Case Study using ICF : Interstitial Lung Disease

Original Editor - Sonal Joshi Top Contributors - Sonal Joshi and Lucinda hampton

Original Editor -

Top Contributors -

Abstract[edit | edit source]

This article will cover a case study of Mr. J, who has been recently diagnosed with Interstitial Lung Disease (ILD). He has been recommended physiotherapy for the same. The article follows the journey of the physiotherapist assessing Mr. J using ICF format.

Please note the below case study is imaginary but inspired from actual ILD patients. Therefore, it may not include all symptoms or signs of the disease condition. Do keep in mind that the patient assessment findings will vary slightly from patient to patient, changing the treatment protocol accordingly.

Client Characteristics[edit | edit source]

A 65-year-old male, Mr. J has complaints of progressive dyspnea with non-productive cough (intermittently) since 3-4 years. He is advised long term oxygen therapy (LTOT) but uses it only SOS. He lives on the first floor with his wife. His building has no lift. His Rate of Perceived Exertion is upto 2 (Modified Borg RPE Scale) on activities of moderate exertion. His HRCT shows ground glass appearance in basal region, along with honeycomb appearance and signet ring sign in middle and lower zones Bilaterally (B/L). He recently had an episode of dyspnea for which he required oxygen therapy but no hospital admission was done. On auscultation he presents with inspiratory crepitations, end expiratory crackles with wheezing sometimes and reduced breath sounds in the lower zone B/L. He is easily fatigued on housework (30 on fatigue assessment scale[1]) and is unable to stand for a long time. He used to work in a spice manufacturing unit for 25 years and later was a chef for many years before he retired. He would like to resume cooking again at least at home as he enjoys it.

Examination Findings[edit | edit source]

It consists of Mr.J's history(H/O), investigations and objective examination. This will primarily focus on respiratory assessment along with other systems.

History[edit | edit source]

Mr. J has a history of,

  • Working in a spice manufacturing unit and as a chef for more than 25 years.
  • Smoking for 7 years, with consumption of about 1 pack per day (approx. 20 cigarettes per day)and has quit 4 years ago.
  • Non-productive cough since 3-4 years
  • Breathlessness on moderate exertion (RPE –2 on Mod. Borg scale)
  • Fatigue (Score of 30 on Fatigue Assessment scale)

Investigations[edit | edit source]

HRCT[edit | edit source]

This high resolution CT (HRCT) helps us understand the diagnosis of ILD, areas of lung involved[2] and is also an outcome measure post physiotherapy treatment.

  • Ground glass appearance in basal region B/L
  • Honeycomb appearance and signet ring sign seen in middle and lower zones B/L

Spirometry[edit | edit source]

Spirometry is the gold standard tool which can be used in the patients for diagnostic, prognostic and treatment monitoring.

  • FEV1/FVC is increased
  • FVC is reduced
  • Signs of restrictive pathology[3]

Objective Examination[edit | edit source]

On Inspection[edit | edit source]

Mr. J was assessed in standing and sitting position. He was found to have,

On Palpation[edit | edit source]

Mr. J assessed in standing position had,

  • Chest expansion
    • Supramammary-0.5 cm
    • Mammary-0 cm
    • Inframammary -0 cm
  • Manual muscle testing
    • B/L lower limb- Gr. 4-
    • Core unable to test as patient getting breathless
    • B/L Upper limb –within normal limit

On Percussion[edit | edit source]

  • Percussion was impaired
  • Reduced resonance was found in lower zones B/L

On Auscultation[edit | edit source]

  • Diminished breath sounds B/L lower zone; more reduced in posterior than anterior region in lower zone
  • Inspiratory crepitation in lower and middle zone
  • End expiratory crackles with wheezing in Lower zone
  • Tactile vocal resonance diminished B/L lower zones

Six Minute Walk Test[edit | edit source]

In order to improve exercise capacity in Mr. J, we need to assess it using a sub-maximal exercise test such as six minute walk test.

The results after patient assessment were as follows,

  • Distance achieved is 320 m with 1 stop of 30 sec due to excessive shortness of breath and desaturation below 88 %
  • Mr. J also used 1 lit. oxygen via nasal prongs during the 6MWT as per consultation with the pulmonologist
  • Ideal for Indian Male: 505.2 m[4]

Summarizing Assessment using ICF[edit | edit source]

Structural and Functional Impairments[5][edit | edit source]

Sr.No. Structural & Functional Impairement Clinical Reasoning

(due to)

Correlate on Examination
1. Non productive Cough Due to chronic airway irritation and fibrosis From H/O indicating chief complaints and smoking for 7 years
2. Ground glass appearance Due to extensive fibrosis and peripheral tissue damage On HRCT
3. Signet ring sign Due to changes of bronchiectasis On HRCT
4. Honeycomb appearance Destruction of alveoli and peripheral airways On HRCT
5. Bronchial wall thickening due to inflammation of airway and presence of irritants From H/O of smoking and from working in spice factory
6. Reduced chest expansion due to lack of proper elastic recoil of lung On inspection and palpation
7. Impaired percussion with reduced resonance in lower zones B/L Extensive tissue damage seen on HRCT On palpation
8. Diminished breath sounds with crepitation present with wheezing Due to bronchiectatic changes with airway inflammation On auscultation
9. Tactile vocal resonance reduced Due to peripheral tissue damage On auscultation
10. Shoulder rounded forward neck posture Due to reduced chest expansion and dyspnea on exertion On inspection and H/O
11. RPE –2 on Mod. Borg scale due to impaired gas exchange causing  chronic desaturation and sec. fatigue From H/O
12. Fatigue of 30 on fatigue assessment scale Due to ventilation-perfusion mismatch leading to chronic desaturation and secondary peripheral muscle weakness From H/O
13. Spirometery shows reduced FVC and increased FEV1/FVC ratio Due to secondary fibrosis on chronic respiratory involvement From Spirometery testing
14. Six minute walk distance is reduced with a stop required Due to dyspnea on exertion and peripheral muscle weakness secondary to chronic fatigue From 6MWT
15. Manual muscle testing shows reduced lower limb strength Due to impaired gas exchange causing peripheral muscle weakness On MMT testing

Activity Limitation[edit | edit source]

  • Mr. J has difficulty in performing ADLs such as self-grooming and household chores
  • Difficulty in climbing stairs
  • Unable to do cooking at home
  • Unable to go for walk in area surrounding the house

Participation Restriction[edit | edit source]

  • Mr. J not comfortable using LTOT outside the house in social functions
  • He has difficulty to go out independently and meet family or friends

Contextual Factors[edit | edit source]

Environmental[edit | edit source]

Sr. No. Barrier Facilitator
1. Lives on 1st floor and has no lift facility Good family support
2. Stays with wife, no one younger stays with them (eg. Children) Has access to physiotherapy home visit due to living in central location

Personal[edit | edit source]

Sr. No. Barrier Facilitator
1. Has issues about using LTOT Has quit smoking since four years
2. Has H/O of smoking for 7 years, thus major risk factor Motivated to start pulmonary rehabilitation program
3. Has normal BMI
4. Has good socioeconomic status, can afford regular PT treatment

References[edit | edit source]

  1. De Vries J, Michielsen H, Van Heck GL, Drent M. Measuring fatigue in sarcoidosis: the Fatigue Assessment Scale (FAS). British journal of health psychology. 2004 Sep;9(3):279-91.
  2. Rabahi MF, Moreira MA, Escuissato DL, Meirelles GD, Marchiori E. Importance of chest HRCT in the diagnostic evaluation of fibrosing interstitial lung diseases. Jornal Brasileiro de Pneumologia. 2021 May 31;47.
  3. Boros PW, Franczuk M, Wesolowski S. Value of Spirometry in Detecting Volume Restriction in Interstitial Lung Disease PatientsSpirometry in Interstitial Lung Diseases. Respiration. 2004 Aug 1;71(4):374-9.
  4. Ramanathan RP, Chandrasekaran B. Reference equations for 6-min walk test in healthy Indian subjects (25-80 years). Lung India: official organ of Indian Chest Society. 2014 Jan;31(1):35.
  5. Antoine M, Mlika M. Interstitial lung disease. Stat Pearls [Internet]. 2023 Jul 21.