Positioning for VQ and breathing exercises

Question 1

What is the rationale behind using this treatment (Pain/Increase ROM/strengthen)? (positioning for VQ)

Answer 1

we want the most optimal VQ (1:1)

by positioning a patient correctly you can optimise their VQ ratio or help treat problems leading to mismatch, often used alongside other treatment techniques such as postural drainage and manual techniques

Question 2

What are the physiological effects of the treatment/how does it achieve the aim? (positioning for VQ)

Answer 2

improved ventilation, enhanced perfusion, reduced work for breathing by eliminating respiratory muscle fatigue, improved oxygenation of blood and tissues

Question 3

What structures are affected by the technique? (positioning for VQ)

Answer 3

alveoli

pulmonary vessels

IPP

position and function of the diaphragm

airways, by promoting the drainage of secretions

Question 4

What principles are used in carrying out the technique? (positioning for VQ)

Answer 4

in a self ventilating adult in the upright position, the dependant lung (just above the bases) has the best VQ matching

Question 5

Why is the IPP more negative at basal level?

Answer 5

weight of fluid in the pleural cavity

Question 6

What level has larger alveoli but why is this a negative?

Answer 6

apical because of the weight of the basal region expanding them

but the smaller underinflated alveoli in the lung bases have greater potential to expand on inspiration

Question 7

What is the analogy used for the difference between apical and basal lungs?

Answer 7

slinky spring

Question 8

Why is there less perfusion in the apical region of the lungs?

Answer 8

volume and pressure of alveoli is high so it encroaches on the surrounding vessels, and gravity causes hydrostatic pressure in the blood vessels to be less above the heart, so less blood flow is directed to the apices

Question 9

What are the 3 zones of the lungs, what are the characteristics of each and what has the best VQ?

Answer 9

Zone 1: apices, low blood flow and expanded alveoli leads to low blood flow and therefore high V/Q at 5:0

Zone 2: middle, potential to expand and good hydrostatic pressure, V/Q ration is about equal at 1:0

Zone 3: bases, alveoli aren’t very expanded, high blood flow, low V/Q at 0:5

Question 10

What is the definition of ventilation and perfusion, then shunting and dead space?

Answer 10

V=rate at which gas enters or leaves the lungs

Q=process of delivery of blood to capillary bed

shunting=area with no ventilation

dead space=area with no perfusion

Question 11

Precautions and Contraindications?

Answer 11

Precautions:
nausea, vomiting, dizziness
cv instability
raised ICP
recent thoracic, abdominal or spinal surgery
burns or wounds

Contraindications:
head and neck injury until stabilise
active haemoptysis (coughing up blood)
undrained pneumothorax (gas in air space) (chest pain, dry cough, bluish skin)
bronchopleural fistula-hole in the lung or bronchus
rib fracture
recent epidural or spinal infusion
pulmonary embolism

Question 12

How does body positioning have an effect on VQ?

Answer 12

ventilation and perfusion will increase towards the dependant area of the lung (lung most affected by gravity)

for example, if someone is placed on their right side, the right lung is the dependant lung

Question 13

What effect does mechanical ventilation have on VQ positioning?

Answer 13

normally inspiration occurs due to negative pressure within the IPS and alveoli, but with mechanical the air flow will take the path of least resistance so the non dependant lung is better ventilated.

Question 14

What is the treatment procedure for positioning for VQ?

Answer 14

introduce yourself

explain purpose of treatment and check contraindications

gain informed consent to carry out treatment

ensure environment is suitable

position patient

observe effects of patient in this position

monitor patient carefully throughout the treatment for any adverse reactions and check they are comfortable and consent throughout.

after reassess the patient and check for any adverse effects

consider position to leave the patient in following treatment and ay advice you would give to other health professionals.

Question 15

What is the rationale behind using this treatment (Pain/Increase ROM/Strengthen etc)? (breathing exercises)

Answer 15

target respiratory problems

breathe with minimal effort and encourage airflow in individuals with respiratory problems

Question 16

What are the physiological effects of the treatment? (breathing exercises)

Answer 16

explained below

Question 17

What structures are affected by the technique? (breathing exercises)

Answer 17

alveoli

diaphragm

respiratory muscles

abdomen

bronchioles

Question 18

What principles are used in carrying out the technique? (breathing exercises)

Answer 18

pt modesty and safety considered

communicate regularly

Question 19

Precautions and contraindications? (breathing exercises)

Answer 19

precautions:
acute medically unwell
acute unstable head, neck, or spinal injury
acute bronchospasm (muscles that line the bronchi tighten and lead to wheezing and coughing)
inadequate pain control

contraindications:
patients unable to participate as breathing exercises require an element of patient participation and understanding

Question 20

What are 6 positions you can tell the patient to do when they are short of breath?

Answer 20

standing leaning forward with your elbows resting on something

standing leaning back against a wall, arms relaxed, feet one foot from the wall slightly spread apart

sitting leaning forward with elbows rested on knees, wrists and hands limp

sitting upright, wrists and hands limp, back against chair

sitting leaning forward with elbows resting on table, can use pillows to rest head on

high side lying, few pillows under head and shoulder, pillow between waist and armpit to stop sliding down the bed, knees and hips slightly bent

Question 21

What should documentation look like for breathing techniques? (breathing exercises)

Answer 21

date, pt name and DOB

date pt VCG, contraindications checked

treated in upright sitting with pillow to support (Ex.)

taught and practiced breathing control

pt had good technique and able to practice independently

no adverse effects following treatment

print my name, signature
student physiotherapist

Question 22

What is the treatment procedure for breathing exercises?

Answer 22

introduce yourself, gain informed consent to carry out treatment

ensure environment is suitable and position patient appropriately using pillow and a towel/blanket for comfort as required

carry out the breathing techniques, communicate regularly and provide feedback on their technique

ensure to monitor the patient carefully throughout for any adverse reactions, e.g. light headedness/dizziness and check they are comfortable with the technique and consent for you to continue

reassess patient and check for any adverse effect

Question 23

What does ACBT consist of?

Answer 23

breathing control, thoracic expansion and forced expiratory technique/huff (FET)

(only cover BC and TE in level 4)

Question 24

What is breathing control and what is it used for?

Answer 24

means normal gentle breathing at tidal volume, low effort, arms supported with upper chest, shoulders and hands relaxed.

breathing gently to be more calm and relaxed, to gain control of breathing, prevent increase in airflow obstruction and allow patients to feel more rested between the active and forced techniques of the cycle

Question 25

How is the breathing control technique applied?

Answer 25

physio places hand over the abdomen

pt gently breathes in and concentrates on allowing the abdominal wall to rise gently under the physios hands, with the abdomen slowly sinking back to rest position when breathing out

upper chest and shoulders should maintain relaxed throughout

emphasis needs to be placed on the importance of regular practice which the pt can do by resting both hands over to abdomen to feel the mvmt caused by diaphragmatic movement not abdominal muscle contraction.

Question 26

What is thoracic expansion and why is it useful?

Answer 26

deep breathing exercises that emphasis deep inspiration with quiet unforced expiration

emphasis is on increasing the lateral movement of the chest particularly towards the lower lobes of the lung

upper chest and shoulders relaxed

air can enter the lungs through pores of kohn (alveoli and neighbour) canals of lambert (alveoli and respiratory bronchiole) channels of martin (between 2 respiratory bronchioles)

the slow deep breaths allow the channels to be accessed more effectively which can allow air to move secretions and reflate collapsed alveoli

Question 27

How to apply the forced expiration technique?

Answer 27

pt positioned appropriately

place palm of hand in midaxillary line over 7th and 8th ribs, fingers relaxed covering the posterior aspect of thorax

instruct pt to relax and breathe out, allowing ribs to sink down and in-not forced.

then apply mild pressure to the chest wall and instruct pt on the next inspiration to expand the lower ribs against your hand.

pressure released at the end of inspiration, but hands kept on chest wall and re-applied when the pt is ready to breathe again