fred Flashcards
respiratory rate
12-16 normal
COPD spo2
his is 90 on air
- 88-92% for patients at risk of CO2 retention (Scale 2) (COPD)
auscultation expiratory crackles left base
Suggests obstruction due to sputum in more proximal, larger airways
* Early expiratory: more central airways
* Late expiratory: more peripheral airways
blood pressure
(S=95-140, D=60-90)
temperature
normal (35.7-38)
COPD
Chronic bronchitis and emphysema together
Emphysema
- permanent destruction and enlargement of alveolar air spaces with loss of elastic recoil and reduced alveolar gas exchange surface area
Chronic bronchitis
* Hypertrophy of mucus glands in larger bronchi
Excessive mucus production
* Excessive expectoration
* Chronic inflammatory changes in smaller bronchi
* airway obstruction causes
1. blockage/plugging in the lumen
2. bronchoconstriction inflammation/edema
3. Outside the airway eg. Parenchyma loss
Forward lean reduces work of breathing
- Stabilise the shoulder girdle to optimise thoracic cage movement
- Dome a flattened diaphram
- Decrease energy consumption
Airway
- Air is black, tissue or fluid is white
Look for trachea - The trachea is normally located centrally or deviating very slightly to the right
True trachial deviation - Pushing of the trachea: large pleural effusion or tension pneumothorax.
- Pulling of the trachea: consolidation with associated lobar collapse.
Apparent tracheal deviation - Rotation of the patient can give the appearance of apparent tracheal deviation, inspect the clavicles to rule out the presence of rotation
bones
- Scapula
- Clavicle
- Vertebra
- Ribs
Pathologies - Fractures #
- Dislocations
- Rib crowding
- Previous surgery
○ Plates
○ Pins
○ Cages
Cardiac
- right- 1/3rd
- left- 2/3rds
sail sign cardiac
* wedge of collapsed tissue behind the heart boarder
* left lower lung collapse
* appears like a boat sail
Diaphragm
- right hemidiaphragm is higher than the left due to the liver
- stomach underlies left hemidiaphragm
- The diaphragm should be indistinguishable from the underlying liver
- if free gas is present (bowel perforation) air accumulates under diaphragm causing it to lift and become visibly separate from the liver
Expansion
- To assess the degree of inspiration it is conventional to count ribs down to the diaphragm. The diaphragm should be intersected by the 5th to 7th anterior ribs in the mid-clavicular line. Less is a sign of incomplete inspiration.
- Less than 5 ribs indicates incomplete inspiration
- More than 7 ribs suggests lung hyper-expansion
Fields & Fissures
- The left lung has two lobes and the right has three
- Fine grey lines that extend throughout the lung fields to within 2cm of the lung edge
o Equal density within the left and right lung fields
o Looking for areas that appear whiter (dense tissue or fluid) OR darker (air) than you would expect
**Horizontal fissure **
* Fluid in horiz fissure and associated pleural effusion.
* Opacity below the horiz fissure so it is clearly defined suggesting infection in middle lobe.
* Horiz fissure has moved from where you would expect it to be suggesting collapse of upper lobe.
Gadgets
- Pacemaker
- ECG lead
- Tracheostomy
- Chest Drain
- Stomach tube Nasogastric
- Sternal wires - Holds sternum back together
- ETT endotracheal tube
- Rods
Hilar or hidden areas
- increased density around the hilar
- bats wing pattern
- pulmonary odema/ fluid overload/ heart failiure & increased blood flow to the area
- The left hilum is often positioned slightly higher than the right, but there is a wide degree of variability between individuals.
- The hilar are usually the same size, so asymmetry should raise suspicion of pathology.
- The hilar point is also a very important landmark; anatomically it is where the descending pulmonary artery intersects the superior pulmonary vein. When this is lost, consider the possibility of a lesion here (e.g. lung tumour or enlarged lymph nodes).
**Causes of hilar enlargement or abnormal position **
* Bilateral symmetrical enlargement is typically associated with sarcoidosis.
* Unilateral/asymmetrical enlargement may be due to underlying malignancy.
* inspect for evidence of the hilar being pushed (e.g. by an enlarging soft tissue mass)
* or pulled (e.g. lobar collapse).
Bullae- common in COPD
- large, air-filled spaces in the lungs that appear more black
- formed by the destruction of alveoli,
- associated with COPD and emphysema.
- They can impair lung function by reducing healthy lung tissue available for gas exchange.
auscultation
- Normal turbulence of air flowing in and out of the lungs produces ‘breath sounds’.
- Louder on inspiration and faded/minimal on expiration
- Inspiratory sounds heard for longer than expiratory
- Over the trachea – bronchial
- Over the lung fields – soft and muffled (described as vesicular), becoming quieter as you move to the base of the lungs.
ACBT
- Breathing control 20-30 seconds – decrease wob
- Huffing followed by cough if needed (FET) – high and low volume to aid sputum clearance
- Breathing control
- 3-4 deep breaths (TEE) – hold and sniff can help improve lung volume
- Breathing control
- 3-4 deep breaths (TEE)
Tidal breathing
Diaphragmatic breathing
One hand on stomach and one hand on chest, breathe in through your nose.
You’ll feel your stomach expand against your hand and your chest should barely move
Breath out through your mouth and you’ll feel your stomach sink back down.
Use of proprioceptive facilitation can be helpful. (push into my hand)
- Forced Expiratory Technique (Fet)
- Forcefully expelling air through an open throat and
mouth - “fogging up a mirror ‘
- Also known as a “huff’
- Helps move sputum from small to larger airways
- Don’t do too many — can cause bronchospasm
- May initiate a cough
- Can be challenging with surgical pain — + supported
Equal pressure points FET
- point at which pressure inside the airway is equal to the pressure outside (intrapleural pressure)
- Forces generated by this manoeuvre cause airway compression and collapse towards the mouth.
- Less exhausting than coughing and as effective for moving distal secretions if not more (coughing increases plural pressure and the collapse/compression is more severe potentially inhibiting clearance)
HUF volumes FET
Medium volume huff
- moves from more peripheral airways
- normal breath in and long huff out
High volume huff
- moves from more central airways
- deep breath, short sharp huff out
Thoracic expansion
- Encouraging lateral chest expansion — hands on for proprioceptive feedback
- Can add a 3’s hold and a ‘sniff’
- Increases collateral ventilation
- Monitor - patients can become lightheaded, 3-5 +/-
3 second hold
shown to decrease collapsed lung tissue and may be good for those with lung pathology as air will first fill in the unobstructed area and the hold may give time for ventilation of collateral pathways.
- Hold - Air travels in direction of least resistance
- Air will go in to region of least resistance, incomplete equilibrium.
- Add a pause or insp hold, allows air to move into more regions and recreating equilibrium by providing additional routes for air to reach alveoli
Percussion:
- rhythmical patting of the chest with a cupped hand
- Performed during normal tidal breathing
- loosens the sputum from the walls of the airways
shakes
- application of large oscillatory movements to the chest wall
- Usually performed on expiration
- Mobilise secretions along the airways
Vibrations
- fine oscillatory movements to the chest wall
- Usually performed on expiration
- Mobilise secretions along the airways
manual technique contraindications
- fractures - rib
- surgical wounds
- frank heamoptysis - alot of blood in sputum
- severe osteoporosis
- severe hypoxia
manual techniques precautions
- bronchospasm
- pain
- osteoporosis
- bone metastases
- near chest drains
goals measureable
use borg – self assessment shortness of breath (2 slightly out of breath)
