CVR Info Flashcards
Bronchial Tree
- Trachea
- Primary, secondary, tertiary bronchi
- Bronchioles
- Alveolar ducts and sacs
The amount of smooth muscle and cartilage decrease down the tree.
Lobes and Fissures
Left: upper and lower
Right: upper, middle and lower
Fissures:
Double fold of visceral pleura
Left: oblique (third thoracic spine to 6th costal cartilage).
Right: oblique and horizontal (4th costal cartilage to oblique fissure).
Pleura
- Parietal layer
Thoracic wall and hemi-diaphragm. Innervated by phrenic and intercostal nerves so v sensitive to pain. - Visceral layer
Outer surface of lung, lung fissures innervated by ANS so not sensitive to pain. - Pleural Cavity
Potential space. Pleural fluid acts as lubrication so layers can glide over each other during breathing.
Inspiration
- Diaphragm (main muscle, innervated by C3,4,5) and intercostal muscles contract.
- Diaphragm flattens, pressing down abdominal content and lifting thoracic cavity increasing its volume.
- External intercostal muscles contract, lifting ribs and sternum, increasing the volume of lungs and decreasing the pressure.
- The pressure on the outside is greater so air rushes in as gas molecules move from high to low areas of pressure.
Accessory muscles:
Sternocleidomastoid lifts sternum.
Scalenes lifts upper ribs.
Expiration
Mainly passive.
Passive recoil of lungs back to normal position. When actively expiring (cough, sneeze) internal intercostal and abdominal muscles contract, depressing the lower ribs and compress abdominal content.
The diaphragm and external intercostal muscles relax and move back to the normal position.
The reduced volume in the lungs increases the pressure in the lungs so air rushes out (gas: high to low).
Causes of COPD
Smoking
Exposure to pollutants, aspestos and chemicals.
Generic (alpha-1 antitrypsin)
Umbrella Term COPD
Chronic Bronchitis
Productive cough for 3 months, 2 consecutive years. Repeated airway inflammation. Specific to bronchi and bronchioles.
- Goblet cells produce more mucus, bacteria gets trapped, infection spreads, more mucus produced and cycle repeats.
- Increased airway resistance (airway narrowing and increased sputum)
Umbrella Term COPD
Emphysema
Alveolar level (become large and damaged).
- Loss of alveolar elasticity leading to floppy airways and low compliance.
- Hyperinflation: diaphragm lowers and alters mechanics leading to airway collapse and gas trapping.
Anatomical Changes, Signs and Symptoms
COPD
Breathlessness, cough, sputum, wheeze, reduced exercise tolerance, depression, incontinence, fatigue, weight loss, ankle swelling (more severe COPD, increased pressure in veins due to right side heart failure = oedema in ankles).
Exacerbations:
Infective: bacterial/viral, temp, decreased sats, changes in CXR, bugs in sputum, change in sputum (viscosity, colour), sputum so thick can’t cough it up, change in bloods (WBC count from 5-11 up to teens).
Non-infective: breathlessness, general symptoms, no infective markers
Subjective History
COPD
PC: reason for referral? Exercise tolerance?
HPC: symptoms? How long? Aggs/eases? Cough? Number of admission in last year?
PMH: working diagnosis? Stage of condition? Other conditions?
DH: normal meds? Effective? Prescribed?
SH: occupation? Smoking? ADLs? Support at home? Mobility levels?
Red/yellow flags
Objective Assessment
Gain consent, introduce self, wash hands, use of appropriate equipment (gloves), ergonomics.
Observations: posture, positions adopted, breathless, WOB, complete sentences?
NEWs Score: raised (due to exacerbations?) increased temp, HR, RR and decreased blood pressure and oxygen sats
Palpation
Auscultation
Management
MDT
Smoking cessation, pulmonary rehab, respiratory nurses, dietician, OT, medication, education, psychosocial support
Educate on:
- healthy lifestyle
- effects of smoking and other options to ween off
- self-management
Treatment
ACBT:
Try to get phlegm from small to large airways.
Relaxes the airways.
10-15 mins
Cycle is dependent on the patient, flexible technique, not rushed.
+ no equipment, can do anywhere, its a combination of techniques
- need to be able to follow commands, airway irritation if not properly carried out, patients can rush
Education:
- pacing
- boom and bust cycle
How to do ACBT
- Breathing control
Breathe gently, in and out of nose (mouth, pursed lips if can’t). Let go of tension with each breath out. Gradually make breaths slower. Close eyes to focus and relax. - Deep breathing exercises with/without hold (TEE)
Long, slow deep breath in (nose if can). Keep chest and shoulders relaxed. Breathe out gently. 3-5 breaths. Hold breath 2-3 seconds at end of breath in. - Huffing
Exhaling through open mouth and throat instead of coughing. Moves sputum up airways to clear it in a controlled way by squeezing air quickly from lungs (as if trying to mist a mirror).
Use tummy muscles to squeeze air out (not so forceful to cause wheeze/tight chest).
Types of huff:
- Small-long: moves sputum from low down chest. Small-medium breath in then huff until lungs empty.
- Big-short: moves sputum higher up chest. Deep breath in and huff air out quickly, should clear without coughing.
Repeat steps 1, 2, 3
Retained Secretions
Causes and Presentation
Causes:
- Failing mucociliary transport system
- Inability to cough due to pain, fatigue, increased volume/viscosity of secretions
- Pneumonia
- Smoking
- Spinal chord/head injury
- Pain, fatigue, dehydration
Presentation:
Increased NEWS score: Increased RR, HR and/or Oxygen requirements. Decreased Oxygen sats
Observe: Increased WOB, dehydration
Palpation: Reduced expansion, palpable secretions
Auscultation: Absent or diminished BS, Bronchial BS, added sounds- crackles or monophonic wheeze.
CXR changes of collapse or consolidation
Bloods: raised WBCC
Look for signs of unsafe swallow if concerned
