Physiotherapy treatment and clinical reasoning CIR Flashcards
(39 cards)
What are the 3 things physios treat?
Lung volume
Sputum retention
Work of breathing
What are the clinical signs of sputum retention?
Audible secretions on auscultation
Tactile fremitus
Increased WOB- use of accessory muscles
Increased RR
Abnormal blood gas
What can cause sputum retention?
Impaired mucociliary clearance= damaged airways, viscocity, smoking, intubation
Excessive secretions
Impaired cough = trauma, surgery, pain, fatigue, reduced GCS, muscle weakness/paralysis
Aspiration
Pain
Post surgery and put on O2
Treatment options for sputum retention
- Mobilise, Hydration, ACBT, Positioning, Pain control, Postural drainage
- Manual techniques, Nebs (alongside positioning etc)
- Positive expiratory pressure (alongside MT)
- Suctioning (alongside MT etc)
- Assisted cough, MHI
Things that effect lung volume
Pneumothorax
Pleural effusion
Atelectasis
COPD
Reduced thoracic mobility- COPD barrel chest, rib fractures, scoliosis
Reduces lung compliance
Respiratory muscle weakness
Increased inward recoil of lungs (can then cause compression of smaller airways leading to reduced gas exchange)
How does volume loss present?
- Difficulty taking breaths
- Reduced chest wall movement
- Reduced breath sounds
- Find crackles on auscultation (associated with sudden opening of previously closed airways)
- Bronchial breath sounds heard elsewhere than over the trachea (signs of pneumonia, atelectasis etc. air spaces become less, allowing sounds from the larger airways to be transmitted more directly to the chest wall. )
- Pain in inspiration
- Reduced exercise tolerance
- Use of accessory muscles
- Reduced sats
- Respiratory failure
Treatment options for volume loss
- Mobilise, ACBT, positioning, incentive spirometer, pain management, postural drainage, thoracic mobility exercises, FET/Cough
- PEP, NIV (non-invasive ventilation)
- Manual hyperinflation
What causes breathlessness and increased WOB?
Deconditioning, muscle innervation, level of fatigue
-Hypoxic drive
- Hypercapnic drive (body tries to compensate by increasing ventilation)
-Anxiety, hyperventilation
- pneumothorax
- sputum retention
How does breathlessness and increase WOB present?
- Tachycardia
- Mouth breathing
- Pattern of breathing
- Accessory muscle use
- Saturations
- Increased resp rate
What are the treatment options for breathlessness and increased WOB
- Rest
- Reassurance
- ACBT
- Teach positions of ease
- Positioning
- Sputum clearance
- Address bronchospasm
- Oxygen
- Inspiratory muscle training
ACBT - Deep breathing (thoracic expansion) what issue is this trying to fix and how? What does the sniff do?
Lung volumes and secretion retention
- Re-expanding any collapsed alveoli and re-open collateral ventilation channels.
- Sniff helps keep ventilation channels open
- The expanding forces between alveoli are greater than at tidal volume and therefore deep breathing may assist with re-expansion (alveolar inter-dependence).
- The deep breaths reduce the resistance between the bronchioles and alveoli and therefore air flows through channels to enhance expiratory flow behind secretions and loosen them.
ACBT - Breathing control: what issue is this trying to fix and how?
Increased WOB
- Helps the patient breath gently, using as little effort as possible
ACBT- Forced expiratory technique: what issue is this trying to fix and how?
Retained secretions
- Small long huff moves sputum from low down in your chest
- Big short huff moves sputum from higher up in your chest
(People who struggle to cough and clear it can be difficult to close the glottis for long enough to be able to cough so the huff moves secretions without closing the glottis)
When would you use percussions instead of vibs/shakes?
Rib fractures
Osteoporosis
A lot of pain/ discomfort
Frail old patient
Directly on surgical wounds
When would you not do ACBT with a patient?
If they have an undrained pneumothorax or a pulmonary effusion
If techniques like ACBT, positioning and MT aren’t effective for sputum retention, what could the next stage of treatment be?
Suctioning and Manual techniques
Positive expiratory pressure
Oscillating positive pressure
Assisted cough (NIPPY)
Manual Hyper Inflation alongside suction
What is positive expiratory pressure and how does it work?
Creates a resistance during exhalation which builds up pressure keeping airways open, preventing premature airway closure and allowing air to get behind sputum.
Promotes collateral ventilation. Allowing air to get behind sputum and push it up towards larger airways
What is Oscillating positive pressure device and how does it work?
A handheld device to facilitate the clearance of mucus.
Exhalation results in oscilliations of expiratory pressure and airflow, which vibrate the airway walls, loosening mucus, preventing collapsing airways and facilitates movement of mucus up airways
What is manual hyperinflation and how does it work?
Squeezing the bag increases the baseline tidal volume during inspiration. The inspiratory hold allows time for the alveoli and collateral airways to open and remain open. The quick release increases the elastic recoil of the lung and increasing the expiratory rate.
Helps moves secretions
(suction after if required)
What is an assisted cough and how does it work?
Uses a positive pressure to fill the lungs, and then swtiches to a negative pressure to produce a high expiratory flow rate.
Helps mimic a cough if a pt is unable to, helps clear secretions and increase tidal volumes.
Contraindications for PEP
Undrained pneumothorax
Air leak as a result of pulmonary surgery- PEP can cause further air to be pushed through these air leaks
Low Bp- reduced venous return to the heart due to increase intrathoracic pressure, making the heart harder to fill and pump blood effectively
Higher ICP
Contraindications of MHI
- Undrained pneumothorax
- Severe bronchospasm (can further narrow the already narrowed airways due to the increased pressure created)
- High Intracranial pressure
- Post pulmonary surgery complication open bronchopulmonary fistula- air leak into the chest cavity
Contraindications for assisted cough
Undrained pneumothorax
Raised ICP (coughing increased ICP already)
Contraindications for suctioning
No specific contraindications but need to consider additional adverse effects which may occur with the patient.
Post pulmonary surgery- may disrupt the anastomosis and causing it to breakdown, leading to bronchopleural fistula
Severe bronchospasm
