Breathing Beyond the Lungs - People can't be Silo'd

(A clinical reflection)

Respiratory physiotherapy is rarely just about lungs. Yet our medical systems are set up in silos that have a lot of barriers to effective communication between these specialties. It's the best we have and there are no easy solutions. However, this case looks through the frustrations and delays a silo'd system can cause. 

Case example

C — recurrent hospital admissions approximately every three months.
Admissions alternated between chest infection and mental health, on a background of neuromuscular disorder.

Respiratory status:

• Spontaneously ventilating on room air

• No formal chest physiotherapy routine

• Access to cough assist

Psychological context:

• Insomnia - mixture of psychological and respiratory factors. 

• Anxiety

• Features of mania

Problem list (by system)

Respiratory

• Atypical baseline respiratory pattern due to chronic condition

• Hyperinflation with tendency toward CO₂ retention

Musculoskeletal

• Reduced expiratory muscle strength

• Limited mobility — electric wheelchair dependent

Gastrointestinal

• Constipation

• Abdominal gas trapping contributing to diaphragmatic restriction

Mental health / medication

• Central nervous system depressant medications during mental health admissions

• Increased risk of CO₂ retention on a baseline of hypoventilation

Environmental / functional

• Limited access to hoist or fully accessible rooms in a mental health ward context--> Increased time spent in bed

• Declining dexterity for electric wheelchair control

• Reduced participation in community activity

Clinical reasoning

Due to silo'd systems standard treatments can have less than favourable outcomes for those in unique and complex circumstances. 

Hyperinflation, reduced expiratory force, abdominal loading, and CNS depressant medication created a situation where CO₂ and mucous clearance was consistently challenged — particularly during periods of reduced mobility and sleep disruption. These factors reduced ventilation and increased risk of chest infection seen in the 'ping pong' of admissions between silos. 

Treatment approach

• Establishment of a regular chest physiotherapy routine

  • Expiratory vibrations

  • Cough assist use

• Teaching accessible expiratory strategies:

  • Pursed-lip exhalation

  • Humming (to prolong exhale and support pressure regulation)

• Communication with the mental health treating team:

  • Letter recommending trial of ?BiPAP during admissions where increased CNS depressant medication was required, to support CO₂ clearance on a system that is persistently challenged at baseline.

Reflection

This case reinforced the importance of generalists and experts in a system that favours experts. We need teams that value bridges between silos. This may aid in more effective, comprehensive and timely care for complex people in siloed systems. I like breathing because it in itself is a bridge between mind and body. Between physical and mental health. It provides a broader lens for cases such as these. 

Summary

Breathing was shaped by:

• Muscle capacity

• Abdominal mechanics

• Medication effects

• Sleep

• Psychological state

• Environment and access