Comp 2 Flashcards
Respiratory rate norms for adults, elementary age children, toddlers, and infants
Adult: 12-20 breaths/min
Elementary age child (6-12 yo): 18-30 breaths/min
Toddler (1-3 yo): 24-40 breaths/min
Infant (birth -1 year): 30-60 breaths/min
Lung ausculation
- how to perform procedure
- 3 things to make note of
Stethoscope head is placed firmly in contact with the chest, progressing over each segment and comparing side to side.
The patient is asked to breathe deeply through the mouth, both in and out, at every contact.
Make note of:
- Sound quality
- Exhalation sound duration relative to inspiration
- Presence of adventitious lung sounds
lung ausculation
Vesicular breath sounds
normal and heard over most of the peripheral lung fields
Exhalation sound lasts about as long as the inhalation sound (although the time for exhalation is normally longer)
Amplitude (volume) of exhalation and inhalation sound is similar, but inhalation may be louder
Abnormal:
Reduction in vesicular sound volume = reduced ventilation
Prolongation of exhalation sound = airway obstruction
tracheal and bronchial sounds
- characteristics
- abnormal results
heard normally over and close to the trachea
Have a characteristic tubular sound
Exhalation time is usually louder and longer
Abnormal:
If bronchial sounds are heard where vesicular are expected = pathology involving loss of air (atelectasis, consolidation/pneumonia)
Bronchovesicular sounds
heard just lateral to tracheal/bronchial and often in the interscapular region (especially on the left)
Represent a continuum of sounds heard from larger airways.
Adventitious breath sounds
abnormal noises heard only with a stethoscope, may be superimposed on normal breath sounds
Wheezes
continuous but high pitched
more commonly heard on exhalation, progressing to inhalation with a greater degree of pathology
Cause: narrowing of airways
- Asthma***
- Chronic Bronchitis
- Congestive Heart Failure
- WH*eeze = High pitched Whistling
- Cause: Bronchospasm/Bronchial edema/Adherent secretions*
Rhonchi
- description
- cause
subtype of wheeze that is low pitched like a snore and implies obstruction of a larger airway (dull sonorous sounds)
Causes: Fluid/mucous in the larger or conducting airways
- Pneumonia
- Chronic Bronchitis
- Cystic Fibrosis
- R**honchi* think R**hinoceros is sleeping and has low pitched Sonorous sounds.
Crackles
- causes
- description/characteristics
fine or coarse discontinuous adventitious lung sounds that sound like brief bursts of popping bubbles
Causes:
-Congestive Heart Failure (CHF)**
- Atelectasis
- Pulmonary Fibrosis
Crackles =* *CHF
More commonly heard toward the end of inhalation, progressing to throughout the inhalation phase with greater degree of pathology.
Beware of sounds made by hair or subcutaneous emphysema that can mimic crackles.
Stridor
- Cause
- Conditions
Occurs with upper airway obstructions resulting in
narrowing of the glottis or trachea
Usually heard upon inspiration, but may be heard upon expiration
Harsh, high pitched “crowing” sound
Seen in patients with foreign object or tracheal stenosis.
Remember:
STridor =Tracheal Stenosis
Pleural rub
sounds like two pieces of leather or sandpaper rubbing together, occurs with both inspiration and expiration
How to perform mediate percussion
Middle finger of nondominant hand is placed firmly on the chest wall. The fingertips of the dominant hand strike the distal phalanx of the stationary hand with a quick, sharp motion.
Percussion performed over each bronchopulmonary segment, comparing contralateral sides at each level.
Try to focus on striking the distal IP joint of your left middle finger with the tip of your right middle finger.
The last 2 phalanges of your left middle finger should rest firmly on your patient’s back. Try to keep the remainder of your fingers from touching the patient, or only rest the tips of them.
When percussing any spot, 2 or 3 sharp taps should suffice.
As you move down toward the base of the lungs, the quality of sound changes.
Normal vs. abnormal response for mediate percussion
Normal resonance due to air in the thorax
Abnormal:
- Hyperresonance: as thoracic air increases
Causes:
- Pneumothorax -> tension pneumothorax (*life threatening)
- Emphysema
- Hyporesonance: decreased thoracic air
Causes:
- Atelectasis
- Pneumonic consolidation
- Pleural effusion
describe the 3 ellicited sounds techniques and what is normal vs. abnormal for each
Egophony procedure
- Have the patient say “eeeeee”
- Healthy = eeeee heard on auscultation
- Unhealthy = nasal “a” or goat call sound auscultated
Bronchophony procedure
- Say “99” repeatedly
- Healthy = not understandable
- Unhealthy = 99 understood
Whispered pectoriloquy procedure
- Whisper 1,2,3
- Healthy = not understood
- Unhealthy = understood 1,2,3
normal vs. abnormal ellicited response chart
if an ellicited response was postive what are the three conditions it might indicate?
These procedures assess the ability of the lungs to transmit sound produced by the voice and to confirm pathology related to loss of alveolar air
- Atelectasis
- Pneumonic consolidation
- Compression by pleural effusion
How to perform percussion
Utilize segmental positions.
Skin must be covered (towel, T shirt, hospital gown)
Thick materials/towels reduce efficacy
Therapist rhythmically strikes the chest with a cupped hand for 2-3 minutes per affected lung segment. Can be done mechanically.
Cupped hands: place thumb adjacent to DIP joint of the index finger.
Try to keep wrists loose and let the perimeter of the cupped hand strike the chest wall as a unit.
Cough following procedure.
how to perform vibration
Utilize segmental positions.
Therapist places one hand over the affected area on each side of the ribcage (or hand over hand over affected segment).
Therapist vibrates the chest wall as the patient exhales rhythmically and with downward pressure.
Vibration in the direction of rib movements during expiration.
Cough following procedure.
how to perform active cycle of breathing
Start with relaxed diaphragmatic breathing (20-30 seconds) in sitting.
Perform 3-4 deep breaths with added thoracic expansion.
May add inspiratory hold of 1-3 seconds.
Relaxed exhalation.
May follow with huffs or FET as secretions move into the large airways.
Relaxed, controlled breathing.
Repeat cycle 2-4 times.
how to perform autogenic drainage
Start with small tidal breaths from ERV in sitting.
Repeated until secretions are felt gathering in the airways.
10-20 breaths.
The cough is suppressed
A larger TV is taken for 10-20 breaths.
A series of larger (approaching VC) breaths.
Followed by several huffs or coughs to expectorate sputum.
lung positioning for the anterior upper lobes, posterior apical segment, and anterior segments
lung positioning for right and left posterior segments, right middle lobe
lung positioning for left lingular, anterior segments (lower lobes), and right lateral segment
lung positioning for left lateral segment, posterior segments, superior segments
When should segmental positioning be used (which techniques?) vs. when should sitting be used? (which techniques)
*Use segmental positions for percussion and vibration.
Active Cycle of Breathing Technique and Autogenic Drainage performed in sitting.
utlility of segmental positions
General Indications
- Enhanced mobilization of bronchial secretions
- Enhanced localized ventilation (when that region of the lung is most superior).
Percussion: Loosens pulmonary secretions
Vibration: Mobilizes secretions along the airways. Enhances ventilation.
indications for active cycle of breathing (3)
- Loosen and clear secretions from the lungs
- Improve ventilation in the lungs
- Improve the effectiveness of a cough
autogenic drainage indications (3)
- Mobilize secretions by creating shearing forces induced by airflow.
- Speed of expiratory flow helps mobilize secretions by shearing them from bronchial walls.
- Once mobilized, secretions are transported from the periphery of the airways to the central airways to be cleared.
Diaphragmatic breathing
Start in supine or with HOB elevated 30-45 degrees.
Patient places one hand on the upper chest and the other just below the ribcage.
PT instruction:
“Breathe in slowly through your nose so that your stomach moves out against your hand. The hand on your chest should remain relatively still. Feel your abdomen gently rise into your hand. Exhale through pursed lips, let the hand on your abdomen descend, while the hand on your upper chest remains still.”
Pursed Lip Breathing
Start in supine or seated position.
PT instruction:
“Breathe in slowly through your nose with the mouth closed for two seconds. Pucker, or purse your lips as if you were blowing out a candle, then gently breathe out through pursed lips, as if trying to make the candle flame flicker, for a four count. Do not blow with force.”
Segmental breathing
Position of the patient
Sitting position for basal atelectasis
Side-lying with affected lung uppermost
Supine or sitting for bilateral expansion
Postural drainage positions
Therapist applies firm pressure at the end of exhalation over the area that needs more expansion.
Patient inhales deeply and slowly expanding the ribcage under the therapist’s hand utilizing the tactile cue.
Regions
Lateral costal expansion: hands on posterolateral lower thorax
Unilateral or bilateral
Instruction: “As you breathe in, expand against my hands.”
Apical costal expansion: hands on anterior upper ribs (avoid sternum), place pressure caudal and dorsal
Instruction: “As your breathe in, push up against my hands.”
Segmental: hands on bilateral
Purpose and indications of diaphragmatic breathing
Purpose: utilizes the diaphragm while limiting the accessory muscles during inspiration
Indications:
Post-surgical patients
Dyspnea at rest
Inefficiency with breathing or SOB during ADLs
Purpose and indications of pursed lip breathing
Purpose: utilized to reduce RR and decrease dyspnea by maintaining positive pressure in the bronchioles. Can help prevent airway collapse in patients with emphysema and helps trapped air escape in patients with COPD.
Indications:
Tachypnea
Dyspnea
Purpose of segmental breathing
Intended to improve regional ventilation and treat pulmonary complications. Facilitates or inhibits chest wall movement through proper hand placements, verbal cues, or coordination of breathing.
technique for segmental breathing
Inhalation should emphasize use of the diaphragm, if this can be done efficiently and effectively.
On exhalation, encourage a relaxed, more complete exhalation to attempt to reduce FRC and the work of breathing.
Manual assistance (chest squeezing) is often useful in relieving acute distress.
indications for segmental breathing
Decreased lung volumes
Decreased chest wall compliance
VQ mismatch
All respiratory disorders (sometimes with modifications for specific pathologies)
Prophylactic for patients subject to:
Hypoventilation
Secretion retention
Venous stasis in the LE
expected outcomes of diaphragmatic breathing (5)
- Decreased RR
- Decreased reliance on accessory muscles of inspiration
- Increased TV
- Subjective improvement of dyspnea
- Improved activity tolerance
Pursed lip breathing expected outcomes
- Decreased RR
- Decreased dyspnea
- Reduced PaCO2
- Improved TV
- Improved SaO2
- Prevent airway collapse in patients with emphysema
- Increase activity tolerance
Segmental breathing expected outcomes (3)
- Increased chest wall mobility
- Expand collapsed alveoli
- Secretion loosening and clearance
Criteria to stop exercise testing in pulmonary patients
- Maximal shortness of breath
- A fall in PaO2 of greater than 20mmHg or a PaO2 <55mmHg
- A rise in PaCO2 of greater than 10mmHg or a PaCo2 greater than 65mmHg
- Cardiac ischemia or arrhythmias
- Symptoms of fatigue
- Increase in DBP readings of 20mmHg, systolic hypertension greater than 250mmHg, decrease in BP with increasing workloads
- Leg pain
- Total fatigue
- Signs of insufficient cardiac output
- Reaching a ventilatory maximum
