Lung Sx, Patients Requiring Ventilatory Support, Outpatient Pulmonary Therapy Flashcards
VATs
Referred to as a VATs (Video Assisted Thoracotomy)
Video camera used
if they can avoid it they do not want to open the chest
What does CDI stand for
clean, dry, intact
Types of lung surgery removal
Lobectomy – a lobe is removed
Segmentectomy – a lung segment is removed
Wedge Resection – a wedge shaped section of the lung is resected
Pneumonectomy – an entire lung is removed
What would be INEFFECTIVE for a pleural effusion
postural drainage and percussion, vibration
Pleurodesis
an irritant (often talc powder) is introduced in the pleural space to create inflammation and tack the two pleura together to prevent recurrent fluid accumulation
What O2 reading is pretty serious
under 86
Ventilators
Patients who are ventilator dependent may also be referred for physical therapy/chest PT
Ventilation can be a short or long term intervention
Four primary reasons for employing endotracheal intubation:
1) Upper airway obstruction
2) Inability to protect lower airway from aspiration
3) Inability to clear secretions from the lower airways
4) Need for positive pressure mechanical ventilatory assistance
Four types of AIRWAY ADJUNCT devices
Oral pharyngeal airway (often used in emergencies)
Nasal pharyngeal airway
Oral endotracheal tube (commonly seen post sx)
Tracheostomy tube
When would an Oral pharyngeal airway be used
emergencies
Short-term or Long-term? Oral endotracheal tube (ETT)
Short-term
commonly seen post sx
Tracheostomy is for and would affect
For patients who require long term intubation
Incision is made in the tracheal rings
Provides greater mobility
Decreases risk of irritation/infection
Tracheostomy tube is inserted below the level of the vocal chords
-speaking
Tracheostomy Tube and considerations for PT
if tubing has condensation you want to drain it
Decannulation is
If the tube comes out it is referred to as a
DECANNULATION
Patient can still breathe
If accidental: needs to be rectified immediately
What is weaning
The process of progressing from mechanical ventilation to breathing on one’s own is referred to as WEANING
Intubation vs Tracheostomy and mobilization
PT intervention for pt’s with tracheostomy has long been standard practice
Intubated pts less mobile
require more assistance
Trached pts ↑ Independence
What is a passy muir and what are some considerations
Tracheostomy tubes can be accessorized with valves to facilitate speech. Passy-Muir is the most common valve
To let them speak they would need this but keep in mind when it is in it is harder to breath, so dont ask person to do anything that demanding
Vents are
Mechanical ventilators deliver gas to patient’s lungs by creating positive pressure to ↑ intrathoracic pressure to expand the chest wall
You can tell how much of the work of breathing is being provided by the ventilator by checking the setting
Four Basic Settings for Vents
CMV (Continuous Mandatory Ventilation)
A/C (Assist Control)
IMV (Intermittent Mandatory Ventilation)
CPAP (Continuous Positive Airway Pressure)
CMV
Controlled Mandatory Ventilation
(set tidal volume and rate)
Machine is preset
Ignores patient effort
Provides set TV and rate
Uncomfortable if patient is conscious
What is an A/C vent setting and what potential harm could be caused
Assist Control - responds to pt effort
Non-weaning mode
Triggered by patient effort
Set rate provides breath in absence of pt effort
Ventilator provides breath at preset tidal volume with every patient effort
Potential for hyperinflation or resp alkalosis
Which vent is for weaning
IMV
CPAP
Continuous Positive Airway Pressure
Ventilator provides an elevated baseline pressure to help a patient breathe spontaneously
Ventilator DOES NOT initiate breaths
less work for person to breath
Weaning stages
Weaning can progress from: CMV→ SIMV→ CPAP→ Tracheostomy Collar (with supp O2) →Nasal Cannula (trach capped) →Room Air
FI O2 is recorded by and how is this different from a nasal cannula
Supplemental O2 is commonly used with a trach collar
Record how much O2 is used by documenting FIO2 (Fraction of Inspired O2) (remember RA = 21% so an FIO2 of 60% is ≈ 3X RA)
Differs from nasal cannula which is recorded in liters of O2
Documented differences of O2 Levels between a
NC vs Collars
NC in l for liters
Collars and masks in FIO2 for fraction of inspired oxygen
Vented pts can:
PT treatment
Dangle
Transfer to geri-chair or regular chair
March in place
Ambulate to limit of circuit
Exclusion Criteria for
Pulmonary PT
Uncontrolled CHF Unstable angina Resting tachycardia (> 100 BPM, slightly higher for post op patients-120 hard cut off) Severe bradycardia (< 50 BPM) Uncontrolled HTN Uncontrolled Pulmonary HTN Other illness which precludes exercise Inability to learn Demonstrated poor motivation Refusal to participate in smoking cessation program Guilty of disruptive behavior
Third Party Payers for Pulmonary rehab require
Documented Respiratory Disease
Documented Functional Limitations
PFTs, other tests (< 60% of normal function)
Pulmonary Care
Respiratory treatment techniques for clearing secretions and relieving dyspnea
Bronchial drainage
Breathing techniques
Cough facilitation
Postural correction and positioning to improve breathing
Relaxation techniques
Types of Airway Clearance Techniques
Active Cycle of Breathing
Autogenic Drainage (used for CF)
Coughing Techniques
ENERGY CONSERVATION TECHNIQUES
key points
Space tasks throughout the day Monitor how you feel throughout the day Take rest breaks after meals/throughout the day Rest BEFORE you are exhausted Perform strenuous activities when you feel you have the most energy Ask for help when you need it Slide things instead of carrying them Use a basket for rollator
BODY MECHANICS AND MOVEMENTS
Maintain a straight back, bend from hips and knees
Use large muscles over small
NEVER RUSH
Move slowly, keep your arms close to your body
Sit if possible when dressing, grooming, preparing food
BREATHING PATTERNS
Use breathing patterns before, during and after activities
PLB
Diaphragmatic
Paced - exhale with effort
Dealing with SOB Exacerbations
Stop activity Find a comfortable position Use PLB and diaphragmatic breathing Do not inhale through the mouth Breathe initially at whatever speed needed to regain control gradually slow rate of breathing
What is Fremitus
Vibration
Produced by voice or presence of secretions in airways
Transmitted to chest wall
Abnormal Finding
Increased Fremitus indicates presence of secretions or consolidation
Decreased Fremitus indicates presence of air or fluid in the pleural space
Postural Drainage Contraindications
ICP > 20 mmHg
Unstabilized head/neck injury
Active hemorrhage
Hemoptysis (use judgment)
Empyema (pus)
Bronchopleural fistula
Pulmonary edema assoc with CHF
Large pleural effusions
PE
Confused/anxious patients
Rib fracture
Surgical wound
Post op where joint compression contraindicated
Contraindications Trendelenburg
Neuro dx: Cerebral aneurysm, ICF drain, coma, recent CVA, uncontrolled sz
↑ ICP contraindicated
Uncontrolled HTN
Distended abdomen
Post esophageal procedures
Cardiovascularly unstable: Acute MI, pulmonary HTN, arrhythmias
Aneurysm, esp AAA
Continuous tube feedings
Unstable fluid balance: CHF, during HD, ascites
Recent hemoptysis related to lung CA
Uncontrolled airway, aspiration risk
Percussion is used for, and you should do it for at least (time)
Loosens secretions Use cupped hand Should sound hollow Percuss only over ribs Percuss for at least one minute
Contraindications for percussion
Pneumothorax
Platelets < 50,000
Cardiovascularly unstable pt
Over rib fx or lesion
Osteoporosis (dexa 3), CA mets, prolonged steroid use
Over sx incisions/sternotomy
Over recent graft, burn or wound
also: When blood too thin (↑ INR, etc.) Hemoptysis (use judgment) Undrained empyema Subcutaneous emphysema PE Flail chest Awaiting R/O for MI Acute TB Severe pain Recent spinal fusion
Vibration, is it different from percussion
Gentler than percussion
Uses flat hand
Always go “down and in”
Coordinate with exhale
