CVR Assessment Flashcards
How does postural drainage work?
By improving ventilation in the dependent lung
How does airway clearance work?
- Collateral ventilation
- Interdependence
- Pendelluft
- Expiratory flow bias
- Enhances oscillatory effect
Which other techniques is postural drainage usually combined with?
- ACBT
- Autogenic drainage (AD)
- Manual techniques
- Positive pressure devices
Why is postural drainage rarely done?
- Time consuming
- Need to huff
Describe autogenic drainage.
- Tidal volume sized breaths at low, mid and high lung volumes
- Inspiratory breath hold
- Faster expiration to create expiratory flow bias
What are the pros of autogenic drainage (AD)?
- Does not require any equipment
- Can be very effective (e.g. in Cystic Fibrosis)
- Can be combined with manual techniques, positive pressure, etc.
What are the cons of autogenic drainage (AD)?
- Can be more difficult to learn than ACBT
- Requires skills to do/teach well
What are the benefits of ACBT?
- Can be combined with other techniques (e.g. postural drainage, manual techniques)
- Can be altered to accommodate different pathologies (e.g. increase breathing control time if patient is SOB)
- Does not require any additional equipment
- Easy to teach/learn
What is Huff/Forced Expiratory Technique in ACBT?
Faster, forced breath to enhance expiratory airflow and create expiratory airflow bias
What is Thoracic Expansion Exercises (TEEs) in ACBT?
Slower, deeper inspiratory breaths +/- breath hold
What is breathing control in ACBT?
Relaxed breaths, allow patient to get their breath back
What are the (3) parts of Active Cycle of Breathing Technique (ACBT)?
- Breathing control
- Thoracic Expansion Exercises (TEEs)
- Huff/Forced Expiratory Technique
What are (4) physio assisted techniques for clearance of airway secretions?
- Chest percussions & vibrations
- Manual hyperinflation & suctioning
- Postural drainage
- Ventilation & oxygen therapy
What are (4) self-administered techniques for clearance of airway secretions?
- Active cycle of breathing techniques (ACBT)
- Forced expiration technique (FET)
- Autogenic Drainage
- Exercise rehabilitation
What are the indications for manual physio techniques?
- Patients with adherent chest secretions (thick, viscous sputum)
- Excessive Airway secretions
- Patients unable to collaborate or actively participate in treatment
- Young patients
What are the typical use cases for manual chest physio?
- Intensive Care (ICU and PICU)
- Patients who are:
~ Heavily sedated
~ Unconscious
~ Neurologically compromised
~ On ventilator support (face mask and tracheostomy) - Young patients
~ Infants and very young children
~ Difficulty in following instructions for more “active” interventions
What are (3) ways to make chest physio easier?
- Medication
- Nebulisation therapy (humidification)
- Device dependant tools
How do you conduct chest percussions?
- ‘Clapping’ on chest wall
- Patient then clears or expels these secretions using expiratory manoeuvre (such as huffing, coughing or FET)
- Percussions applied using a cupped hand to a specific segment of the chest wall while the patient breathes at a tidal volume
What is the purpose of chest percussions?
To dislodge bronchial secretions
What are the key considerations when applying percussion technique?
- Percussion strength to be based on patient feedback
- Force application must be equal
- Frequency of 100-480 times/min must be maintained
- Slow down the technique if force on dominant and non dominant hand does not match
- Avoid percussion over bony prominences such as spine of scapula, spinous processes & clavicle
Should the force applied during chest vibrations cause discomfort?
No, just sufficient to compress the ribcage and improve expiratory flow
How do you complete fine oscillatory chest vibrations?
Application of fine oscillation or oscillatory movements combined with the compression of the chest wall using flattened hands
How are fine vibrations of the chest completed?
Transmitted to the patient’s chest wall from the therapist’s hands (via the isometric alternative contraction of the forearm flexors and extensors)
When are chest vibrations to be completed?
During expiration/exhalation
Why are manual physio techniques difficult to consistently apply?
Due to differences in skill, force application + other factors
What has shown to be more effective than manual chest physio?
- FET
- Oscillatory positive expiratory pressure devices (acapella, flutter devices) in conjunction with peritoneal dialysis
- Other active chest physio techniques (e.g.: ACBT, FET, huffing, coughing + exercise)
How does medication make chest physio easier?
Mucolytic & expectorant agents
How does nebulisation therapy make chest physio easier?
Aerosolisation of medication or saline to increase mobility of secretions (commonly – salbutamol, saline)
- Humidification (via nebulizer using saline or hypertonic saline)
How do device dependant tools make chest physio easier?
Flutter or acapella devices for positive expiratory pressure
What must you be mindful of when altering a patient’s position?
- Underlying pathophysiology
- Cardiopulmonary function
- Contraindications
- Care considerations
What must be done after altering positioning to improve V/Q matching?
Must carefully monitor patient, as some positions may cause deterioration of V/Q matching
How can V/Q matching be maintained in healthy lungs?
In supine
What are (2) examples of something that can happen when a patient is in prolonged supine placement to alter their V/Q matching?
Examples:
- Pulmonary oedema can accumulate in dependent areas altering ventilation but perfusion remains the same (V/Q mismatch)
- Atelectasis (Lung collapse) in in dependent areas lungs, airway secs and cardiac/abdominal compression (can alter V/Q matching and lead to shunting)
When would you use prone position to improve V/Q matching?
Patients with cardiopulmonary compromise or ARDS
What are the benefits of placing a patient in prone to improve V/Q matching?
- Increased ventilation in dependent areas
- Improved dorsal chest wall compliance
- Stablisation of the anterior chest wall
- Reduced shunt fraction
- Decreases cardiac & abdominal compression
What are the negatives of placing a patient in prone to improve V/Q matching?
- Blood flow continues to distribute preferentially to the dorsal lung, as does ventilation in this position- improving V/Q matching
- There appears to be less of a gravitational perfusion gradient than in supine
- Lying prone abdomen free has been shown to be more beneficial than lying prone abdomen restricted
- It may be poorly tolerated or contraindicated on haemodynamically unstable patients and may logistically difficult with a ventilated patient
- Can cause airway compromise
What can happen when a patient side-lying on the affected lung side (with unilateral lung disease)?
V/Q mismatch leading to hypoxaemia
What can happen when a patient side-lying on their right side (with bilateral lung disease)?
Improve V/Q matching, attributed to cardiac compression & increased right lung volumes
Why is supine position worst for paediatric patients when V/Q matching?
- Abdominal contents compromise diaphragm function
- Position of heart in thorax compress lung tissue
- In supine ventilation best anteriorly and perfusion best posteriorly so V/Q mismatch
What position is best for paediatric patients for V/Q matching?
Prone
Why do an A-E assessment?
- Gives a routine, systematic approach to use to affectively assess your patient
- Can be used to rapidly detect a life-threatening emergency
- Focuses on fixing immediate issues before moving on
- Can be used to regularly reassess the patient to check for improvement or deterioration
Describe part A of an A-E assessment.
Airway:
- Is this patent (i.e. open, or not?)
- If not you need to rectify this before moving any further as the patient will be unable to get adequate oxygen into the body
- Get help immediately
- Give high flow oxygen (15L via non-rebreathe mask)
Describe part B of an A-E assessment.
Breathing
- Look, listen, feel: crackles, tactile fremitus, use of accessory muscles, SpO2%
- Respiratory Rate (RR):12 – 16 is considered “normal”
- Oxygen: what is SpO2 (normal 94 – 98% or 88 – 92% if known CO2 retainer), room air or oxygen - what is FiO2, what mode of delivery (e.g. nasal specs)
- Auscultation: can you hear air throughout both lungs? Are there added sounds, e.g. wheeze or crackles? Are they on inspiration, expiration?
- Percussion: hyper-resonant = more air (e.g. pneumothorax), dull = less air (e.g. consolidation)
- Chest x-ray: what does this show? When was it taken? Is it different to previous x-rays?
- Arterial Blood Gases
Describe part C of an A-E assessment.
Circulation:
- Heart rate 50 – 100bpm considered within normal limits, < 50bpm = bradycardia, > 100bpm = tachycardia
- Heart rhythm (e.g. sinus rhythm, atrial fibrillation, sinus bradycardia, ventricular tachycardia)
- Blood pressure systolic/diastolic, 120/80 considered “normal”
- Temperature – 37.2 oC “normal”, < 35.0 hypothermia, >
- Urine output: “normal” 0.5 – 1.5ml/kg/hr
- Look at blood test results (e.g. inflammatory markers, haemoglobin, clotting, kidney and liver function)
Describe part D of an A-E assessment.
Disability:
- A (alert) able to follow instructions appropriately and/or communicate
- C (confused) awake but confused or disorientated
- V (verbal) will wake to voice
- P (pain) responds to pain, e.g. sternal rub
- U (unresponsive), i.e. does not respond to voice or pain
Describe part E of an A-E assessment.
Exposure:
- Look at patient for clues to their condition (e.g. rashes, bleeding, sites of infection)
- Note any lines or drains or attachments
