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CVR > Introduction to treatment > Flashcards

Introduction to treatment Flashcards

1
Q

What are we aiming to treat?

A

Sputum retention
Reduced lung volume
Increased work of breathing (WOB)
Pain
Fatigue
Reduced exercise tolerance

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2
Q

Hypoxia and respiratory failure

A

Caused by several of our problems
Hypoxia - life threatening

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3
Q

Oxygen therapy

A
  • Is a drug
  • Should be prescribed with target sats
  • In an emergency situation when someone is critically unwell
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4
Q

In emergency situations…

A

When a patient is critically unwell OR has SpO2 <85%.

Once stable, aim for SpO2 94-98% or patient-specific target range.

15L via a reservoir mask/non rebreathe mask

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5
Q

Target saturations

A
  • 94-98% for most (Scale 1) (BTS)
  • 88-92% for patients at risk of CO2 retention (Scale 2) (BTS)
  • 92-96% for Covid positive patients
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6
Q

How might we adjust oxygen delivery for WOB and sputum

A
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7
Q

Titrating up and down

A
  • Increase FiO2 if SpO2 is lower than target range
  • Decrease FiO2 if SpO2 is higher than target range
  • Monitor SpO2 for 5mins at every change
  • If FiO2 is increased, medical assessment is needed
  • Ensure any changes are documented
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8
Q

Too much oxygen is harmful

A
  • Absorption atelectasis (absorption of oxygen from alveoli exceeds replenishment of alveolar gas, so that the alveoli are no longer held open by cushion of inert nitrogen ‘nitrogen wash out’.
  • High concentrations may impair the respiratory drive of hypercapnic COPD patients.
  • Excess oxygen depletes protective anti-oxidants, causing oxygen toxicity.
  • Affects on the CV system.
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9
Q

Pactical tips with oxygen therapy

A

Beware of air at the wall (black)
Setting the flow

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10
Q

Nebulisers

A
  • Direct delivery of medication to the lungs
  • Saline can aid airway clearance by reducing the viscosity of sputum
  • Bronchodilators can reduce bronchoconstriction to aid air flow

Saline 0.9% or 7% - hypertonic

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11
Q

Other medications-

A
  • To consider from DH - mucolytics, parkinsons meds
  • Pain management- need extra, encourage to use e.g. PCA
  • Timing of these is important
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12
Q

What is positioning used for

A

For postural drainage/gravity assisted drainage

For V/Q matching

For WOB

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13
Q

Postural drainage

A
  • Uses gravity to assist drainage of secretions
  • Area to be drained positioned highest
  • Most affected area drained first
  • Ideally 10 mins in each position
  • Max 3 positions per session
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14
Q

Postural drainage positions

A
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15
Q

Precautions/contraindications with postural drainage head down

A
  • When placing head down:
  • Increased WOB
  • Head and neck pathology/Raised ICP
  • Cardiovascular pathology
  • Abdominal pathology
  • Pregnancy
  • Obesity
  • Care with attachments
  • Reflux GERD/GORD or nausea
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16
Q

V/Q matching (ventilation/perfusion)

A

**Upper zone **- elevated ventilation, reduced perfusion
**Middle zone **- ventilation = perfusion
Lower zone- reduced ventilation, elevated perfusion

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17
Q

AIms

Positioning to decrease work of breathing

A

Aims:
* Stabilise shoulder girdle/optimise thoracic cage movement
* Dome a flattened diaphragm
* Decrease energy consumption

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18
Q

Positioning to decrease work of breathing - in standing

A

Relaxed standing
Forward lean standing

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19
Q

Positioning to decrease work of breathing - in sitting

A

Relaxed sitting
Forward lean sitting

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20
Q

Positioning to decrease work of breathing- supported sitting and high side lying

A

Supported forward lean sitting
Supported high side lying

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21
Q

Breathing exercises

A

Active cycle of breathing technique (ABCT)

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22
Q

Active cycle of breathing - 3 stage cycle

A

1) Breathing control
2) Thoracic expansion exercises (TEEs)
3) Forced expiratory technique (FET) or “huff”

Flexible and can be adapted to the patient
Can be used by patient without assistance

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23
Q

ABCT cycle

A

Breathing control 20-30 seconds
3-4 deep breaths (TEE)
Breathing control
3-4 deep breaths (TEE)
Breathing control
Huffing followed by cough if needed

Cycle

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24
Q

Breathing control

A

Tidal breathing

Encourage:
Relaxation of upper chest
Diaphragmatic breathing

Use of proprioceptive facilitation can be helpful.
Get hands on!

Continue until patient is ready to progress

Diaphragmatic breathing can allow the patient to control their breathing - one hand on stomach

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25
Q

Thoracic expansion exercises

A
  • Simply - deep breathing exercises (DBEs)
  • Encouraging lateral chest expansion – hands on for proprioceptive feedback
  • Can add a 3’s hold (shown to decrease collapsed lung tissue) and a ‘sniff’
  • Increases collateral ventilation
  • Monitor - patients can become lightheaded, 3-5 +/-
26
Q

Forced expiraotry technique (FET)-

A
  • 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
  • Medium and high volume
  • Don’t do too many – can cause bronchospasm
  • May initiate a cough
  • Can be challenging with surgical pain – + supported
27
Q

Adapt the treatment to the patient it’s flexible

A

**BC **
* Can reduce WOB

TEE
* Hold and sniff can help improve lung volume

FET
* High and low volumes to aid sputum clearance
* Can also be taught prophylactically

Add in more or less of each component to meet the needs of the patient

28
Q

TEE anf FET

Precautions

A

Consider whetehr the patient can follow instructions

Bronchospam – care with FET, may have or need bronchodilators prior to maximise effects

Consider numbers of TEE and effects on BP

29
Q

Manual techniques MTS

A

Percussion
Shakes
Vibrations

30
Q

Percussion

A

Rhythmical patting of the chest with a cupped hand

Performed during normal tidal breathing

Loosens the sputum from the walls of the airway

31
Q

Shakes

A

Application of large oscillatory movements to the chest wall

Usually performed on expiration

Mobilise secretions along the airways

32
Q

Vibrations

A

Five oscillatory movements to the chest wall

Usually perfromed on expiration

Mobilise secretions along the airways

33
Q

Percussion - patient friendly communication

A

Pat your chest

34
Q

Precautions and contraindications with percussions

A

Precautions
Bronchospasm
Pain
Osteoporosis
Bone metastases
Near chest drains

Contraindications
Fractures (rib)
Surgical wounds
Frank haemoptysis
Severe osteoporosis
Severe hypoxia

35
Q

Frank haemoptysis

A

Copius amounts of blood in sputum

36
Q

How could you make increasing lung volume more effective?

A

Positioning
Breathing control
Thoracic expansion

37
Q

Risk assessment for Mobilisation and exercise - TILEO

A
  • Think about what you plan to do
  • How will you manage that safely?
  • Incorporates aspects of A-E
  • CV stability
  • Oxygen requirement
  • Attachments
  • Any weight bearing restrictions?
  • Any investigations outstanding?
38
Q

Mobilisation
1) Can be to:
2) May require aids to assist

A

**Can be to: **
* The edge of the bed
* A chair
* Walking from A to B
* Achieving functional level to return home

May require aids to assit:
For support and safety
To reduce the load and work of breathing

Useful for addressing our 3 main problems

39
Q

Exercise

A
  • To maintain ROM and muscle strength
  • To improve exercise tolerance
  • To increase lung volumes
  • To aid sputum clearence
    • Prescription – what type and to what level, rep and sets.
    • Patients can be independent with exercises
40
Q

Monitoring exercise tolerance

A

BORG scale

41
Q

Pulmonary rehabilitation (PR)

A
  • 6-12 week programme
  • Education & Exercise (cardio & strengthening)
  • Usually run in groups
  • Should involve the MDT
  • Aims to improve patient’s physical fitness and ability to manage their own condition
42
Q

Education and advice

A
  • Long term secretion management
  • Hydration and diet
  • Medication
  • Pacing and activities
  • Exercise/ Pulmonary rehabilitation
  • Smoking cessation
  • Signs of infection
43
Q

It is vital to evaluate and re-evaluate before, during and after every treatment

A
44
Q

Approximate conversion values for venturi

A

Venturi 24% (blue) 2-3 l/min

Venturi 28% (white) 4-6 l/min

Venturi 35% (yellow) 8-12 l/min

Venturi 40% (red) 10-15 l/min

Venturi 60% (green) 15 l/min

Reservoir mask at 15 l oxygen flow
Seek medical advice

45
Q

Absorption atelactasis

A

Refers to a loss of lung volume caused by the resorption of air within the alveoli.

46
Q

V/Q matching

A

The regional matching of the flow of fresh gas to flow of deoxygenated capillary blood

47
Q

Postural drainage-
Apical segments of both upper lobes

A

Sat in incline with pillows behind back and neck (more behind the neck)

48
Q

Postural drainage -
Anterior segments of both upper lobes

A

Lying flat with pillow under neck and leg (from bum to ankle)

49
Q

Postural drainage -
Lateral and medial segments of middle lobe

A

Lying in decline on side with pillow under neck and under back

50
Q

Postural drainage -
postural segment of right upper lobe

A

Lying in prone flat with pillows under neck and belly

51
Q

Postural drainage-
Superior and inferior segments of the lingula lobe

A

In deline on side-
pillow under neck and back

51
Q

Postural drainage-
Posterior segment of the left upper lobe

A

On stomach flat with multiple pillow under head

52
Q

Postural drainage-
Apical segments of both lower lobes

A

Lying prone flat with pillow under neck and hip area

53
Q

Ventilation/perfusion ratio

A

Efficiency and adequcy of the ventilation-perfusion coupling

Ventilation- the air that reaches the alveoli

Perfusion- the blood that reaches the alveoli via the capillaries

54
Q

Forced expiratory technique (FET) -
Medium moves from more peripheral airways

A

Normal breath in and long huff out

55
Q

Forced expiratory technique (FET) -
High moves from more central airways

A

Deep breath, short sharp huff out

56
Q

Physiology of forced expiratory technique

A

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)

57
Q

Bronchospasm

A

Happens when the muscles that line your bronchi (airways in your lungs) tighten

58
Q

Bronchodilators

A

Medication that make breathing easier by relaxing the muscles in the lungs and widening the airways.

59
Q

Reduced exercise tolerance-

A

Feel breathless
Avoidance
Do less
Muscles become weak and less efficient
Get more breathless
Repeat

60
Q

What are the three main phases of ABCT

A

1) Breathing control (6 breaths)
2) Deep breathing exercises or thoracic expansion exercises
3) Huffing or FET

CVR (11 decks)

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