Comp 2

Question 1

Respiratory rate norms for adults, elementary age children, toddlers, and infants

Answer 1

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

Question 2

Lung ausculation

• how to perform procedure
• 3 things to make note of

Answer 2

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

Question 3

lung ausculation

Answer 3

Question 4

Vesicular breath sounds

Answer 4

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

Question 5

tracheal and bronchial sounds

• characteristics
• abnormal results

Answer 5

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)

Question 6

Bronchovesicular sounds

Answer 6

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.

Question 7

Adventitious breath sounds

Answer 7

abnormal noises heard only with a stethoscope, may be superimposed on normal breath sounds

Question 8

Wheezes

Answer 8

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*

Question 9

Rhonchi

• description
• cause

Answer 9

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.

Question 10

Crackles

• causes
• description/characteristics

Answer 10

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.

Question 11

Stridor

• Cause
• Conditions

Answer 11

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

Question 12

Pleural rub

Answer 12

sounds like two pieces of leather or sandpaper rubbing together, occurs with both inspiration and expiration

Question 13

How to perform mediate percussion

Answer 13

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.

Question 14

Normal vs. abnormal response for mediate percussion

Answer 14

Normal resonance due to air in the thorax

Abnormal:

1. Hyperresonance: as thoracic air increases

Causes:

• Pneumothorax -> tension pneumothorax (*life threatening)
• Emphysema

2. Hyporesonance: decreased thoracic air

Causes:

• Atelectasis
• Pneumonic consolidation
• Pleural effusion

Question 15

describe the 3 ellicited sounds techniques and what is normal vs. abnormal for each

Answer 15

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

Question 16

normal vs. abnormal ellicited response chart

Answer 16

Question 17

if an ellicited response was postive what are the three conditions it might indicate?

Answer 17

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

1. Atelectasis
2. Pneumonic consolidation
3. Compression by pleural effusion

Question 18

How to perform percussion

Answer 18

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.

Question 19

how to perform vibration

Answer 19

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.

Question 20

how to perform active cycle of breathing

Answer 20

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.

Question 21

how to perform autogenic drainage

Answer 21

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.

Question 22

lung positioning for the anterior upper lobes, posterior apical segment, and anterior segments

Answer 22

Question 23

lung positioning for right and left posterior segments, right middle lobe

Answer 23

Question 24

lung positioning for left lingular, anterior segments (lower lobes), and right lateral segment

Answer 24

Question 25

lung positioning for left lateral segment, posterior segments, superior segments

Answer 25

Question 26

When should segmental positioning be used (which techniques?) vs. when should sitting be used? (which techniques)

Answer 26

\*Use segmental positions for percussion and vibration. Active Cycle of Breathing Technique and Autogenic Drainage performed in sitting.

Question 27

utlility of segmental positions

Answer 27

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.

Question 28

indications for active cycle of breathing (3)

Answer 28

1. Loosen and clear secretions from the lungs 2. Improve ventilation in the lungs 3. Improve the effectiveness of a cough

Question 29

autogenic drainage indications (3)

Answer 29

1. Mobilize secretions by creating shearing forces induced by airflow. 2. Speed of expiratory flow helps mobilize secretions by shearing them from bronchial walls. 3. Once mobilized, secretions are transported from the periphery of the airways to the central airways to be cleared.

Question 30

Diaphragmatic breathing

Answer 30

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.”

Question 31

Pursed Lip Breathing

Answer 31

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.”

Question 32

Segmental breathing

Answer 32

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

Question 33

Purpose and indications of diaphragmatic breathing

Answer 33

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

Question 34

Purpose and indications of pursed lip breathing

Answer 34

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

Question 35

Purpose of segmental breathing

Answer 35

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.

Question 36

technique for segmental breathing

Answer 36

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.

Question 37

indications for segmental breathing

Answer 37

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

Question 38

expected outcomes of diaphragmatic breathing (5)

Answer 38

1. Decreased RR 2. Decreased reliance on accessory muscles of inspiration 3. Increased TV 4. Subjective improvement of dyspnea 5. Improved activity tolerance

Question 39

Pursed lip breathing expected outcomes

Answer 39

1. Decreased RR 2. Decreased dyspnea 3. Reduced PaCO2 4. Improved TV 5. Improved SaO2 6. Prevent airway collapse in patients with emphysema 7. Increase activity tolerance

Question 40

Segmental breathing expected outcomes (3)

Answer 40

1. Increased chest wall mobility 2. Expand collapsed alveoli 3. Secretion loosening and clearance

Question 41

Criteria to stop exercise testing in pulmonary patients

Answer 41

* 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