CardioRespiratory Flashcards
What are the physical examinations?
inspection, palpation, percussion, auscultation
What 5 things should you inspect?
vital signs, mechanism of ventilation, thoracic shape, head/neck/extremities, speech/cough/sputum
What are the 4 vital signs?
HR, RR, BP, SPO2
How to take HR, and what to note
radial artery with index and middle finger. Ask patient to be quiet and count for 15 secs and multiply by 4. Note rate, rhythm, and strength of pulse
Different HR?
bradycardia: <60bpm, normal: 60-100bpm, tachycardia: >100bpm
Rhythms
normal: regular consistent pattern, irregular: irregular but consistent pattern (bigeminy, trigemini), irregularly irregular: irregular but inconsistent pattern (atrial fibrillation)
How to measure RR and the wording for too high, normal, and too low?
Do it without the patient knowing. Bradypnea (less than 12), eupnea (12-20), tachypnea (greater than 20)
Normal RR for an adult?
12-20
normal RR for adolescent?
16-20
normal RR for child
20-30
normal RR for toddler (2yr)
25-32
normal RR for infant (6month)
30-40
normal newborn RR
35-40
How to take blood pressure?
upright seated, left arm supported at heart level, palpate brachial artery and place cuff 1 inch above that. stethoscope under cuff and on pulse and ask patient to be quiet. inflate until pulse is gone then add an extra 20 mmHg, Deflate slowly. Systolic BP is first noise, diastolic is when gone.
BP values
hypotension : <90/60.
normal: 120/80
hypertension: >140/90
orthostatic hypotension (SBP drops by 20 from lying to upright)
Considerations for taking BP measurements
Ensure cuff size is approx 80% of arm
too large= underestimate BP
too small= overestimate BP
Locations for SPO2 reading
finger or ear lobe
Normal value for SPO2 and when to require supplemental O2
Normal is 95-100%, below 90% warrants further investigation.
What is the normal breathing pattern? Percentage diaphragmatic vs costal?
> 70% diaphragmatic and <30% costal. 0% shoulders
What are signs of distress or increased metabolic demand?
apical, paradoxical, flail chest, use of abs to actively expire
Ratio of inspiration: expiration in normal, obstructive and restrictive diseases
normal- 1:2
obstructive- 1:3(or more)
restrictive- 1:1
What are the threee areas of mechanisms of ventilation to be aware of?
breathing pattern, ratio of inspiration:expiration, and depth (normal v shallow)
What are 4 abnomral thoracic shapes that can affect mechanics of ventilation and V/Q matching?
funnel chest (pectus excavatum), pigeon chest (pectus carinatum), kyphoscoliosis, barrel chest (AP:lateral = 1:1)
What to look for in the head? (3)
colour, cyanosis, nasal flaring
What to look for in the neck? (2)
accessory muscle use, jugular venous distension
What to look for in the extremities? (5)
capillary refill, clubbing, colour, edema, muscle wasting
What is a clubbing sign in fingers?
Schamroth’s Sign. put index fingers together and if there is a gapping (or no diamond window) then clubbing is present. A clubbed finger has a >180 degree bend.
4 things to analyze with coughs?
effective (strength), productive, presistent (freq), wet or dry
Sputum characteristics (4)
quantity, colour, consistency, odour
what does clear sputum indicate?
saliva
what does white sputum indicate?
normal (perhaps asthma)
what does yellow sputum indicate?
mucopurulent: infected (chronic bronchitis, cystic fibrosis, pneumonia)
what does green sputum indicate?
purulent (emphysema, advanced pneumonia, bronchiectasis, lung abscess)
what does brown flecks sputum indicate?
carbon particles (smoker, smoke inhalation)
what does pink (frothy) sputum indicate?
pulmonary edema
what does frank blood sputum indicate?
hemoptysis (tb, lung cancer, pulmonary infarction)
What are 6 things to palpate for during respiratory examination?
chest wall expansion, diaphragmatic excursion, edema, pain and crepitus, tracheal positioning, tactile fremitus
What are the two methods for assessing chest wall expansion?
manual method or circumferential method
what is the manual method for assessing chest wall expansion?
hands on and assessing for symmetry and amount of movements in 3 areas (upper lobes @ sterno-costal, middle lobes/ lingual @ verebro-costal, and lower lobes @lateral costal)
What is the circumferential method for assessing chest wall expansion?
using a measuring tape and comparing full inspiration vs full exhalation. Measure @ axilla or 10th rib. Take 3 measurements and record best 3.
What are the 3 methods for assessing diaphragmatic excursion?
Manual method, circumferential method, and diaphragmatic percussions
what is the manual method for assessing diaphragmatic excursion?
hand placed on the apex of belly during inspiration
what is the circumferential method for assessing diaphragmatic excursion?
place tape at level of apex of belly and instruct patient to first exhale and then maximally inhale
What are two things to assess with edema?
Pitting vs non-pitting and the level (how far up does it extend)
What are 4 possible conditions that may cause respiratory edema?
right-sided heart failure, pregnancy, lymphedema, systemic diseases
What would pain indicate when doing a respiratory examination?
palpation producing pain could aid in differentiating between angina due to an organic nature or musculoskeletal pain.
What is crepitus in the respiratory area and what does it indicate?
it is when air bubbles are trapped in the subcutaneous tissue and a crackling sensation can be palpated (known as subcutaneous emphysema).
Possibly caused by air leak from chest tube, trauma, pneumothorax
Where should the trachea be located?
between the sterno-costal joints
What would increase and decrease in lung volume or pressure do to tracheal positioning respectively?
increase volume/ pressure pushes mediastinum away (pneumothorax, pleural effusion, tumor/mass). Decrease volume/pressure shofts mediastinum ipsilateral (atelectasis, pleural fibrosis, pneumonectomy)
What is the mediastinum?
The mediastinum is an area found in the midline of the thoracic cavity , that is surrounded by the left and right pleural sacs. It is divided into the superior and inferior mediastinum, of which the latter is larger.
What is tactile fremitus? How do you perform it?
palpable vibration of the chest wall that results from the transmission of sound vibrations through the lung tissue to the chest wall. Therapists uses palm of hand to feel for vibrations from sound transmitted when a patient repeats loudly “99”
What does an increase in sound transmission mean when performing tactile fremitus?
more dense tissue (ie. pneumonia)
What does a decrease in sound transmission mean when performing tactile fremitus?
less dense tissue (ie. pleural effusion, pneumothorax)
What are the two types of percussion you can do?
diagnostic percussion and diaphragmatic percussion
what is the purpose diagnostic percussion?
to determine the density if the underlying tissue. Can detect abnormalities up to 5 cm in depth.
What tissues will alter ability to perform diagnostic?
SUBCUTANEOUS FAT
how do you perform diagnostic percussion?
place the finger of a hand with an extended DIP directly on the chest wall with firm pressure
Strike the DIP of the hand placed on the chest wall with the tip of the middle finger of the other
hand
Motion comes with quick snap of the wrist
Perform 2-3 strikes
Best performed on exposed skin (use proper draping)
What are the 3 percussion sounds you could hear?
resonant, dull, hyperresonant (tympanic)
What does resonant percussion sound mean?
normal aerated lung tissue (air:tissue ratio normal) over normal lung tissue
What does a dull percussion sound mean?
non-aerated lung tissue (air:tissue ratio below normal). could be atelectasis, pneumonia, over organs, tumor.
What does hyperresonant (tympanic) percussion sound mean?
hyperinflated lung (air:tissue ratio above normal) (COPD, pneumothorax, over empty stomach)
How do you perform diaphragmatic excursion?
Performed with patient in sitting
Ensure patient knows how to use diaphragm (if not, educate)
Patient is asked to maximallyexhale and hold as therapist percusses down the same
side of the chest wall (posteriorly) Therapist makes a marking when a dull sound is
heard (diaphragm)
Patient is asked to maximally inhale and hold as therapist percusses down one side of
the chest wall (posteriorly) from the point of the last marking. Therapist makes a
marking when a dull sound is heard (diaphragm)
Normal-3-5cm difference. D E with hyperinflation +other conditions
Note: Diaphragm sits higher on Right than Left
what are the normal breathing sounds?
vesicular, bronchial, bronchovesicular.
what are the abnormal breath sounds?
crackles, wheezes, pleural friction rub, stridor?
What is a vesicular breath sound?
Soft and low-pitched
Heard over peripheral lungtissue (i.e. entire lung except for anterior
and posterior areas over trachea and main stem bronchi) Indicates normal lung.
I:E = 3:1
What is a bronchovesicular breath sound?
Mixture of bronchial and vesicular :E = 1:1
Inspiration is soft, low-pitched Exhalation is loud, high-pitched
What is a bronchial breath sound?
Loud, high-pitched, hollow quallty Louder on exhalation
I:E = 1:1 or 1:2
Distinct pause between I and E Heard over trachea and manubrium
What is a crackles (rales) breath sound?
short, explosive
What are the classifications of crackles?
timing: inspiratory vs expiratory
quality: coarse vs. fine
coarse: usually sputum/secretions
fine: usually fluid (ie. pulmonary edema), also heard in atelectasis and fibrosis.
what is a wheeze (rhonchi) breath sound?
musical, can be affected by coughing.
What are the classifications of wheezes?
pitch: high vs low
timing: inspiratory vs. expiratory
duration: short or long
notes: monophasic vs polyphonic
What is a pleural friction rub (extrapulmonary sound)?
Long, low-pitched, leathery creaking sound
Produced by frictional resistance between layers
Pain may be associated with a pleural friction rub.
May be confused with pericardial rub from heart. To differentiate ask patient to hold their
breath. If rub sound persists then it is a pericardial rub. If rub sound disappears, it is a pleural friction rub.
What is a stridor breathe sound?
Loud, musical, high-constant pitch
Audible from a distance without stethoscope
Most prominent during inspiration
Due to turbulent air flow (upper airway obstruction or narrowed airways)
What are the 3 voice sounds techniques?
egophony, whispered pectoriloquy, bronchophony
How do you perform egophony voice sounds test?
ask the patient to repeat “E” as you auscultate, if you hear “A” it is an indication of consolidation (mucous or lung tissue)
How do you perform whispered pectoriloquy voice sounds test?
whispered words change from muffled over normal lung tissue to clear(er) over areas of consolidation
How do you perform bronchophony voice sounds test?
increased intensity and clarity of vocal resonance indicated consolidation
What are the 4 categories of pulmonary function tests?
volume, capacity, flow, diffusion studies, respiratory muscle strength
What is tidal volume?
the volume of air inhaled or exhaled during a single breath in a resting state (normal quiet breathing)
What is inspiratory reserve volume (IRV)?
the max amount of air inhaled following a normal inspiration
What is expiratory reserve volume (ERV)?
the max amount of air that can exhaled after a normal exhalation
what is the residual volume?
the volume of air remaining in the lungs at the end of maximum expiration (can’t exhale it)
What does a decreased tidal volume indicate?
restrictive disease, lung cancer, atelectasis, msk impariment
What does increase residual volume indicate?
obstructive disease
what does decreased residual volume indicate?
restrictive disease, lung cancer, atelectasis, msk impairment
what does increased inspiratory reserve volume indicate?
obstructive disease
what does decreased inspiratory reserve volume indicate?
restrictive disease
what does decreased expiratory reserve volume indicate?
pleural effusion, pneumothorax, ascities
what are the four lung capacities?
total lung volume, vital capacity, inspiratory capacity, functional residual capacity
Define total lung volume and what does it consist of?
the volume of gas in the lungs at the end of maximum inspiration.
TLC= VT+IRV+ERV+RV
Define vital capacity and what does it consist of?
the maximum amount of gas that can be expired from the lungs following a maximum inspiration
Define inspiratory capacity and what does it consist of?
the maximum amount of gas that can be inspired from the resting expiratory level
Define functional residual capacity and what does it consist of?
the amount of gas remaining in the lungs at the resting expiratory level.
Differential diagnosis of capacities regarding obstructive and restrictive lung disease?
decreased capacity= restrictive
increased capacity= obstructive
What is forced vital capacity?
the total volume of air that can be expired after a maximal inhalation (independednt of time)
What is forced expiratory volume
the maximum voume of air that can be expired from maximal inhalation in x seconds
What is FEV1/FVC%?
the percent of FVC that can be expired in 1 second
<70% = obstructive disease
Obstructive values: FVC, FEV1, and FEV1/FVC (%)?
FVC: normal or low
FEV1: low
FEV1/ FVC: low
Restrictive values: FVC, FEV1, and FEV1/FVC (%)?
FVC: low
FEV1: normal or low
FEV1/ FVC: normal or high
What are diffusion capacity of Carbon Monoxide (DLCO)?
tests which measure the functioning gas exchange from the lungs (alveoli) to the blood (pulmonary capillary bed)
What are the problems associated with low DLCO?
could be a problem wth pulmonary or circulatory system (ex emphysema, fibrosis, anemia)
What are the problems associated with high DLCO?
problem with circulatory, but not pulmonary.
What are the two tests that assess respiratory muscle strength>
maximal inspiratory pressure (MIP)
maximal expiratory pressure (MEP)
What is the maximal inspiratory pressure (MIP)?
patient attempts a maximal inspiratory effort through a blocked mouthpiece.
a patients MIP reflects the strength of the patient’s inspiratory muscles
What is the maximal expiratory pressure (MEP)?
patient attempts a maximal forced expiratory effort through a blocked mouthpiece after a full inhalation
a patients MEP reflects the strength of the patient’s expiratory muscles
Arterial Blood Gas test
a test used to measure amount of arterial gases (eg. oxygen, carbon dioxide) and acidity (pH) of arterial blood.
pH
normal: 7.35-7.45
a measure of the hydrogen ion concentration in the blood which indicates the alkalinity or acidity of the blood
PaCO2
normal: 35-45mmHg
respiratory acidosis
low pH and high PaCO2.
patient hypOventilating leads to increase PaCO2 (>45 mmHg)
respiratory alkalosis
high pH and low PaCO2.
patient hypERventilating leads to decrease PaCO2 (<35mmHg)
HCO3
22-26 mEq/L
metabolic alkalosis (HCO3)
high pH and high HCO3 (>26 mEq/L)
metabolic acidosis (HCO3)
low pH and low HCO3 (< 22 mEq/L)
PaO2
80-100 mmHg
Mild, moderate, severe hypoxemia
mild- 60-80 mmHg
moderate- 40-60mmHg
severe- <40mmHg
ABG compensation- uncompensated
the pH level is abnormal, with one component (PaCO3 or HCO3) abnormal and the other normal
ABG compensation- partially compensated
the pH is abnormal, with the other compnent (PaCO3 or HCO3) also being abnormal
ABG compensation- compensated
the pH is normal, the other component (PaCO3 or HCO3) also being normal
Interpreting ABGs
1) is the pH acidotic, alkalotic, normal?
2) is the PaCO2 acidotic, alkalotic, normal?
3) is the HCO3 acidotic, alkalotic, normal?
4) is it compensated, partially compensated or uncompensated
Obstructive lung disease
respiratory disorder(s) characterized by increased airway resistance and obstruction affecting expiratory airflow.
- including chronic bronchitis, emphysema, asthma, bronchiectasis
airway obstruction will lead to
decreased forced expiratory flow rates: FEV1, FEV1/FVC, FEF 25-75%, PEFR
increased air trappin (static volume): RV, TLC, FRC
etiology of
Obstructive lung disease
smoking, air pollution, genetics (alpha-1 antitrypsin deficency), infection, aging, allergy
Chronic Bronchitis
productive cough on most days for 3 months/year for 2 consecutive years (provided other conditions have been ruled out)
Chronic Bronchitis: Pathophysiology
- hypertrophy + hyperplasia of mucous glands and goblet cells (Increased mucus)
- decreased number of cilia (secretion retention)
- chronic inflammatory changes in bronchial walls
- decreased gas exchange (d/t formation of misshapen and large alveolar sacs)
Chronic Bronchitis: etiology
long term irritation of tracheobronchial tree (1. smoking, 2. pollution)
Chronic Bronchitis: clinical presentation- inspection
- obese and cyanotic “blue bloater”
- mucus colour can be white, yellow, or green
- possible increase JVP and ankle edema (CB commonly associated with RHF)
Chronic Bronchitis: clinical presentation- palpation
tactile fremitus: decreased in areas of air trapping, increased in areas of secretion retention
Chronic Bronchitis: clinical presentation- percussion
hyper-resonant over areas of air trapping, dull over areas of secretion retnetion
Chronic Bronchitis: clinical presentation- auscultation
decreased BS, early inspiratory wet crackles, possible wheezing
Chronic Bronchitis: clinical presentation- ABGs
large decreased PaO2, increased PaCO2
Chronic Bronchitis: clinical presentation- CXR
cardiomegaly, white haziness
Emphysema
enlargement of the airway distal to the terminal bronchioles, accompanied by destruction of their walls
Types of emphysema and explain
centrilobar (more common)
- affects respiratory bronchioles
- M>f
- rare among non-smokers
- commonly found in patients with chronic bronchitis
Panlobar
- affects terminal and respiratory bronchioles
- due to alpha-antitrypsin deficiency
Emphysema: pathophysiology
- bullae may be found in these patients
- develops from an obstruction of the air flow during expiration
- leads to hyperventilation -> destruction of alveolar walls -> decreased elastic recoil, increased dead space, decreased gas exchange (alveloar walls rupture and alveolar capillaries are destroyed)
Emphysema: etiology
smoking, pollution, alpha-antitrypsin deficency
Emphysema: clinical presentation- inspection
- thin and wasted “pink puffer”
- barrel chest
- I:E ratio prolonged (1:3 or longer exhalation)
- pused lip breathing
- increased accessory respiratory muscle use (30% diaphram, 70% accessory muscles)
- other signs of respiratory distress (eg leaning over with hand on knees to unload thorax)
Emphysema: clinical presentation- palpation
- tactile fremitus: decreased
- chest wall expansion: decreased
Emphysema: clinical presentation- percussion
hyoer-resonant
Emphysema: clinical presentation- ascultation
- decreased BS, may have dry crackles
Emphysema: clinical presentation- ABGs
decreased PaO2 (moderate hypoxemia), normal or increased PaCO2
Emphysema: clinical presentation- CXR
- increased black area ( hyperinflated + decreased lung tissue)
- flattened diaphram (hyperinflated)
- flattened ribs (no angles)
- narrow mediastinum (thin elongated heart)
Asthma
chronic inflammatory condition of the airways characterized by hyper-responsiveness of the airways (trachea and bronchi) to various stimuli which results in narrowing of the airways
Asthma- pathophysiology (acute attack)
- decreased threshold of airway smooth muscle reactivity
- leads to bronchospasm, bronchial wall edema, and inflammation, and increased secretions within the lumen of the airways
- narrow arways increase airway resistance (both in and out)
Asthma- etiology
unknown
What factors can trigger intrinsic asthma (idiopathic)?
-drugs eg aspirin
- exercise-induced asthma (EIA)
- inhaled irritants eg smoke, pollution, chemicals
- repiratoru infectins eg common cold
- stress (emotions)
- weather eg humidity, cold air
What factors can trigger extrinsic asthma (allergic)?
- animals
- dust
- feathers
- food
- mold
- pollen
Clinical presentation (during attack only) of asthma?
PFT pre and post bronchodilators shows significant improvements
reports of “chest tightness” and dyspnea
Asthma: clinical presentation- inspection
increased accessory respiratory muscle use
other signs of respiratory distress
Asthma: clinical presentation- palpation
tactile fremitus: decreased
chest wall excursion : decreased (d/t air trapping)
Asthma: clinical presentation- percussion
hyper-resonant
Asthma: clinical presentation- auscultation
decreased BS, wheezing, possible crackles
Asthma: clinical presentation- ABGs
decreased PaO2, increased PaCO2 in severe cases, decreased pH (respiratory acidosis)
Bronchiectasis
- irreversible, abnormal dilation of medium-sized bronchi and bronchioles resulting in airflow.
- commonly associated with chronic inflammation and infection within these airways
- considered an extreme form of chronic bronchitis
Bronchiectasis- Pathophysiology
- destruction of bronchial wall causing permanent dilation of airways
- ciliated walls replaced by non-ciliated, mucus-secreting cells
- pooling of infected secretions leading to recurrent infections
- may cause atelectasis distal to obstruction
Bronchiectasis- Etiology
- post infection (most common: necrotizing bacterial pneumonia)
- congenital disorder (eg cystic fibrosis, cilary defect, airway defects)
- bronchial obstruction (eg aspiration, cancer)
- other (eg. connective tissue diseases, systemic disorders, immunodeficiencies, idiopathic).
Bronchiectasis: clinical presentation- inspection
- thin and fatigued
- clubbing
- increased accessory respiratory muscle use
- other signs of respiratory distress
- severe cough
- increased ++ mucus (foul-smelling, purulent, may contain blood)
Bronchiectasis: clinical presentation- palpation
- tactile fremitus: depends on specific lung changes present
- chest wall excursion : decreased (d/t air trapping)
Bronchiectasis: clinical presentation- percussion
depends on specific lung changes present
Bronchiectasis: clinical presentation- CXR
- dilated airways (seen in varicose or cystic type)
- dark lung fields in areas of trapping
- flattened diaphragm
- may or may not see areas of consolidation or atelectasis
- high resolution CT is more commonly used to help diagnose bronchiectasis.
Restrictive lung diseases
- parenchymal diseases
- pleural diseases
- chest wall diseases
- neuromuscular disorders
Explain what restrictive lung disease is?
diseases that restrict the lung from expanding fully.
decrease in compliance -> decrease negative pressure -> decreased air entry
What are parachymal diseases?
interstitial pulmonary fibrosis
sarcoidosis
atelectasis
ARDs
What is interstitial pulmonary fibrosis?
thickening of the interstitium of the avelolar walls which progress to fibrosis or scarring
Interstitial pulmonary fibrosis- pathophyiology
decreased lung compliance
increased elastic recoil
increased fibroblasys results in increased collagen leading to fibrosis or scarring
decreased diffusion capacity
Interstitial pulmonary fibrosis- etiology
idiopathic (most common)
enviromental exposure to inorganic dust, toxic gases, and certain drugs
there may be genetic factor
some connective tissue disorders are disorders are associated with IPF eg RA
Interstitial pulmonary fibrosis: clinical presentation- inspection
-dyspnea
-increased RR and shallow breathing (tachypneic breathing)
- dry unproducitve cough
- clubbing
- cyanosis
- decreased chest expansion
Interstitial pulmonary fibrosis: clinical presentation- palpation
tactile fremitus: increased
Interstitial pulmonary fibrosis: clinical presentation- percussion
dull
Interstitial pulmonary fibrosis: clinical presentation- auscultation
late fine inspiratory crackles
Interstitial pulmonary fibrosis: clinical presentation- ABGs
decreased PaCO2 and PaCO2
Interstitial pulmonary fibrosis: clinical presentation- CXR
small contracted lungs
raised diaphram
diffuse reticular markings (mainly in lower lobes)
High resolution CT is more commonly used to help assess the severity of IPF.
What is sarcoidosis?
a disease involving granuloma development in the lungs, skin, lymph nodes and other organs
What is Atelectasis?
Collapse of alveoli or lung tissue
- can be sub-segmental, segmental or lobar distribution
What is the Pathology/ etiology of atelectasis?
- obstruction (eg. mucus plug, tumor, foreing body)
- decreased nitrogen
- decreased surfactant (increased surface tension)
- compression
- hyperventilation
- hypoventilation
Clinical presentation of ATELECTASIS:
Inspection
palpation
percussion
auscultation
ABGS
CXR
Inspection
- dyspnea, cyanosis, increased RR and shallow breathing (tachypneic breathing)
palpation
- tactile fremitus and chest wall expansion (on effected side) decreased
percussion
- dull directly over compressed tissue
auscultation
- decreased BS or absent, fine inspiratory crackles
ABGS
- decreased PaO2
CXR
- ipsilateral shift of mediastinum, increased density in area of atelectasis, elevated hemi-diaphram (tenting)
order of doning PPE
sanitize, gown, mask, eye protection, gloves
order of doffing PPE
gloves, gown, sanitize, goggles, mask, sanitize
contact precaution
MRSA, VRE, ESBL, C-Diff, Norovirus, uncontained drainage/ diarrhea
droplet precautions
mumps
rubella
pertussis (whooping contact)
influenza (droplet and contact)
pheumonia (droplet and contact)
meningitis
acute respiratory illness
airbornne precautions
TB
Disseminated shingles
measles
severe acute respiratory syndrome
varicella
pneumonectomy
removal of a lung
lobectomy
removal of a lung lobe
segmental resection
removal of a segment of a lobe
wedge resection
removal of a portion of a lung
lung volume reduction surgery or bullectomy
removal of large emphysematous tissue
Thoracotomy- where? Muscles incissed? Postioning?
4th intercostal space
lats, SA, ext/int intercostals, traps, rhomboids
can techincally lie on either side, if pneumonectomy then dont lie on surgical side. Just ensure no kink in tube and not poisitioned about incicions site
Thoracotomy- education
deep breathing
supportie coughing
line education
scar managment
relaxation
bed mobility
positioning
transfers
early mobilization
possible complications of pulmonary surgery
aspiration, increase pain, phrenic nerve impairment, actelectasis, ulcers, DVT
DVT- S&S
leg pain
tenderness
ankle edema
calf swelling
dilated veins
positive Homan’s sign
DVT- prevention? What to do if suspected?
early mob
ankle pumps
anti-coagulants
graduated compression stockings
if suspected, stop movement
sternal incisions (cardiac surgery) healing timeline
6-8 weeks to heal
sternal incisions (cardiac surgery)- UL limitations
- no pushing
- no pulling
- no lifting one arm above 90 deg
- no hand behind back
- no driving for 4 weeks
- no lifiting >10 lbs
Explain Mechanical Ventilation
machine to assist mvmt of air
negative or positive pressure (only positive used commonly)
invasive (endotrachotube or tracheostomy)
non-invasive (nasal mask, complete face mask)
When is mechanical venitaltion used?
severe hypoventialtion, hypoxia, hypoexemia
central depression
decrease WOB and respiratory muscle fatigue
poor pulmonary hygiene (clearance)
Complications of mechanication ventialtion
barotrauma (alveolar rupture)
volutrauma (alveolar distension)
ventilator acquired pneumonia (VAP)
diaphragm atrophy
hemodynamic compromise
Types of mechanical ventilation
mandatory (total control)
- continous mandatory venilation; invasive
assisted
- assisted control ventialtion; invasive
spontaneous
- synchronized intermittent mandatory ventilation; invasive
- continuous positive airway pressure; non-invasive or invasive
What are the two ventilators adjucts
PEEP (positive end expiratory pressure)- helps give an end boost to keep alveli open
PSV (pressure support ventilation)- helps with inspriation
How to assess weaning?
spontaneous breathign trail
Why is pre-exercise screening important?
identifies whether a patient is at risk of exercise
What type of exercise testing can we do as PTs?
submaximal testing
- 6 minute walk test
predictive submaximal exercise test
- treadmill tests (modified Bruce protocol)
- cycle ergonometer test
FITT Principle: Frequency
3-5 times a week
FITT Principle: Intensity
level of difficulty,
standard intensity ranges 60-85%
high risk ranges 50-75%
could be through a number of ways.
How do you calculate target HR
max HR (220-age)
Target HR= HR max x % intensity desired (using Borg Scale)
What is Borg Scale?
Original is 6-20 ( because multiply number by 10 and will result in you HR)
Modified is 0-10 and not as easy to do
FITT Principle: Time
30-60 for moderate (150 min/week)
20-60 for vogorous (75 min/week)
FITT Principle: Type
Should be anything aerobic or resitant training
FITT Principle: Saftey concerns
upper body for those with BP issues should be avoided
Cardioresp Intervention
Positioning
breathing exercise
airway clearance techniques
forced expiratory techniques
exercises
Positioning for V/Q matching
unilateral- good lung down
bilateral- prone
pneumonectomy- do not lie with affected side up
ARDS- lie in prone “proning”
Position for COPD Dyspnea
any position that offloads the ES.
standing against wall, on knees
standing, leaning on table
sitting leaning elbows on table
sitting leaning on table
Breathing exercises
deep diaphramic breathing
pursed lip breathing for COPD
Inspiratory muscle training
segmental breathing
sustained maximal inspiration
airway clearance
postural drainage
percussion
vibration
PEP devices
Independent breathing techniques
suctioning
postural drainage contra-indications
ICP> 200 mmHg
Spinal instability/ surgery/ injury
active hemoptysis
empyema
bronchopleural fistula
pulmonary edema b/c of HF
large pleural effusion
elderly, confused or anxious person
initial rib fractures
surgical wound or healing tissue (initially)
PE
untreated pneumothorax
Postural drainage contra-indications for those in Trendelenburg position?
ICP increased
uncontrolled hypertension
distended abdomen
esophageal surgery or GERD
recent gross hemoptysis related to recent lung carcinoma
uncontrolled airway at risk for aspiration
contraindications for Percussions and Vibrations?
severe osteoporosis
rib fracture
pulmonary embolus
pneumothorax
anticoagulation therapy
malignancy
burns/ skin grafts
open wounds
Increased ICP
subcutaneous emphysema
GI bleeding
Suction Contraidications
severe decrease O2 saturation (<92%)
increased ICP
hemoptysis
malignant arrhythmia
hyperinflation post-CABG and head injury
Potential Complications of Suction
infection mucosal (tracheal and bronchial) trauma
hypoxia/hypoxemia
hemodynamic instability
laryngospasm/ bronchospasm
altelectasis
pneumothorax
increased ICP
pain
anxiety
Ways to limit complications with suctioning
infection control measures
hyperoxygenation
hyperinflation
limit suction time (no > 10-15 secs) and time b/w (30 secs)
medication and sedation prior to procedure
Four stages of coughing
inspiration
glottal closure
compression
expulsion
