Cardiopulmonary Flashcards
Consolidation (x-ray)
Air-filled spaces are replaced by water, pus or blood due to disease.
a) an air bronchogram: airways contain air and appear as black branching structures against a white background of airless lung
b) shadowing in consolidation will often be denser and clearly demarcated at its lower border (fluid sinks due to gravity)
Localized consolidation -> infection
Widespread consolidation -> ARDS or pulmonary oedema or bilateral pneumonia
Collapse (atelectasis)
• Increased density of the collapsed lobe
• Shift of fissures towards side of collapse
• Hilar shift and distortion to side of collapse
• Crowding of vessels and airways
• Mediastinal shift to side of collapsed lobe
• Crowding of ribs on side of collapsed lobe
• Elevation of hemidiaphragm on side of collapsed lobe
Pneumothorax
Air entering the pleural space.
Commonest cause: penetrating injuries & breeches of visceral pleura
• Black lung field with NO lung markings
• Mediastinal shift away from pneumothorax
• Hyperinflated lung
• Edge of lung pulled away from rib cage resulting in lung collapse
Haemothorax
Blood entering the pleural space.
Commonest cause: trauma
• Grey lung field in supine
• Uniform white density over lung field with meniscus sign in sitting
• Possible mediastinal shift away from haemothorax
Pleural effusion
Pleural effusion
Fluid accumulating in the pleural space
Commonest cause: fluid overload (cardiac failure, protein loss) or infection, malignancy, trauma or surgery
• Loss of lung volume
• Loss of costophrenic angle – meniscus sign
• Uniform white shadowing below meniscus sign
• Upper border of effusion peaks laterally
• Mediastinal shift
COPD
• Hyperinflated lungs (9 – 10 intercostal spaces) with horizontal ribs
• Black lung fields with peripheral markings
• Flattened diaphragms
• Elongated narrow heart shadow
• Bullae visible in advanced disease
Bronchiectasis
Irreversible dilatation of bronchi, usually associated with inflammation.
• Bronchial wall visible either as single thin lines or as parallel ‘tram- lines’
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• Ring and curvilinear opacities which represent thickened airway walls seen end-on.
• Infective consolidation
• Overinflation if disease is widespread
Cardiac failure & pulmonary oedema
• Diffuse bilateral lung field shadowing
• Upper lobe blood vessel diversion
• Enlarged heart shadow
• Angel-wing (butterfly) shadowing around hilae
• Left ventricular failure -> Kerley B lines (oedema of interlobular
septa; horizontal, non-branching, white lines at the periphery of the lung just above the costophrenic angle)
Precaution of oxygen therapy
• Impaired respiratory drive in hypercapnia COPD pts
• Oxygen toxicity → stiff lung syndrome
• Blindness in Children
• Absorption atelectasis in mechanical ventilated patients. • Drying of mucous membrane
• Patient dependency
• Fire/explosion hazard
General physiotherapy considerations
with oxygen therapy
• If a patient is receiving continues oxygen on the ward, treat at the bedside if portable oxygen is not available.
• Document the device and supplemental oxygen used during physiotherapy interventions.
• Ensure the device is fitted correctly and flow of oxygen as should be according to order and specific device.
• Monitor the patient’s skin for potential breakdown due to pressure from the mask of cannula. Provide appropriate padding without interfering with the fit of the device.
• Observe mask for the accumulation of sputum and clear or change if needed
Indications for humidification therapy during physiotherapy interventions
• Thick tenacious secretions
• Non-optimal use of the upper respiratory tract
• Poor cough effort limiting movement of secretions • Oxygen therapy resulting in mucosal dehydration
Hazards humidification
• Potential increase work of breathing in patients due to adding increase resistance.
• Cold mist or water can cause bronchoconstriction in patients with hyper reactive airways.
• Water reservoirs may become infected with pathogens such as Pseudomonas species.
V/Q matching
Upright position = bestV/Q matching
• Side-lying (if patient unable to get out of bed or sit at 60° head up angle
in bed) = best V/Q matching in lower lung
• ‘Good lung down’ principle should be used to improve V/Q matching for patients with unilateral lung disease who cannot tolerate an upright position
• Consider prone or head-down tilt positioning for appropriate patients with bilateral lower lobe disease.
• NB: difference in treatment aims between body positioning for PD and body positioning for V/Q matching
Effects of surgery on respiratory process.
• Lung volumes
• Reduction in vital capacity and FRC • VC [40% less] & FRC [70% at 24hrs
post-op]
• Changes may persist to 5-10 days post op.
• Respiratory muscle function
• Diaphragmatic excursion reduced
Normal FRC
• V/Q mismatch and hypoxemia commonly occur after major surgery.
• Mucociliary clearance and cough effectiveness are reduced following surgery.
• PPC may develop in high risk patients.
• The effects on the respiratory system is a combination of the result of anaesthesia, the surgery performed, pain levels of individuals and physical inactivity post-operatively.
Post-operative physiotherapy
Melbourne Group Scale
• Assess and identify problems to guide selection of treatment techniques.
Techniques could include the following:
• Deep breathing exercises
• Supported coughing
• Nebulization
• Early mobility out of bed to improve V/Q matching
•TENS to manage pain with thoracotomy and laparotomy patients.
•Upper limb and trunk movements. •Inspiratory muscle training against resistance
•PEP devices to assist with sputum clearance.
•Home exercises to increase activity level and improve exercise tolerance after discharge from hospital.
Key points for managing a post-operative patient during physiotherapy
• Always assess if pain is adequately managed e.g. monitor pain levels with VAS
• Always note if the patient has pinpoint pupils and is drowsy as it could influence your management.
• Always check vital signs and oxygen saturation
• If patient had a spinal block or epidural for pain management always assess motor and sensory function of the lower limbs, especially before mobilizing the patient.
• Liaise with the medical team regarding mobilization orders.
• Ensure adequate length in tubing when moving a patient
• Don’t kink lines
• If patient has any drainage tubes attached observe for leakage prior to moving a patient
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Key points for managing a post-operative patient during physiotherapy
• Take note of the urine catheter during activity
• If positioning a patient ensure tubes, catheter is supported
• Mobilise patients with shoes or barefoot but never on socks
• Stand close to the patient when mobilizing the patient for the first time
• Teach supported coughing
• IV lines
• Is it running?
• Is their blood tracking in the line? • Has the IV tissued?
