Lung Sx, Patients Requiring Ventilatory Support, Outpatient Pulmonary Therapy

Question 1

VATs

Answer 1

Referred to as a VATs (Video Assisted Thoracotomy)

Video camera used

if they can avoid it they do not want to open the chest

Question 2

What does CDI stand for

Answer 2

clean, dry, intact

Question 3

Types of lung surgery removal

Answer 3

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

Question 4

What would be INEFFECTIVE for a pleural effusion

Answer 4

postural drainage and percussion, vibration

Question 5

Pleurodesis

Answer 5

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

Question 6

What O2 reading is pretty serious

Answer 6

under 86

Question 7

Ventilators

Answer 7

Patients who are ventilator dependent may also be referred for physical therapy/chest PT

Ventilation can be a short or long term intervention

Question 8

Four primary reasons for employing endotracheal intubation:

Answer 8

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

Question 9

Four types of AIRWAY ADJUNCT devices

Answer 9

Oral pharyngeal airway (often used in emergencies)
Nasal pharyngeal airway
Oral endotracheal tube (commonly seen post sx)
Tracheostomy tube

Question 10

When would an Oral pharyngeal airway be used

Answer 10

emergencies

Question 11

Short-term or Long-term? Oral endotracheal tube (ETT)

Answer 11

Short-term

commonly seen post sx

Question 12

Tracheostomy is for and would affect

Answer 12

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

Question 13

Tracheostomy Tube and considerations for PT

Answer 13

if tubing has condensation you want to drain it

Question 14

Decannulation is

Answer 14

If the tube comes out it is referred to as a
DECANNULATION

Patient can still breathe

If accidental: needs to be rectified immediately

Question 15

What is weaning

Answer 15

The process of progressing from mechanical ventilation to breathing on one’s own is referred to as WEANING

Question 16

Intubation vs Tracheostomy and mobilization

Answer 16

PT intervention for pt’s with tracheostomy has long been standard practice

Intubated pts less mobile
require more assistance

Trached pts ↑ Independence

Question 17

What is a passy muir and what are some considerations

Answer 17

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

Question 18

Vents are

Answer 18

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

Question 19

Four Basic Settings for Vents

Answer 19

CMV (Continuous Mandatory Ventilation)

A/C (Assist Control)

IMV (Intermittent Mandatory Ventilation)

CPAP (Continuous Positive Airway Pressure)

Question 20

CMV

Answer 20

Controlled Mandatory Ventilation
(set tidal volume and rate)

Machine is preset

Ignores patient effort

Provides set TV and rate

Uncomfortable if patient is conscious

Question 21

What is an A/C vent setting and what potential harm could be caused

Answer 21

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

Question 22

Which vent is for weaning

Answer 22

IMV

Question 23

CPAP

Answer 23

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

Question 24

Weaning stages

Answer 24

Weaning can progress from:
CMV→
SIMV→
CPAP→
Tracheostomy Collar (with supp O2)
→Nasal Cannula (trach capped)
→Room Air

Question 25

FI O2 is recorded by and how is this different from a nasal cannula

Answer 25

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

Question 26

Documented differences of O2 Levels between a

NC vs Collars

Answer 26

NC in l for liters

Collars and masks in FIO2 for fraction of inspired oxygen

Question 27

Vented pts can:

PT treatment

Answer 27

Dangle
Transfer to geri-chair or regular chair
March in place
Ambulate to limit of circuit

Question 28

Exclusion Criteria for

Pulmonary PT

Answer 28

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

Question 29

Third Party Payers for Pulmonary rehab require

Answer 29

Documented Respiratory Disease

Documented Functional Limitations

PFTs, other tests (< 60% of normal function)

Question 30

Pulmonary Care

Answer 30

Respiratory treatment techniques for clearing secretions and relieving dyspnea
Bronchial drainage
Breathing techniques
Cough facilitation
Postural correction and positioning to improve breathing
Relaxation techniques

Question 31

Types of Airway Clearance Techniques

Answer 31

Active Cycle of Breathing

Autogenic Drainage (used for CF)

Coughing Techniques

Question 32

ENERGY CONSERVATION TECHNIQUES

key points

Answer 32

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

Question 33

BODY MECHANICS AND MOVEMENTS

Answer 33

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

Question 34

BREATHING PATTERNS

Answer 34

Use breathing patterns before, during and after activities

PLB

Diaphragmatic

Paced - exhale with effort

Question 35

Dealing with SOB Exacerbations

Answer 35

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

Question 36

What is Fremitus

Answer 36

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

Question 37

Postural Drainage Contraindications

Answer 37

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

Question 38

Contraindications Trendelenburg

Answer 38

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

Question 39

Percussion is used for, and you should do it for at least (time)

Answer 39

Loosens secretions
Use cupped hand
Should sound hollow
Percuss only over ribs
Percuss for at least one minute

Question 40

Contraindications for percussion

Answer 40

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

Question 41

Vibration, is it different from percussion

Answer 41

Gentler than percussion

Uses flat hand

Always go “down and in”

Coordinate with exhale