start to. Their capacity, their pain tolerance, their threshold, all of that. So strengthening has such benefit, even for, um, vital sign response, the improvement in blood pressure and heart rate as well, which strengthening is profound. . My recommendation is start with big muscle groups.

Start with function. Start somewhere. It just depends on your person. I literally perform breathing, aerobic training, and strengthening with almost every single patient I see. Even in the acute care setting, even in the icu, what does it look like? Very different from my patient and outpatient. Meet your patient where they're [00:27:00] at, maximize their ability, give them the tools to progress.

I get a lot of flack maybe for doing Bed exceeded their X standing their X with my patients in the hospital setting. I get asked a lot like, do you think that's really helping? And I'll be super clear if I'm doing bed, bed thx, it looks like ankle pumps and quad sets and short a quads and long a quad. Um, straight leg raises and heel slides.

Yeah, that looks super basic and simple. And. Here's what I have to say. Don't poo poo it, because if it's difficult for your patient to perform, that patient is going to improve from performing it. And now you gave 'em a tool, you gave 'em a home exercise program that they may perform on their own time, and then you're gonna have extra.

Benefit if they're capable of sitting, then I'm gonna throw in [00:28:00] seated exercises. And quite frankly, I do it as a strengthening plus a warmup to then get to the aerobic side of things. And the other piece I wanted to just touch on, and I think this is gonna be its own episode at some point, cuz it's a constant conversation, is what aerobic training looks like in the hospital setting. It's primarily ambulation. I tend to use a peddler with my patients in the icu. I tend to bring it with my patients with heart failure, but it doesn't happen with every patient. I have to plan for it. But walking is easy, right? In the sense that you don't need equipment, you have plenty of space to do it, and you're gonna get good functional outcome, which is so important.

So I am not downplaying ambulation or walking what I am gonna say. Words matter and how you say something and how you approach something in your care matters. Even for our [00:29:00] profession, walking is important. It is functional. We have things like gate speed that determine discharge, location, use those words.

It holds more weight. It is more profound and makes sure that when you are performing walking, Or ambulation, which I would prefer to say that you're doing in a way that it's skilled if you are ambulating a good distance, that you're doing it to improve aerobic capacity, that you are assessing vital sign response, pre and post, and maybe even during that, you're looking for that increase in heart rate, increase in blood pressure, and making sure that you're not having a greater than 4% drop in your SPO two, an appropriate vital sign response is, pacing with activity and ambulation and stair training is functional and important and valuable for that patient, and it's [00:30:00] skilled.

So it's super important that when you incorporate these things that you think about how you present it to the patient, to the other staff members. , how you say things matter. If you're performing strengthening, and you're performing bed xx, and you poo poo it like it means nothing. Well, guess what? The patient's gonna think.

It's not important when in fact it has good benefit. If that patient can go from not moving their legs against gravity to moving their legs against gravity, well then they're ready for that next progression. Whether. Another set or increasing resistance or changing position or performing in, in a more functional way.

That's the progression. The whole point is to improve from the original base, and you're gonna do that when you incorporate. Purposeful breathing exercises, aerobic training and strengthening, and [00:31:00] each piece, each component has to start from where your patient begins. You can't jump three steps forward when they haven't been able to do the prior steps, right?

Like I can't be doing resistance bands if I can't move against gravity. I can't be putting weight on my squats if I can't do a sit to. We know this, but sometimes I feel like it needs to be articulated. And more importantly, I really need to emphasize that we have to be looking at the patient's response to set activity, because that's really where the skill lies, and that's how you know your patient is improving.

And that's what we should be documenting when we're writing up our assessment. So breathing can be progressed from diaphragm activation. To resistance training, aerobic training can be progressed. I recommend utilizing interval training with appropriate vital sign [00:32:00] response and progress strengthening against gravity and progress to resistance to function.

Think big muscle groups, think functional activity and make it count. We truly have so many tools that we can use to help our patients get. . Honestly, sometimes going back to the basics and thinking about the why is the most important part or the most efficient way to improve your patient's outcome.

Don't be afraid of the basics. They're there for a reason. They work. So my parting words to you are, if you are treating patients that have cardiac or lung disorders, start to incorporate the trife. Breathing, aerobic training and strengthening, and honestly, let me know how it goes. I 100% stand behind the trifecta.

I've used it with my patients. I've seen the [00:33:00] benefits. I know it works. So hopefully that was helpful. If you have any questions, please reach out. I always look forward to hearing from you. Um, best way to reach me is either on Instagram through the dms or shoot me a text 9 1 3 3 0 8 4 4 9 4. I hope you all have a wonderful day and whatever you have to do, get after it.