L4-5: Low Lung Volumes, Atelectasis and Ventilation Strategies

Question 1

Which lung segment is auscultated at the point marked X?

Answer 1

Right upper lobe anterior segment (rib 2-4, midclavicular line)

Question 2

An extrathoracic wheeze characteristically more marked during inspiration. True or False.

Answer 2

True

Question 3

An intrathoracic wheeze characteristically more marked during expiration. True or false.

Answer 3

True

Question 4

An intrathoracic wheeze characteristically more marked during _____ (inspiration/expiration).

Answer 4

expiration

Question 5

An extrathoracic wheeze characteristically more marked during ______ (inspiration/expiration).

Answer 5

inspiration

Question 6

What is type II respiratory failure?

Answer 6

Hypoxaemia with hypercapnia

Question 7

What is the colour of low VS high oxygen concentration?

Answer 7

• Low: Green
• High: White

Question 8

Why care about Ventilation? What is the aim?

Answer 8

1. No breath = No life
2. Ventilation strategies are vital in Physio toolkit
3. Ax outcome and modify Rx as needed

Aim = Identify ventilation problems / individuals at risk of these problems –> select and implement most appropriate technique/s for individual

• Treat and identify ventilation problems

Question 9

What does BIBA stand for?

Answer 9

BIBA: Brought in by ambulance

Question 10

What does ICC stand for?

Answer 10

Intercostal catheter

Question 11

What are 3 pieces of information found in the bed chart?

Answer 11

1. Vital signs
   
   1. BP
   2. HR
   3. RR
      
      1. Normal: 12-16 breaths
   4. SpO2
      
      1. Normal: >96% FiO2
2. Pain
   
   1. VAS
3. Medications
   
   1. PCA

Question 12

What are 7 characteristics of the patient interview?

Answer 12

1. Main concern
   
   • eg. Painful rib fractures; pain-limited cough
2. Pain
   
   • eg. Sharp, over injured area
3. Cough
   
   • eg. Ineffective due to pain ; avoiding // non-productive
4. SOB
5. PMHx - Medical chart info confirmed
6. Functional ability - Independent, No formal exercise usually performed
7. Social Hx - Medical chart info confirmed

Question 13

What are 2 major things to be aware of in the physical examination?

Answer 13

1. Environment / Attachments
   
   1. Supine, resting in bed
   2. Hudson mask, FiO2 0.35, SpO2 91%
   3. ICC: Swinging, bubbling, draining (Module 2)
   4. PCA: Dorsum L) hand
2. Patient general state
   
   1. Alert, cooperative
   2. Grimacing in discomfort
   3. Posture: Guarding R) side
   4. Colour: NAD

Question 14

What are 4 characteristics of environment/attachments to be aware of in the physical examination?

Answer 14

1. Supine, resting in bed
2. Hudson mask, FiO2 0.35, SpO2 91%
3. ICC: Swinging, bubbling, draining (Module 2)
4. PCA: Dorsum L) hand

Question 15

What are 4 characteristics of patient general state to be aware of in the physical examination?

Answer 15

1. Alert, cooperative
2. Grimacing in discomfort
3. Posture: Guarding R) side
4. Colour: NAD

Question 16

What are 5 major assessments of the physical examination?

Answer 16

1. Respiration
   
   1. Chest shape - NAD
   2. Breathing pattern
      
      • ↓ Costal expansion R) side
      • Pain on deep inspiration - avoiding
   3. ↑ Accessory muscle use
      
      • With not wanting to expand the thorax
2. Palpation
   
   1. ↓ R) basal costal expansion
   2. ° Fremitus
      
      • Retained secretions
3. Auscultation
   
   1. ↓BS R) base
   2. °AS
4. Cough – not performed at this time due to 8/10 pain
5. Circulation
   
   1. DVT check – calves SNT (soft, non tender)
   2. Pulses ++ tibialis anterior, dorsalis pedis, all R)= L) = N

Question 17

What does NAD stand for?

Answer 17

NAD: No abnormality detected

Question 18

What does AS stand for?

Answer 18

AS: added sounds (eg. crackles)

Question 19

What are 5 stages of respiration?

Answer 19

1. Respiratory controller
2. Respiratory muscles
3. 1. Rib Cage + pleura
   2. Abdomen
4. Movement of air
5. Alveolar ventilation

Question 20

What are 2 characteristics of the respiratory controller as the 1st stage of respiration?

Answer 20

1. Respiratory center – involuntary
2. Cortical control – voluntary

• Eg:
  
  • Breathing more due to CO2 (involuntary)
  • vs
  • Voluntarily breathing deeper

Question 21

What are 4 conditions that may affect the respiratory controller as the 1st stage of respiration?

Answer 21

1. Pharmacological eg post-op, over-dose
2. Head injury
3. Tumour
4. CVA/ stroke

Question 22

What is respiration like a normal patient VS a COPD patient?

Answer 22

• Normal drive to breath: built up of CO2
• COPD drive to breath: decrease of CO2

Question 23

What is the pathway to respiratory muscles into the 2nd stage of respiration?

Answer 23

Nerve conduction, synapses- Neurological injuries

That affect the respiratory controller

Question 24

What are 3 conditions that may affect the pathway to respiratory muscles as the 2nd stage of respiration?

Answer 24

1. Guillian Barre syndrome
2. Spinal cord injury
3. Poliomyelitis

Question 25

What are ***respiratory muscles*** in the ***2nd stage of respiration***?

Answer 25

Diaphragm, intercostals, SCM, scalenes

Question 26

What are 4 ***conditions*** that may ***respiratory muscles*** in the **2nd stage of respiration**?

Answer 26

Can be less effective 1. Myopathies 2. Muscular dystrophy 3. Fatigue 4. Surgery * Eg. midline surgery (inhibited diaphragm)

Question 27

What are 3 characteristics of ***rib cage + pleura*** in the **3rd stage of respiration**?

Answer 27

1. Bone 1. Rib #s 2. Post cardiac surgery 3. Kyphoscoliosis * Physically limiting the bucket handle mechanism 2. Pleura 1. Pneumothorax * Fluid or blood caught around the thorax (Pressure/squash on lung --\> lung can’t move properly) 2. Haemothorax 3. Pleural effusion 3. Abnormal chest wall compliance

Question 28

What are 3 pressure changes of the ***abdomen*** in the **3rd stage of respiration**?

Answer 28

1. Distention (Limits amount of space the lung has to expand/move) * Eg 1. Obesity 2. Pregnancy 3. Peritoneal fluid (ascites) 4. Pancreatitis 5. Constipation 6. Abdominal surgery 2. Abnormal mechanics (muscle flaccidity) * Eg 1. Spinal injury 2. Guillian Barre

Question 29

What are 2 characteristics of the ***movement of air*** in the **4th stage of respiration**?

Answer 29

1. Inhibition; Pain 1. Eg: (Not wanting to expand the lungs) 1. Surgery 2. Chest trauma 2. Compression 1. Eg: 1. Tumour 2. Pneumothorax 3. Haemothorax 4. Cardiomegaly * Physically compressing lung (unable to get air in easily)

Question 30

What are 3 characteristics of the ***alveoli ventilation*** in the **5th stage of respiration**?

Answer 30

1. Bronchi to alveolus 1. Secretions within bronchi 2. Tumour within bronchi 3. Bronchitis; Asthma 4. More narrow bronchi --\> harder to get air through 2. Within alveolus 1. Decreased surfactant 2. Pulmonary oedema 3. Inflammation of tissue 3. Pneumonia 1. Emphysema 1. Larger, floppy airways, that has less SA = less effective

Question 31

What is the impact on ventilation for a patient who has abdominal surgery?

Answer 31

Question 32

What are 3 characteristics of the respiratory system?

Answer 32

1. Complex system 2. Interdependent components 3. Conditions affecting one part of system will affect overall process

Question 33

What are 9 important concepts of ventilation?

Answer 33

1. Functional residual capacity (FRC) 2. Closing capacity (CC) 3. Hypoxaemic pulmonary vasoconstriction 4. Atelectasis 5. Critical opening pressure 6. Newtonian Law of Viscosity 7. Collateral ventilation 8. Alveolar interdependence 9. Time constants

Question 34

What is ***functional residual capacity (FRC)*** as the **1st important concept of ventilation**?

Answer 34

* Volume of gas in the lung after a normal expiration * Participates in gas exchange during insp. AND exp. * Balance between inward recoil of lungs and outward recoil of chest wall

Question 35

What is static lung volumes?

Answer 35

Question 36

What is ***closing capacity (CC)*** as the **2nd important concept of ventilation**?

Answer 36

* Volume of air in lung when small airways in dependent lung **start to collapse** during **expiration** (trapping air inside) * Healthy, young individual (approximately): * **CC = RV (residual volume)** * **CC \< FRC** * If CC ≥ FRC during normal expiration there may be **collapse** of airways in dependent lung areas, resulting in **reduced ventilation** to these areas

Question 37

What is the change of FCR with ***position***? What position should you aim for and why?

Answer 37

Upright: Gravity helps to keep abdominal content down --\> lung isn't squashed (optimal space) Supine: No effect of gravity of abdominal content --\> lung squashes (less space) ***Aim for upright positions = improve FRU*** * ***Air in lungs that participate in ventilation during inspiration and expiration***

Question 38

What is the change of FCR with ***age***?

Answer 38

Question 39

What is the impact fo FCR and CC on treatment?

Answer 39

1. FRC lowest in supine vs sitting vs standing --\> aim for upright positions to increase FRC 2. Be aware of changes with age: 1. CC \> FRC in supine by ~45y 2. CC \> FRC in standing by ~65y 3. (& weaker respiratory muscles) 4. Risk of early closure of airways --\> risk of hypoventilation/collapse 3. Decreased FRC with obesity (Adipose tissue is squashing the lungs --\> less space for lungs to expand): 1. Identify those at risk --\> aim for positions to increased FRC

Question 40

What is ***hypoxaemic pulmonary vasoconstriction*** as the **3rd important concept of ventilation**?

Answer 40

1. Protective response 2. V/Q mismatch (Ventilation and perfusion mismatch) --\> decreased PaO2 1. Constriction of pulmonary vessels 1. This is hypoxaemic pulmonary vasoconstriction (Low O2) 2. This will divert blood to areas with greater ventilation (increased perfusion to areas of increased ventilation) 3. • This will increased PaO2 (protection) *Blood flow to area of more O2 instead of from area with no O2. Constricts blood flow to no O2 area.*

Question 41

What is ***atelectasis*** as the **4th important concept of ventilation**?

Answer 41

* Atel” = imperfect, “ectasis” = expansion * “Collapse” = collapsed alveoli * If alveoli are not ventilated, or are unstable --\> collapse * May involve: * Small groups of alveoli * Lung segment / lobe * Whole lung

Question 42

What are 4 types of ***atelectasis*** as the **4th important concept of ventilation**?

Answer 42

1. Micro , Plate 2. Compression 3. Absorption 4. Surfactant impairment

Question 43

What are 3 characteristics of ***microatelectasis*** as the 4th important concept of ventilation?

Answer 43

1. Patchy areas of atelectasis not resulting in shift of structures 2. If not adequately treated may become major atelectasis 3. All post-surgical patients will have microatelectasis

Question 44

What are 3 characteristics of ***plate atelectasis*** as the **4th important concept of ventilation**?

Answer 44

1. Small areas of collapse 2. Thin white lines on CXR 3. Pulmonary oedema, pneumonia

Question 45

What are 6 examples of ***compression atelectasis*** as the **4th important concept of ventilation**?

Answer 45

1. Tumour external to bronchi- Compression (physically unable to expand --\> unstable --\> collapses) 2. Pneumothorax 3. Pleural effusion 4. Cardiomegaly * Large heart --\> physically compressing the lung --\> unable to expand 5. ↑ pleural pressure (or less negative) 6. Relaxed diaphragm eg surgery, anaesthesia

Question 46

What are 5 characteristics of ***absorption atelectasis*** as the **4th important concept of ventilation**?

Answer 46

1. If bronchus or bronchiole is blocked (eg. secretion causing a muscus plug) 1. Gas in unit distal to obstruction is trapped 2. Gas uptake by blood continues 3. Gas pocket collapses 2. Or, if high FiO2 (oxygen therapy) 1. Decreased Nitrogen (Nitrogen is a structural unit) * \>21% of O = \< nitrogren (stable airways --\> collapse; V/Q mismatch) 2. V/Q mismatch

Question 47

What are 2 characteristics of ***surfactant impairment for*** ***atelectasis*** as the **4th important concept of ventilation**?

Answer 47

Surfactant --\> maintain SA of alveoli 1. Surfactant covers large alveolar surface 2. Reduces alveolar surface tension 1. Stabilizes alveoli 2. Prevents collapse 3. Surfactant affected (impaired) by: 1. Anaesthesia 2. Supplemental O2 (dry) 3. Mechanical ventilation 4. Infection 5. Pre-term neonate * Have not developed adequate surfactant

Question 48

What are 6 effects of atelectasis as the 4th important concept of ventilation?

Answer 48

1. Ventilation-perfusion mismatch 1. hypoxemia ( PaO2) 2. in some cases  hypercapnia 2. Decreased FRC 3. Decreased compliance 4. very difficult to re-inflate 5. Increased WOB 6. Increased O2 consumption

Question 49

What are 3 clinical signs of atelectasis as the 4th important concept of ventilation?

Answer 49

1. Palpation 1. Decreased chest wall movement (unilaterally or bilaterally) 2. +/-temperature 2. Auscultation 1. Decreased or absent breath sounds and/or fine end-inspiratory crackles 3. Special tests 1. Decreased SpO2, PaO2 2. CXR These signs may not all be present

Question 50

What are 3 ***CXR signs*** of ***atelectasis*** as the **4th important concept of ventilation**?

Answer 50

1. Shift of structures (TOWARDS collapse) 1. Fissures 2. Diaphragms 3. Mediastinum 4. Trachea 2. Crowding of vessels 1. Increased density (whiteness) of collapsed lobe 3. Separation of lung markings in noninvolved area 4. Crowding of ribs 5. Silhouette sign – loss of border

Question 51

Look at the above example of (L) lung collapse. What are signs that suggest (L) lung collapse in the above CXR?

Answer 51

Question 52

What are 8 ***risk factors*** for ***atelectasis*** as the **4th important concept of ventilation**?

Answer 52

1. Surgical Incision (abdo / thoracic / cardiac) 2. Previous respiratory condition 3. Smoking history 4. Obesity 5. Age 6. Impaired cognitive function 7. Monotonous pattern of mechanical ventilation 8. Body position (supine, slouched)

Question 53

What are 8 ***factors ↑ risk of atelectasis post surgery*** for ***post surgical atelectasis*** as the **4th important concept of ventilation**?

Answer 53

1. Surgery 2. Splinting (/ Sore) 3. Shallow breathing 4. Supine, Slumped 5. ↑ Secretions 6. ↓ Surfactant 7. Synthetic (mechanical) ventilation 8. °Sighs 9. + Smoking history 10. Size (obesity)

Question 54

What are 3 important concetps to ***reverse atelectasis*** as the **4th important concept of ventilation**?

Answer 54

1. Critical opening pressure 2. Slow laminar flow 1. (Newtonian Law of Viscosity) 3. Inspiratory hold 1. Collateral ventilation 2. Alveolar interdependence 3. Surfactant release 4. Time constants

Question 55

What are 1 important concept of ***slow laminar flow*** to ***reverse atelectasis*** as the **4th important concept of ventilation**?

Answer 55

(Newtonian Law of Viscosity)

Question 56

What are 4 important concepts of ***inspiratory holds*** to ***reverse atelectasis*** as the **4th important concept of ventilation**?

Answer 56

1. Collateral ventilation 2. Alveolar interdependence 3. Surfactant release 4. Time constants

Question 57

What is ***critical opening pressure*** as the **5th important concept of ventilation**?

Answer 57

***Pressure needed to overcome surface tension and achieve initial reinflation of collapsed regions*** * Example: Inflate a completely deflated balloon * It is difficult to inflate initially, * Then the rest is easier * Inflating alveoli is similar to this

Question 58

What is ***Newtonian Law of Viscosity*** as the **6th important concept of ventilation**? What is the aim? What is the 3 benefits?

Answer 58

Sticky surfaces peel apart more easily when the action is done SLOWLY ***Aim for “slow laminar flow” inspiration*** Slow, deep, smooth inspiration (\<0.2 L/s) from FRC will: 1. Allow regions with long time constants to fill 2. Fill lower lung regions 3. Encourage opening of alveoli

Question 59

What are the 3 benefits of ***slow laminar flow inspiration*** in ***Newtonian Law of Viscosity*** as the **6th important concept of ventilation**?

Answer 59

Aim for “slow laminar flow” inspiration * Slow, deep, smooth inspiration (\<0.2 L/s) from FRC will: 1. Allow regions with long time constants to fill 2. Fill lower lung regions 3. Encourage opening of alveoli

Question 60

What are the 3 effects of ***fast, shallow, erratic inspiration*** in ***Newtonian Law of Viscosity*** as the **6th important concept of ventilation**?

Answer 60

1. Not allow regions with long time constants to fill 2. Not fill lower lung regions – only upper lung regions 3. Not encourage opening of alveoli

Question 61

What is ***collateral ventilation*** as the **7th important concept of ventilation**?

Answer 61

* Slow laminar flow * Air will eventually flow through different pathways collateral ventilation) * Slow unplug (with some pressure) (Law of viscosity)

Question 62

What is ***alveolar Interdependence*** as the **8th important concept of ventilation**?

Answer 62

Recoiling the collapsing alveoli (with larger breath) * Neighbouring alveoli will stop the collapse

Question 63

What is the equation for ***time constants*** as the **9th important concept of ventilation**?

Answer 63

**Time constant = compliance x resistance of an alveolar unit**

Question 64

What is ***time constants for a healthy lung*** as the **9th important concept of ventilation**?

Answer 64

time constants of all alveoli are relatively uniform - ie **_same_** rate and pressure to inflate alveoli

Question 65

What is ***time constants for an impaired lung*** as the **9th important concept of ventilation**? What are 6 characteristics?

Answer 65

time constants of all alveoli are different - ie **different** rates and pressures to inflate alveoli 1. Alveolar units with ↑ resistance take longer to fill 2. Alveoli with ↑ compliance (ie. floppy) take longer to fill 3. AND, alveoli with ↓ compliance (ie. stiffer) take a greater inspiratory effort to fill 4. Non-uniform time constants 5. ↑ time required to fill alveoli with fresh air 6. ↑ time required to empty alveoli of stale air 1. ↑ respiratory rate 2. ↓ time for inspiration and expiration 3. ↓ ventilation! Inspiratory hold / plateau can allow for different time constants * Allow for times that parts of lungs that collapsed to re-expand

Question 66

What are 6 ***medical management of atelectasis*** as the **4th important concept of ventilation**?

Answer 66

1. Pain relief 2. Bronchoscopy 3. Drainage of pneumothorax / pleural effusion 4. Removal of tumour / obstruction 5. Recruitment maneuvers (if ventilated) 6. Surfactant therapy

Question 67

What are 10 physiotherapy techniques to improve ventilation? **EXAM QUESTION**

Answer 67

1. ***Pain relief*** 2. ***Positioning*** 3. Breathing exercises 4. Demand ventilation / Mobilisation 5. Facilitation techniques 6. Incentive spirometry 7. Positive expiratory pressure devices 8. Non-invasive ventilation 9. Manual & ventilator hyperinflation 10. [Oxygen therapy] * Needs to be in conjunction with other methods. Cannot be the primary management.

Question 68

What are the 3 ***aims of pain relief*** as the **1st physiotherapy techniques to improve ventilation**? What are 3 roles?

Answer 68

Aim to optimise inspiratory volume 1. Support, positioning 2. Modalities such as TENS 3. Time Ax and Rx with pain medications; oral, IV, PCA, epidural IMPORTANT: Physiotherapists do not prescribe or deliver medications to patients But we do: 1. **Monitor** patient’s pain levels prior to starting treatment as well as during treatment 2. **Time** treatment with pain relief 3. Optimise comfort throughout, eg support & positioning

Question 69

What are the 3 characteristics of ***positioning*** as the **2nd physiotherapy techniques to improve ventilation**?

Answer 69

1. High sitting 2. Sitting out of bed (SOOB) / Standing 3. Lateral / side lying ( / High side lying) 4. Prone lying

Question 70

What is the benefit of ***upright positioning*** as the **2nd physiotherapy techniques to improve ventilation**? What are 4 principles why this works?

Answer 70

↑ FRC “Slinky spring” principle 1. Apices have ↓ compliance 2. Bases have ↑ compliance --\> greater ↑ in volume with ventilation 3. ↑ Perfusion in bases (gravity) 4. Ventilation matches perfusion

Question 71

What are 4 characteristics of **(*****high sitting) positioning***as the**2nd physiotherapy techniques to improve ventilation**?

Answer 71

1. Patients often slump in the bed / plinth 1. Ensure hip joint at bed crease 2. If move down bed, will slump more 2. Use chair if possible (SOOB) 3. Care with patients with obesity, may need to sit \<60º 4. Aim to improve position prior to Ax and Rx

Question 72

What is ***(lateral / side lying) positioning*** as the **2nd physiotherapy techniques to improve ventilation**?

Answer 72

Can be high side lying

Question 73

What are 2 characteristics of ***positioning (in non-ventilated patient)*** as the **2nd physiotherapy techniques to improve ventilation**?

Answer 73

1. Perfusion goes to dependent lobe (lower side), ventilation follows 2. But, after ~30 minutes dependent lobe becomes compressed

Question 74

What are 3 characteristics of ***positioning (in unilateral lung disease)*** as the **2nd physiotherapy techniques to improve ventilation**? What is the exact positioning?

Answer 74

Position with ‘good’(unaffected) lung dependent to improve overall gas exchange 1. Perfusion to dependent (‘good’) lung 2. Ventilation follows perfusion to dependent (‘good’) lung 3. Gas exchange improves EXAMPLE, if L) lung is the ‘bad’ lung: R) side lying, thus R) lung is the ‘dependent’ lung (lower) 1. ↑ Perfusion and ventilation to R) lung 2. Will improve gas exchange if L) lung is affected

Question 75

What are 4 characteristics of ***(standing) positioning*** as the **2nd physiotherapy techniques to improve ventilation**?

Answer 75

1. Greatest FRC 2. Can use FLS (forward-lean standing) to help relieve SOB 3. Good for patients with paralytic ileus 4. Tilt-table if appropriate

Question 76

What are 2 characteristics of ***(prone) positioning*** as the **2nd physiotherapy techniques to improve ventilation**?

Answer 76

1. ↑ Lung compliance, secondary to stabilisation of anterior chest wall 2. Apply with caution - may be poorly tolerated, or contraindicated

Question 77

What are 6 characteristics of ***breathing exercises*** as the **3rd physiotherapy techniques to improve ventilation**? What are 2 contraindications?

Answer 77

1. Slow, laminar flow 2. Facilitate BBE (Bi-basal expansion) to ↑ ventilation 1. If BBE is not available, facilitate at ant abdomen 3. Verbal, &/or tactile facilitation (eg fine vibration) to↑movt 4. Avoid accessory muscle use 5. +/- IH (inspiratory hold) / plateau or ‘sniff’ manoeuvre at end of deep insp (unless contraindicated) 6. IMPORTANT: ensure ≤5 consecutive breaths, to avoid hyperventilation 7. Contraindications: 1. Severe ↑ WOB (eg, intercostal recession) 2. Air trapping (severe hyperinflation)

Question 78

What are 4 characteristics of ***Demand Ventilation/Mobilisation*** as the **4th physiotherapy techniques to improve ventilation**?

Answer 78

UL and LL movements 1. ↑muscle activity 2. ↑ minute ventilation **(RR (respiratory rate) X TV (tidal volume))** 3. ↑ cardiac output 4. ↑ O2 extraction at tissue Care: Even low intensity activity will impact patients with acute cardiorespiratory impairments

Question 79

What are 2 ***facilitation techniques*** as the **5th physiotherapy techniques to improve ventilation**?

Answer 79

1. Stretch facilitation 2. Neurophysiological facilitation (NPF) * (perioral stimulation; intercostal stretch) ## Footnote **Aim to ↑ventilation in patients with ↓LOC**

Question 80

What are 5 characteristics of ***(stretch) facilitation techniques*** as the **5th physiotherapy techniques to improve ventilation**?

Answer 80

1. Based on stretch reflex, PNF 2. Quick stretch of intercostal muscles at end of expiration, before the start of inspiration 3. Stronger contraction of intercostals (more forceful) 4. Larger inspiration 5. Monitor effect prior to performing next stretch

Question 81

What are 5 characteristics of ***incentive spirometry*** as the **6th physiotherapy techniques to improve ventilation**?

Answer 81

1. Visual cue to provide feedback regarding inspiration 1. Flow device eg Triflow, Cliniflo 2. Volume device eg Voldyne, Coach 2. Principles of improving ventilation (slow laminar flow…)

Question 82

What are 3 characteristics of ***Positive Expiratory Pressure (PEP) devices*** as the **7th physiotherapy techniques to improve ventilation**?

Answer 82

1. Positive pressure during expiration eg like breathing out through pursed lips 2. ↑FRC and splints airways open 3. Less commonly used for ventilation; usually for ***airway clearance***

Question 83

What are 2 characteristics of ***Non Invasive Ventilation (NIV)*** as the **8th physiotherapy techniques to improve ventilation**?

Answer 83

1. Positive pressure ventilation via mask / mouthpiece 2. Eg, CPAP, BiPAP, IPPB

Question 84

What are characteristics of ***Manual & Ventilator Hyperinflation*** as the **9th physiotherapy techniques to improve ventilation**?

Answer 84

Question 85

What are 4 summaries of **physiotherapy techniques to improve ventilation**?

Answer 85

1. Variety of techniques – using the same principles to reinflate alveoli (slow laminar flow,… ) 2. Consider patient presentation 1. Eg age, conscious vs unconscious 3. Can use combination of techniques – eg pain relief, position into high sitting, breathing exercises (TEE), mobilisation 4. Regular exercises needed eg each hour * Prescribe frequency and duration

Question 86

How will you modify your approach fro different ages and stages (eg.children)?

Answer 86

1. Instruments 2. Bubbles 3. Feathers, 4. Balloons 5. Pin wheel 6. Games with blowing ball

Question 87

What are 3 characteristics of ***increased work of breathing***? What are 2 management?

Answer 87

Can occur with respiratory distress, respiratory failure, COPD, anxiety, exertion 1. ↑ accessory muscle use 2. ↑ RR 3. ↓ energy available for other organs Management of increased WOB: 1. Positioning 2. Breathing control (BC)

Question 88

What are 3 characteristics of ***positioning*** in **increased work of breathing (WOB)?**

Answer 88

1. “Recovery positions” 2. Supported positions 1. Forward lean sitting / standing 2. Relaxed sitting / standing 3. Recruitment of axiohumeral muscles 1. Reverse origin-insertion action 2. Assists respiration 3. Hands on hips, knees, head --\> fixate LL --\> use muscles in a reverse origin-insertion action and move the chest/ribs

Question 89

What are 6 characteristics of ***breathing control (BC)*** in **increased work of breathing (WOB)**?

Answer 89

1. Gentle tidal breathing 2. Emphasise lower chest, not upper chest --\> Minimal effort expended 3. Inspire through ***nose to warm, humidify and cleanse air*** (but through mouth if nose is blocked) 4. Intersperse throughout other techniques for recovery & to prevent airflow obstruction 5. Duration of BC depends on pt’s presentation 6. 2-3 breaths, up to minutes++

Question 90

What are 6 features in the clinical problem solving framework?

Answer 90

1. **Problem** (what problem/s does this patient have that I can treat?) 2. **Evidence** (how do I know this problem exists? ie, Ax findings) 3. **Pathophysiological cause** (what causes this problem?) 4. **Management & rationale** (what can I do to help improve this problem, & why have I selected this approach?) 5. **Outcome measures** (how will I know if this Mx is working?) 6. **+ Special considerations** (what do I need to think about before assessing / treating this patient?)

Question 91

Example clinical problem solving framework?

Answer 91

Question 92

What is the handover/ward round report?

Answer 92