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DPT 629: Cardio > PT Interventions for the Pulmonary System > Flashcards

PT Interventions for the Pulmonary System Flashcards

1
Q

generally a person’s SpO2 goal will be bw ______%

A

90-92%

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2
Q

for someone with COPD, what might their SpO2 goal be?

A

88%

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3
Q

if the appropriate prescription is written, can the PT titrate O2 up/down?

A

yup

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4
Q

t/f: in the event of an energy that warrants administration of supplemental O2, the PT may provide supplemental O2, but the physician should be notified and an order should be written following the event

A

true

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5
Q

at the end of a PT session, what needs to be checked on the O2 before leaving?

A

we need to return supplemental O2 to their prior level and flow rate if changed

if the pt can’t maintain their prescribed SpO2 at previous levels, inform the provider

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6
Q

if a pt’s SpO2 drops below 90% what should we do?

A

stop and do coughing techniques, pursed lip breathing, positional change, or deep breathing and recheck SpO2

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7
Q

after doing breathing/coughing techniques if you reassess O2 and it is still below 90%, what should you do if they are not on O2?

A

consult the MD for revised O2

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8
Q

after doing breathing/coughing techniques if you reassess O2 and it is still below 90%, what should you do if they are on O2 and you have an MD order to titrate?

A

adjust the flow as needed and/or change the delivery method

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9
Q

after doing breathing/coughing techniques if you reassess O2 and it is still below 90%, what should you do if they are not on O2 and you can’t contact the MD?

A

decrease activity level

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10
Q

a pt’s SpO2 drops below 90% so you stop and do breathing/ coughing techniques. You reassess and O2 is still below 90%. They are on O2 and you can’t contact the MD so you decrease activity and check their SpO2 again. Their SpO2 is still below 90%, what should you do?

A

stop activity and discuss with the MD

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11
Q

your pt’s SpO2 drops below 90% so you stop and do breathing/coughing exercises and reassess their O2 and it’s above 90%, what do you do?

A

monitor and continue the POC

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12
Q

your pt drops below 90% so you do coughing/breathing exercises and they are still below 90%. You decrease the activity level and reassess O2 and it is above 90%, what do you do?

A

monitor and continue the POC

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13
Q

when adjusting O2, go up by ___ liters/min at a time and wait for a response

A

1

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14
Q

t/f: at any point b4 turning up the O2, try breathing/coughing exercises

A

true

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15
Q

what is a precaution with oxygen usage?

A

can be negative in pts w/chronically elevated CO2 levels (COPD)

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16
Q

why do we have to be careful titrating O2 with someone who has chronically elevated CO2 (like COPD)?

A

bc increased O2 can decrease their RR and/or depth of respiration

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17
Q

what are some signs that O2 may be too high?

A

if the pt is lethargic, disoriented, or drowsy after increasing their O2 titration

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18
Q

generally, if the O2 tank is less than __%, we should refill it before activity

A

30

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19
Q

what things do we need to consider with O2 before activity?

A

is the O2 delivery device appropriate?

is there adequate O2 in the tank?

can the delivery be escalated if necessary?

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20
Q

what is the most common pt population for pulmonary rehab?

A

chronic lung disease w/fxnal limitations (COPD)

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21
Q

other than pts with COPD, what other pts may be good candidates for pulmonary rehab?

A

pts with interstitial lung disease or pulmonary HTN

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22
Q

t/f: there is a lack of research for pulmonary rehab for secondary pulmonary diseases like pulmonary fibrosis from chemo

A

true

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23
Q

what is the goal of pulmonary rehab?

A

focus on fxnal capacity and health related QOL, NOT improvement of the disease processes or lung fxn measures

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24
Q

t/f: the goal of pulmonary rehab is to improve PFTs for pts

A

false

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25
Q

what are the key measurement domains for pulmonary rehab?

A

exercise capacity

clinical symptoms

health-related behaviors

psychosocial status

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26
Q

what is the traditional setting for pulmonary rehab?

A

outpatient is the most common, but can also be inpatient or home care

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27
Q

what is a common barrier to pts getting pulmonary rehab?

A

it is often outpatient, and these pts have a hard time getting out to go to therapy

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28
Q

what is the typical timeline for pulmonary rehab?

A

6-12 weeks 2-3x/week

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29
Q

who may or may not be on the pulmonary rehab team?

A

PT, OT, behavioral health, social work, pharmacy, nutrition

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30
Q

who is always involved in pulmonary rehab?

A

medical director, respiratory therapist, pt and family, and program director

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31
Q

what are the components of pulmonary rehab?

A

pt assessment and individualized goal setting

exercise and fxnal training

self-management education

nutritional intervention

psychosocial management

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32
Q

what is the gold standard for testing exercise and fxnal level?

A

6MWT

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33
Q

what are examples of education topics for pts in pulmonary rehab?

A

normal A&P

pathophys of chronic lung diseases

description and interpretation of medical tests

breathing retraining

airway clearance

meds

respiratory devices

benefits of exercise

ADLs

diet and nutrition

irritant avoidance

exacerbation and infection prevention

coping skills

advance directive planning

palliative care

leisure activity

travel

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34
Q

ideally, in a perfect world, what would be involved in a PT management eval for pulmonary rehab?

A

chart review

pt interview

physical exam

nutritional assessment

chest evaluation

MSK and integ exam

fxnal eval

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35
Q

what would be included in a nutritional assessment?

A

weight

height

BMI

recent weight changes

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36
Q

what would be included in a chest evaluation?

A

auscultation of heart and lungs

cough assessment

inspection of breathing pattern

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37
Q

what would be included in a MSK and integ exam?

A

jt ROM

gross strength of extremities and trunk

posture

gait

skin inspection

edema inspection

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38
Q

what would be included in a fxnal eval?

A

ADLs/IADLs

balance and gait

prior LOF

need for adaptive equipment

fall risk

leisure (social and fam activity)

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39
Q

what is the order of PT interventions for pulmonary rehab?

A

1) airway clearance
2) fxnal training (energy conservation, relief of dyspnea, breathing retraining)
3) physical endurance (endurance training, strength training, flexibility, respiratory muscles training)

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40
Q

what are the 3 different reasons for positioning?

A

1) positioning for dyspnea relief
2) positioning to maximize ventilation/perfusion matching
3) paired positioning and breathing techniques

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41
Q

what are the different positions for dyspnea relief?

A

w/arms supported (or in closed chain)

tripoding

leaning against a wall

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42
Q

what does positioning with arms supported (or in closed chain) do for dyspnea relief?

A

the accessory muscles can act on the rib cage and thorax, allowing more expansion for inspiration

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43
Q

what does tripoding do for dyspnea relief?

A

intraabdominal pressure rises and pushes the diaphragm up in a lengthened position

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44
Q

what does positioning changes do for dyspnea relief?

A

creates a better length-tension relationship by fixing the UE so the other end of the muscles can work in moving the rib cage for more efficient muscle use

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45
Q

what does the Q in VQ matching mean?

A

perfusion

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46
Q

what does the V in VQ matching mean?

A

ventilation

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47
Q

what is perfusion?

A

the amount of blood flow

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48
Q

what is ventilation?

A

air flow in and out of an area

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49
Q

t/f: perfusion and ventilation are unequal thought the lungs and changes with position

A

true

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50
Q

t/f: generally blood flow follows gravity with perfusion

A

true

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51
Q

what area of the lungs gets the most perfusion?

A

the lowest (dependent) parts

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52
Q

in sitting/standing, where is the most perfusion in the lungs?

A

at the bases of the lungs

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53
Q

in supine, where is the most perfusion in the lungs?

A

to the posterior lungs

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54
Q

in S/L, where is the most perfusion in the lungs?

A

on the side of the lungs you are lying on

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55
Q

when there is lower interpleural pressure, is there increased or decreased volume at the end of expiration?

A

increased

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56
Q

when there is an increased volume at the end of expiration, is there higher or lower potential to expand (compliance)?

A

lower

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57
Q

when there is lower potential to expand (compliance) is there higher or lower ventilation?

A

lower

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58
Q

t/f: dependent areas tend to have greater compliance and greater ventilation

A

true

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59
Q

t/f: ventilation is altered by mechanical ventilation

A

true

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60
Q

in sitting, where in the lungs is there more potential to open (compliance)?

A

at the bases of the lungs bc they are more compressed

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61
Q

bc the top of the lungs are not very compressed in sitting/standing, is there more or less potential to open (compliance)?

A

less

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62
Q

if the base of the lungs are compressed 50%, they can open __%

A

50

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63
Q

if the top of the lungs are compressed 10%, they can open __%

A

10

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64
Q

best oxygenation is achieved where the V/Q ratio is …

A

1:1

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65
Q

if there is low V, but high Q, what happens?

A

there is decreased O2 to deoxy blood

there is decreased CO2 elimination

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66
Q

if there is high V, but low Q, what happens?

A

limited ability to increase overall PaO2 bc available hemoglobin saturates quickly

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67
Q

t/f: ventilation/perfusion goes up when you go down the lungs in sitting/standing

A

true

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68
Q

where is there optimal VQ in upright positioning in the lungs?

A

at about rib 4/5

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69
Q

when the FRV is increased, is there more or less alveolar collapse?

A

less

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70
Q

in upright position, VQ is highest where and decreases moving where?

A

highest at the bases
decreased moving cephalically

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71
Q

t/f: with larger lung volumes there is improved diaphragm excursion

A

true

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72
Q

what is the best position to optimize VQ most times?

A

in upright positions

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73
Q

in supine the FRV is ____ which leads to ___ airway collapse

A

decreased, increased

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74
Q

t/f: lower FRV leads to more airway collapse

A

true

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75
Q

t/f: dependent airway collapse leads to VQ mismatch

A

true

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76
Q

what happens to VQ matching in supine?

A

there is reduced lung volume leading to lower FRV and more airway collapse

increased resistance to the diaphragm from abdominal contents

dependent airway collapse=VQ mismatch

narrowing of airways

secretion pooling

compressed bronchioles leads to thickened mucus

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77
Q

VQ is highest where is SL?

A

in the dependent lung

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78
Q

in unilateral lung disease, how do we position a pt in SL?

A

with the “good” lung down

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79
Q

in SL which lung do we want on the bottom to maximize VQ?

A

the good lung

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80
Q

why do we want the “bad” lung on top in SL?

A

bc gravity can drain the secretions

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81
Q

besides VQ matching, what is an advantage of SL?

A

it offloads a lot of boney prominences

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82
Q

why would we put someone in prone for VQ matching?

A

for pts on mechanical ventilators

less lung mass anteriorly means that there is less lung collapse in prone than in supine

more even VQ distribution

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83
Q

what conditions would we put someone in prone for?

A

mechanical ventilated pts

ARDS

COVID-19

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84
Q

why would we put a pt in Trendelenburg positioning for VQ matching?

A

bc it is optimal for facilitating secretion drainage from the lower lobes of the lungs

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85
Q

t/f: trendelenburg positioning may alleviate dyspnea in pts with COPD

A

true

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86
Q

what are some contraindications for Trendelenburg positioning?

A

CHF

cardiomyopathy

acute brain injury

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87
Q

why is Trendelenburg positioning good for VQ matching?

A

bc it allows gravity to pull the abdominals up to help the diaphragm have more room to expand for ventilation

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88
Q

t/f: most people tolerate Trendelenburg positioning well

A

false, most pts can’t tolerate it

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89
Q

when are therapeutic positioning techniques and paired breathing strategies indicated?

A

for pts who have weakness or inhibition of the diaphragm

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90
Q

t/f: therapeutic positioning techniques should taught at rest and then incorporated into fxnal mobility activities

A

true

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91
Q

what pts may be good candidates for therapeutic positioning techniques?

A

SCI, phrenic nerve injuries, post-abdominal surgery, or pts on mechanical ventilation for a long time

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92
Q

at rest, ___pelvic tilt will encourage a diaphragmatic breathing pattern

A

posterior

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93
Q

how does posterior pelvic tilt encourage diaphragmatic breathing?

A

by closing the anterior chest and putting the diaphragm on stretch for better length-tension relationship

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94
Q

what is the therapeutic positioning and paired breathing for inspiration?

A

shoulder flexion

abduction

ER

upward eye gaze

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95
Q

what is the therapeutic positioning and paired breathing for expiration?

A

shoulder extension

adduction

IR

downward eye gaze

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96
Q

how do we use paired breathing in bed mobility?

A

exhale while rolling (flexion bias)

inhale while coming to sit w/trunk extension (ext bias)

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97
Q

how do we use paired breathing for sit to stands?

A

exhale during hip/trunk flexion

inhale during hip/trunk extension

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98
Q

breathing exercises are primarily used to address what?

A

ventilation

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99
Q

t/f: breathing exercises may also address airway clearance as a consequence of improving ventilation

A

true

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100
Q

pursed lip breathing is used for what?

A

dyspnea relief

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101
Q

what are the indications for pursed lip breathing?

A

increased RR, dyspnea, and wheezing

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102
Q

what are the goals of pursed lip breathing?

A

relief of dyspnea, reduced RR, improved activity tolerance, reduced wheezing

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103
Q

what breathing exercise helps splint airways open for expiration?

A

pursed lip breathing

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104
Q

t/f: pursed lip breathing helps prolong expiration

A

true

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105
Q

how long should expiration be compared to inspiration?

A

expiration should be twice as long as inspiration

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106
Q

what is the technique for pursed lip breathing?

A

instruct the pt to breathe in for 2 counts and breathe out as if through a straw for 4 counts

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107
Q

what is diaphragmatic breathing?

A

breathing technique that facilitates outward motion of the abdominal wall while reducing upper ribs cage motion during inspiration

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108
Q

what are the indications for diaphragmatic breathing?

A

hypoxemia, tachypnea (upper chest breathing), atelectasis, anxiety, excess secretions

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109
Q

what are the goals for diaphragmatic breathing?

A

eupnea, improved SpO2, reduction of atelectasis, anxiety, excess secretions

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110
Q

t/f: diaphragmatic breathing should be taught in multiple positions

A

true

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111
Q

why should diaphragmatic breathing be taught in multiple positions?

A

bc there is not necessarily carryover from one position to another

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112
Q

how should we progress positions for teaching diaphragmatic breathing?

A

start in supine, progress to sitting, standing, and then ambulation

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113
Q

what are the facilitation techniques for diaphragmatic breathing from least to most reliance on the therapist?

A

posterior pelvic tilt

tactile cues using own hands or therapist’s hands on their stomach or objects like a weight

upper chest relaxation (contract-relax techniques)

sniffing technique

scoop technique

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114
Q

t/f: if you do too many breathing exercises in a row it can lead to hyperventilation

A

true

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115
Q

what is the sniff technique for diaphragmatic breathing?

A

position the pt in a gravity eliminated position (SL or semi fowlers) and in posterior pelvic tilt

instruct the pt to sniff 3x

give verbal feedback to breathe through the diaphragm

instruct the pt to sniff deeply 2x but longer this time

progress to a single sniff

continue to provide cuing to sniff more slowly, quietly, and with less effort

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116
Q

what is the scoop technique for diaphragmatic breathing?

A

position the pt in gravity eliminated position and posterior pelvic tilt

place your hand on the pt’s abdomen and feel their normal breathing

during expiration, follow the diaphragm up and under the ribs

during the next inspiration, instruct the pt to breathe into your hand

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117
Q

what is the technique for upper chest inhibition for diaphragmatic breathing?

A

perform diaphragmatic scoop technique

place your other forearm gently over their upper chest at the level of the sternal angle

for the first few breaths allow the forearm to move w/the chest while performing diaphragm scoop

during the next inspiration, have the forearm stable, applying gentle pressure to prohibit upper chest mov’t

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118
Q

when is upper chest inhibition used for diaphragmatic breathing?

A

after all other diaphragmatic activation techniques have been tried and failed

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119
Q

t/f: upper chest inhibition may help a pt recruit the diaphragm during inhalation

A

true

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120
Q

what are the indications for upper chest inhibition?

A

excessive accessory muscles use in inspiration

121
Q

what is the goal of upper chest inhibition?

A

to reduce accessory muscle use

122
Q

what are the indications for lateral costal expansion?

A

asymmetric chest wall expansion, localized lung consolidation/secretions, asymmetric posture

123
Q

what are the goals of lateral costal expansion?

A

symmetric chest wall expansion, mobilization of secretions, corrected posture

124
Q

t/f: lateral costal expansion can be unilateral or bilateral technique

A

true

125
Q

what is the unilateral technique for lateral costal expansion?

A

have the pt in SL on the unaffected side

abduct the pt’s arm over the head

at the end of expiration, the therapist provides a quick stretch to initiate inspiration (shouldn’t be resistance to wall expansion)

therapist provides firm pressure throughout inspiration

126
Q

what is the BL technique for lateral costal expansion?

A

pt in semi-fowlers or sitting

therapist on either side of the rib cage and breathe into the hands

at the end of expiration give sharp brief stretch

127
Q

what are the indications for segmental breathing?

A

localized chest wall expansion, localized lung consolidation/secretions, asymmetric posture

128
Q

what are the goals of segmental breathing?

A

symmetric wall expansion, mobilization of secretions, corrected posture

129
Q

what is the technique for segmental breathing?

A

place your hand over the area of the lungs that demonstrates less mov’t or has decreased ventilation and instruct the pt to breathe into the hand

130
Q

when is segmental breathing used?

A

when there is pathology in a particular lung segment

131
Q

what are the indications for inspiratory/breath hold technique?

A

hypoventilation, ineffective cough, atelectasis

132
Q

what are the goals for inspiratory/breath hold techniques?

A

improved VQ matching, resolution of atelectasis, improved cough effectiveness

133
Q

what is the technique for inspiratory/breath hold techniques?

A

pt is instructed to take as deep a breath as possible and then hold at max inspiration for 2-3 seconds followed by passive expiration

134
Q

what are the indications for stacked breathing?

A

hypoventilation, atelectasis, ineffective cough, pain, uncoordinated breathing pattern

135
Q

what are the goals of stacked breathing?

A

improved VQ matching, resolution of atelectasis, reduced pain, improved cough effectiveness

136
Q

what is the technique for stacked breathing?

A

pt is instructed to take a deep breath and briefly hold

pt is then instructed to take another breathe in and briefly hold

pt continues taking breaths in until they can no longer inspire any more

end with passive expiration

breathe in until you can see that they can’t breathe in anymore and then let it all go

137
Q

what are the indications for incentive spirometry?

A

hypoventilation, atelectasis, ineffective cough

138
Q

what are the goals for incentive spirometry?

A

improve ventilation, reverse atelectasis, stimulate cough, diaphragmatic breathing

139
Q

what is a typical population that will use incentive spirometry?

A

post-op pts

140
Q

what is the technique for incentive spirometry?

A

instruct pt to take a long, slow breath in through the mouthpiece

breathe in as deeply as they can while maintaining the bead in the middle position

therapist can set a desired lung volume or can instruct the pt to attempt to beat their own last breath

141
Q

typical instructions for incentive spirometry are to complete __ breaths in one hour

A

10

142
Q

what is the definition of paced breathing?

A

volitional coordination of breathing during activity

143
Q

what are the indications for paced breathing?

A

low endurance for household mobility or ADLs, dyspnea on exertion, fatigue, anxiety, tachypnea

144
Q

what are the goals of paced breathing?

A

increased activity tolerance, reduce dyspnea, reduce fatigue, lower anxiety, eupnea

145
Q

t/f: paced breathing is for diaphragmatic weakness

A

false, that is paired breathing

146
Q

what is the technique for paced breathing for rhythmic activities like ambulation and stairs?

A

use rhythm of the activity to time breathing

breathe in for 2 steps breathe out for 4 steps

147
Q

what is the technique paced breathing for non-rhythmic activities like STSs and bed mobility?

A

breathe in to prep for the activity, breathe out during the movt

147
Q

t/f: paced breathing can be helpful for painful trunk incisions

A

true

148
Q

t/f: paced breathing can be combined with diaphragmatic breathing or pursed lip breathing

A

true

149
Q

what are airway clearance techniques?

A

manual or mechanical procedures that facilitate mobilizations of secretions from airways

150
Q

what are the indications for airway clearance techniques?

A

impaired mucociliary transport

excessive pulmonary secretions

ineffective or absent cough

(overall impaired airway clearance)

151
Q

what things would let us know that airway clearance is impaired?

A

wet cough, crackles on auscultation, egophany, frematus on palpation

152
Q

you should select optimal airway clearance techniques based on what?

A

pathophysiology and symptoms

stability of medical status

pt’s adherence to the techniques

153
Q

should we facilitate secretions from proximal or peripheral first?

A

from peripheral to move them closer

154
Q

what are the goals of airway clearance?

A

optimize airway patency

increased VQ matching (clears secretions that block O2 exchange)

promote alveolar expansion

increased gas exchange

155
Q

what are simple forms of airway clearance?

A

deep breathing, coughing techniques, and mobility

156
Q

what are the 4 stages of an effective cough?

A

1) an inspiration greater than tidal volume (>60% VC) w/trunk ext

2) closure of the glottis

3) contraction of abdominals and intercostals muscles, producing positive intra-thoracic pressure

4) sudden opening of the glottis and forceful expiration of air w/trunk flexion

157
Q

what is the only stage of an effective cough that we as PTs can’t influence?

A

2) closure of the glottis

158
Q

what are some things that tell us the pt is having problems with glottis closure?

A

they can’t hold in a deep breath

159
Q

what is the 1st line of intervention to promote effective cough?

A

positioning and teaching proper coughing technique

160
Q

how can we maximize inspiration for proper cough?

A

verbal cues, position, and arm mov’t (extension with arms up and out)

161
Q

how can we maximize intrathoracic and intraabdominal pressures?

A

with contractions/mov’t (breath hold, stacked breathing)

162
Q

how can we orient the pt to respective timing?

A

using trunk mo’vt for expulsion

163
Q

how should we teach post op pts to cough?

A

with a pillow to splint

164
Q

why do we teach post op pts to splint while coughing?

A

bc it is painful for them

165
Q

what is huff coughing?

A

forced expiration technique (FET)

alternative to coughing

166
Q

what pts would benefit from huff coughing?

A

pts with pain from incision

fatigue from frequent coughing

167
Q

what are the benefits from huff coughing?

A

less painful and fatiguing

helps stabilize collapsible bronchiole walls

breath hold helps separate mucus from airway walls and gets air behind the mucus

168
Q

what is the technique for huff coughing?

A

sit upright and take a breath in then pause holding the breath

forcefully exhaled the breath w/mouth opened

like fogging up a mirror

start with medium depth inspiration and gradually increase size of inspiration

169
Q

shallow to medium breaths affect ___ airways

A

peripheral

170
Q

deep breaths affect ____ airways

A

proximal

171
Q

what are the characteristics of effective huffing?

A

mouth open in an o shape

forced expiration

mid volume moves peripheral secretions

high volume moves proximal secretions

muscles of chest/abdomen contract

sounds like forced sigh

crackles heard if excessive secretions are present

172
Q

what are the characteristics of ineffective cough?

A

mouth half/almost closed

always using high volume inspiration

abdominal muscles not used

sounds more like hissing/blowing

mouth in “e” shape

too vigorous/long (irritating on the airways)

too gentle

too short

“catching/grunting” at the back of the throat

173
Q

what is manually assisted coughing?

A
174
Q

who would use manually assisted coughing?

A

pts with neuromuscular impairments that cause muscle weakness leading to an ineffective cough (SCI, ALS, vent)

175
Q

t/f: in manually assisted coughing, the pt plays an active role

A

true

176
Q

what is manually assisted coughing technique?

A

instruct the pt to take deep breaths and deliver manual assistance as they cough

with hands on other side of the belly button, push into the abdomen

177
Q

what is the goal of manually assisted coughing technique?

A

increased cough effectiveness

178
Q

who do we use counter rotation for?

A

young children, pts with high tone, pts with cognitive impairments

179
Q

what is counter rotation technique?

A

performed in SL using PNF techniques to facilitate inspiration/expiration w/rotary mov’t

after facilitating a full inspiration, compression of the thorax is applied in all planes to aid the cough

180
Q

what are mechanical aids for coughing?

A

devices and techniques that apply manual or mechanical forces to the body or intermittent pressure changes to the airways to assist w/coughing

mechanical cough delivers deep insufflations followed by deep exsufflations

may add abdominal thrust

181
Q

mechanical cough delivers deep ____ followed by deep _____

A

insufflations, exsufflations

182
Q

what are some considerations for airway clearance techniques?

A

should be performed at least 30 minutes minutes prior to or after a meal or tube feeding

optimize pain control prior

consider use of inhaled bronchodilators prior to intervention

monitor vital signs throughout

monitor pt tolerance and response

183
Q

what is chest PT?

A

percussion and vibration

184
Q

what is the goal of chest PT?

A

to loosen retained secretions when there is impaired mucociliary transport

185
Q

t/f: chest PT is used in combo w/other techniques so secretions can be cleared after they’re loosened

A

true

186
Q

what other techniques may be used in combo with chest PT?

A

active cycle breathing and postural drainage

187
Q

what is the main combo of PT treatments for pts who can’t actively participate?

A

chest PT and postural drainage

188
Q

t/f: chest PT may produce temporary desaturation?

A

true

189
Q

what are the indications for chest PT?

A

CF, bronchiectasis, respiratory muscles weakness, mechanical ventilation, ineffective cough, fremitus w/palpation, bronchial breath sounds, crackles on auscultation

190
Q

what are the precautions for chest PT?

A

uncontrolled bronchospasms

osteoporosis

rib fx

metastatic CA to the ribs

tumor airway obstruction

PE

subcutaneous emphysema

recent skin grafts or flaps on the thorax

191
Q

what is percussion?

A

manual: rhythmic clapping w/cupped hands

mechanical: electrical/pneumatically powered device used to reduce caregiver fatigue or allow self treatment

192
Q

where should percussion be applied?

A

to the affected lung segments

193
Q

how long should we do percussion on the affected area of the lungs?

A

3-5 minutes each segment

194
Q

what should percussion sound like?

A

hollow sound under your cupped hands

195
Q

what is involved in the preparation for percussion and vibration chest PT?

A

place pt in appropriate position

apply thin layer of fabric over the area

adjust the bed height for caregiver body mechanics

196
Q

what is the technique for percussion?

A

cup your hands with the thumb and fingers adducted

should create a hollow thudding noise not a clapping noise

keep shoulders, arms, wrists relaxed

go at a rate of 100-480x/min

apply throughout inspiration/expiration

avoid boney prominences

avoid implanted medical devices

197
Q

is percussion applied during inspiration or expiration?

A

both

198
Q

what is vibration?

A

manual or mechanical

low amplitude, high frequency oscillation applied via therapists hands during expiration only to the affected lung segments

199
Q

is vibration applied during inspiration or expiration?

A

expiration

200
Q

where is vibration applied?

A

to the affected lung segments

201
Q

what is the technique for vibration?

A

place hands on the affected area (side by side or one on top of the other)

instruct the pt to take deep inspiration and @ peak apply gentle but steady co-contraction of the UE throughout expiration

202
Q

what is active cycle of breathing? (IMPORTANT)

A

specific cycles of 3 techniques used for airway clearance

203
Q

what are the 3 techniques involved in active cycle breathing?

A

breathing control (diaphragm breathing)

thoracic expansion

forced expiratory technique (huff)

204
Q

what is demonstrated to be as effective as airway clearance performed by a caregiver/therapist?

A

active cycle of breathing

205
Q

what is breathing control in active cycle of breathing?

A

gentle tidal volume breathing with relaxed upper chest and shoulders

206
Q

what is the purpose of breathing control in active cycle of breathing?

A

essential to prevent bronchospasms

207
Q

what is thoracic expansion in active cycle of breathing?

A

active deep inspirations with passive expiration w/ or w/o percussion/vibration

208
Q

what is the purpose of thoracic expansion in active cycle of breathing?

A

loosens secretions

209
Q

what is the purpose of forced expiratory technique in active cycle of breathing?

A

progressively move secretions from peripheral to proximal airways for expectoration

210
Q

what sized huffs should be used first and why?

A

medium sized huffs to move secretions from the periphery to proximal

211
Q

what is the cycle in active cycle of breathing?

A

breathing control for 5-10 sec

3-4 thoracic expansion exercise

breathing control 5-10 sec

3-4 thoracic expiratory exercises

breathing control 5-10 sec

2 huffs of medium sized volume then start against until you can do 2 consecutive cycles with dry nonproductive coughs

212
Q

what is the adaptation for hyperactive airways ion the active cycle of breathing?

A

prolonged breathing control times

213
Q

what is the adaptation for tenacious (thicker) secretions?

A

do more cycles of thoracic expansion b4 FET

214
Q

what is the adaptation for if we hear audible secretions moving from large airways in the active cycle of breathing?

A

change to deep volume huffs

215
Q

what is postural drainage used for?

A

airway clearance

216
Q

what is postural drainage?

A

assuming body positions that let gravity assist in draining secretions from each lung segment

217
Q

with postural drainage, in each position the segmental bronchus of the area to be drained is arranged ___ to the floor

A

perpendicular

218
Q

t/f: priority is given to treating the most affected lung segment 1st in postural drainage

A

true

219
Q

with postural drainage, what should be encouraged bw positions as secretions mobilize?

A

deep breathing and coughing

220
Q

when postural drainage is used in combo with percussion/vibration, how long should we work in each position?

A

3-5 minutes

221
Q

when postural drainage is used alone, how long should we work in each position?

A

5-10 minutes

222
Q

can postural drainage positions be modified if the optimal position is contraindicated?

A

yup!

223
Q

what are the signs of intolerance in postural drainage?

A

SOB, anxiety, dizziness, nausea, HTN, bronchospasms

224
Q

what are the precautions for postural drainage?

A

pulmonary edema

hemoptysis

massive obesity

large pleural effusion

massive ascites

225
Q

what are relative contraindications for postural drainage?

A

increased intracranial pressure

hemodynamic instability

recent esophageal anastomosis

recent spinal fusion surgery

recent head trauma

diaphragmatic hernia

recent eye surgery

226
Q

what is generally the last choice for airway clearance after the other techniques have been tried and failed?

A

airways suctioning

227
Q

what is the goal of airway suctioning?

A

removal of secretions that the pt is unable to clear

228
Q

what are the 2 types of suctioning?

A

oropharyngeal and tracheal

229
Q

what are the 2 types of tracheal suctioning?

A

deep and inline

230
Q

if a pt is hooked up to ventilator, what kind of tracheal suctioning would be used?

A

inline tracheal suctioning

231
Q

if a pt is not hooked up to a ventilator, what kind of tracheal suctioning would be used

A

deep tracheal suctioning

232
Q

what is the goal of oropharyngeal suctioning?

A

to remove secretions from the oral cavity and pharynx

233
Q

what are the indications for oropharyngeal suctioning?

A

difficulty expectorating or swallowing

decreased consciousness

visible secretions obstructing airways

vomit in the mouth

noisy breath sounds

234
Q

what is the device used in oropharyngeal suctioning?

A

a hard plastic device called a Yankauer suction catheter

235
Q

what is the technique for oropharyngeal suctioning?

A

pt in semi-fowlers or sitting with a towel over their chest

hand hygiene

mask, goggles, face shield

check suction is working with saline in a clean basin

insert the catheter into a pts mouth and run it along the gumline and pharynx on both sides

rinse the catheter using saline form the clean basin

clean the pts face and reposition as needed

hand hygiene

236
Q

what is tracheal suctioning used for?

A

pts with artificial airways that need airway clearance

237
Q

what is an open tracheal suctioning?

A

a free cathert is placed into the airway each time, no longer attached to a mechanical ventilator but has an open trach

238
Q

what is an inline (closed) tracheal suctioning?

A

suction catheter is kept connected to the vent, using the attachment attached to the vent for suctioning

239
Q

what is the general technique for tracheal suctioning?

A

pt in fowlers or semi fowlers position

explain the procedure to the pt

pre-oxygenate the pt (100% FiO2 or manual bagging)

adjust suction setting to lowest effective (100-150 mmHg)

quickly and gently insert the catheter into ET tube w/applying suction

stop at the level of the carina (when resistance is first felt and withdraw 1 cm

apply suction covering the cath vent

withdraw the cath slowly while rotating to expose secretions to side holes

240
Q

what are possible complications with tracheal suctioning?

A

hypoxia

cardiac dysrhythmias

infection

airway trauma

241
Q

how do we prevent hypoxia from tracheal suctioning?

A

by providing pre-oxygenation (100% FiO2 or manual bagging)

by providing rest breaks bw reps

242
Q

how do we prevent cardiac dysrhythmias from tracheal suctioning?

A

by providing pre-oxygenation

by limiting each suction attempt to 10-15 seconds

by providing rest breaks bw reps

243
Q

how do we prevent infection from tracheal suctioning?

A

by using sterile techniques for open suctioning

244
Q

how do we prevent airway trauma from tracheal suctioning?

A

by using gentle insertion techniques

by withdrawing 1cm prior to applying suction

245
Q

what are PEP devices?

A

positive expiratory pressure devices that can be smooth flow or oscillatory

246
Q

what is the theory behind PEP devices?

A

increased back pressure pushing out mucus plugs

stents airways open during expiration

utilizes collateral ventilation

may reinflate collapsed alveoli

may help air get behind secretions to move them peripherally

247
Q

how do PEP devices with oscillations work?

A

they provide varied flow rates and accelerated expiratory flows

248
Q

how is the resistance of an EG Acapella PEP oscillation device adjusted?

A

with a dial

249
Q

is the EG Acapella PEP oscillation device position dependent?

A

nope

250
Q

what resistance do we want with PEP devices?

A

moderate difficulty for the pt

251
Q

how do flutter valve PEP devices with oscillations work?

A

the device is position dependent and can be angle up to increase pressure or angled down to decrease pressure

252
Q

what are the downsides of the flutter valve PEP devices?

A

they are harder to objectify resistance with

cant be used in a positions bc they resistances are position dependent

253
Q

how many breaths is standard to do with PEP devices?

A

5-10 breaths

254
Q

what are high frequency chest wall oscillation devices?

A

inflatable vest connected to an air-pulse generator that create different air flow rates to move secretions from the periphery to proximal and decrease mucus viscocity

255
Q

what is the purpose of high frequency chest wall oscillations devices?

A

to move secretions from the periphery more proximal

to decrease mucus viscocity

256
Q

high frequency chest wall oscillation devices can be used in conjunction with what other treatment?

A

nebulizer

257
Q

how long are the high frequency chest wall oscillation devices used?

A

10 minutes at a time

258
Q

high frequency chest wall oscillation devices should progress from ____ to _____ to ____ frequency

A

low, medium, high

259
Q

t/f: deep breathing and coughing should be encouraged bw frequencies with high frequency chest wall oscillation devices

A

true

260
Q

what is manual hyperinflation?

A

an old technique for re-inflation of collapsed lung areas

261
Q

what is the goal of manual hyperinflation?

A

to re-inflate collapsed areas of lung and mobilize secretions

262
Q

t/f: there are many contraindications for manual hyperinflation

A

true

263
Q

how many caregivers are required for manual hyperinflation?

A

2

264
Q

what is the technique for manual hyperinflation?

A

the 1st caregiver uses a manual inflation bag to deliver as low, deep, inspiratory breath as possible

pause after the inspiration then a quick release for rapid exhalation

2nd caregiver applies vibration during the expiration

265
Q

what is manual therapy used for?

A

to address MSK restrictions to breathing

266
Q

what is the goal of manual therapy?

A

to improve ventilation by reducing restriction in soft tissue mobility or thoracic jt mobility

267
Q

what are the techniques to mobilize the thorax?

A

towel roll/pillow placement to mechanically open upon the ant/lat chest wall

use of UE patterns to facilitate the opening of individual lung segments

counterrotation of the trunk

use of ventilatory mov’t strategies to facilitate the opening of the entire thorax

special rib mobs to free up individual segments

myofascial release techniques to free up restricitve connective tissue around the thorax

soft tissue release techniques to lengthen individual tight muscles

268
Q

what manual therapy techniques can we use for anterior chest restrictions?

A

position the pt in supine and have the pt roll onto a towel roll vertically along their spine

encourage deep breathing, focusing on the area of restriction

to progress, add active/passive UE mov’t

269
Q

if someone is REALLY tight in the anterior chest, what adjustment can we make to our manual therapy techniques?

A

place another pillow under their head or use towel rolls under the arms

270
Q

how long do we hold a prolonged stretch in manual therapy positions?

A

work up to 5-10 minutes

271
Q

what manual therapy techniques can we use for lateral chest restrictions?

A

position the pt over a towel roll in SL with the side of restriction on top

encourage deep breathing into the area of restriction

to progress, add passive/active UE mov’t

272
Q

what technique uses the same training concepts from MSK and applies it to respiratory muscles?

A

ventilatory/respiratory muscle training

273
Q

what MSK principles does ventilatory/respiratory muscle training use?

A

overload

specificity

reversibility

strength and endurance programs

274
Q

t/f: we may need to use other techniques to re-teach proper breathing mechanics prior to initiating a program using a device for respiratory muscle training

A

true

275
Q

what are the two types of respiratory muscles trainings?

A

inspiratory and expiratory muscle training

276
Q

do PTs use inspiratory or expiratory muscle training more?

A

inspiratory muscle training

277
Q

what are the indications for expiratory muscle training?

A

decreased strength or endurance of the diaphragm or intercostal muscles

278
Q

how do we measure inspiratory muscle strength?

A

MIP (max inspiratory pressure)

279
Q

how do we measure MIP?

A

using a device

from residual volume

measure peak pressure over 2 seconds

pt instructed to breathe all the ya out and then breathe in throught the device

measures in cmH2O

280
Q

weakness of the inspiratory muscles is generally defined as MIP<___ cmH2O

A

60

281
Q

what are the types of IMT devices?

A

threshold, resistive loading, and voluntary isocapnic hyperpnea

282
Q

which IMT device has a ceiling effect?

A

threshold IMT devices

283
Q

what IMT device allows airflow through the device after a pre-determined pressure is met?

A

threshold IMT device

284
Q

what IMT device has a relatively low max pressure

A

threshold IMT device

285
Q

what IMT device is the type utilized by athletes and increase the resistance applied?

A

resistive loading IMT device

286
Q

which IMT device progressively increases the load on the resp muscles during inspiration?

A

resistive loading IMT device

287
Q

does a threshold or resistive loading IMT device have a higher max pressure?

A

a resistive loading IMT device

288
Q

which IMT device induces a person to increase their RR to increase the strength and endurance of the respiratory muscles rather than the resistance?

A

the voluntary isocapnic hyperpnea IMT device

289
Q

how high does the voluntary isocapnic hyperpnea IMT device get the RR?

A

up 50-60 rpm

290
Q

what is the goal of IMT (inspiratory muscle training)?

A

to increase inspiratory muscle strength, reduce dyspnea, and increase inspiratory capacity

291
Q

there is evidence for use for IMT for what populations?

A

COPD, HF, failure to wean from ventilation, SCI, ALS, GBS, Polio, MS, muscular dystrophy, myasthenia gravis, ankylosing spondylitis

292
Q

t/f: research shows that IMT is better than aerobic training for carryover

A

false, it is greater with aerobic training

293
Q

who more frequently is involved with expiratory muscle training?

A

SLP

294
Q

what are the indications for expiratory muscle training?

A

ineffective cough or swallow

295
Q

what are the goals of expiratory muscle training?

A

to increase strength of expiratory muscles, increase cough effectiveness, and decrease aspiration risk

296
Q

what device is used for expiratory muscle training?

A

a threshold device

297
Q

what is the training protocol for expiratory muscle training?

A

5 sets, 5 breaths, 5 days/week, 5 weeks

298
Q

what muscles are the focus of expiratory muscles training?

A

muscles of the deep throat

DPT 629: Cardio (11 decks)

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