Pulm part 1 Flashcards
name the 9 levels of the hierarchy
- Mobilization & Exercise (Dr. Emmel)
- Body Positioning
- Breathing Control Measures
- Coughing Maneuvers
- Relaxation and Energy Conversation
- ROM Exercises
- Postural Drainage
- Manual Techniques
- Suctioning
Hierarchy level that aims to elicit a gravitational stimulus that stimulates being upright and moving as much as possible: Active; Active Assist; or Passive
body positioning
- seek optimal ventiation
- facilitate chest excursion in all 3 planes
What are the goals of body positioning?
- Improve length-tension relationship of muscles used during respiration (shoulder muscles do shoulder things?)
- Incorporate passive stretch on the chest wall
- Use natural coordination of thunk-chest respiration to maximize movement (pairing)
What are strategies for positioning in supine?
1st Strategy: Towel roll longitudinally between scapula to open up anterior chest (Increase thoracic extension- increase length/tension of intercostals
2nd Strategy: Remove pillows under patients head. (Increase thoracic extension and length tension of scalenes)
3rd Strategy: Butterfly Position (Loser Cobra- increased pectoral use)
What are the reasons sidlying increases oxygenation by creating a differential shunt?
- Ease of Diaphragmatic movement
- Promote relaxed-inhibition of posture for increased ease of breathing
- Utilize Butterfly position
What is the principle for upright posture for breathing?
Upright posture challenges the component of balance and an unsupported spinal column
- Unsupported leads to possible over activation of muscles
What are the strategies for upright posture?
- Towel Roll behind ischial tubes for anterior pelvic tilt (wedge placement—length tension of abs up or down???)
- Retraction of scapula towards neutral position
- Externally rotated UE
- Pull head into neutrality or chin tuck (improved swallow and phonation including utterance length)
What positions increase inspiration?
- Trunk Extension
- Shoulder flexion, abduction, external rotation (loser cobra)
- Upward eye gaze (Pediatric principle)
What positions increase expiration?
- Trunk flexion
- Shoulder extension, adduction, Internal Rotation
- Downward Eye Gaze
Hierarchy level that aims to augment alveolar ventilation, to facilitate mucociliary transport, and to stimulate coughing
Breathing control measures
What are the indications for breathing control measures?
- Primary or secondary pulmonary discharge
- Trauma or pain from surgery
- Apprehension
- Bronchospasm
- Airway Clearance Dysfunction
- Rib Fractures
- Sedentary patients
Desgined to mimic natural sighing or yawning by encouraging you to take slow, deep breaths
Incentive spirometry
- ten breaths every hour on you r incentive spirometer
- By inhaling deep you can mobilize the secretions and open up areas that have collapsed or are on the verge of collapsing
How do you instruct someone to use an incentive spirometer?
1) Slide the yellow patient goal indicator to the volume level (ml) prescribed by your physician
2) With your lips on the mouthpiece, exhale completely. Close Lips around mouthpiece lightly at end of exhalation
3) Inhale slowly. Match arrow in desired area…not too slow or fast
4) Inhale as deeply as you can and then pause for 6 seconds
5) Note the level of the yellow piston
Provides collateral ventilation to open up regions of the lungs that would be closed off. This collateral ventilation enabled air to reach obstructed areas. Alveoli often have these collateral channels
Positive expiratory pressure
- originally for CF
What is an easy way to keep track if body positioning has affected breathing mechanics?
utterance length
- how many words pt can get out without taking a breath
how much of total VO2 consumption is taken by muscular work and vital capacity?
5% m work
10% vital capacity
Why does PEP work for conditions like CF?
- Mucus Plug blocks duct preventing gas exchange. Collateral channel too resistive to normal pressure
- Alveoli collapses due to lack of air support
- Inceased inhalation pressure often not enough…need exhalation with back pressure
how long does a Thera-PEP session usually take?
20 minutes
When should someone use PEP devices?
- early morning
- before bed
- whenever it is needed
Breathing technique: Helps breathe out more stale air due to clogged/narrow airways; Keep up pressure in airways with slow exhalation that is resisted by pursed lip breath
Pursed lip breathing
- let shoulders/ neck drop
What type of voice use facilitate diaphragmatic breathing vs upper chest breathing?
- soft and rhythmic for diaphragm
- loud and demanding for uper chest
What are the best ways to ensure diaphragmatic breathing will be most successful
- 3-4 breaths then rest (warn about lightheadedness)
- Concentrate on each breath for slow and deep.
- Practice contextually and in different positions.
- Practice in environment/etc where they usualy resort to diaphragmatic breathing
- Variable practice to achieve mastery
- Pursed Lip exhalation plus nostril inhalation- inherently diaphragmatic and slows rate of breathing but reaches the more basilar segments of lungs for increased oxygenation.
- During exercise and other activities [increased stress]
- Master this before loading on other activities
What should the normal timing be of breathing?
Diaphragm > Lateral costal expansion > Lower anterior chest wall> upper chest wall
- can use PNF technique, quick stretch
- promot overall sequencing of chest wall movements
What are ways to inhibit the upper chest?
- Position forearm over upper chest
- Apply pressure/resistance to upper chest
- Progress pressure with each expiratory cycle
- Re-assess breathing pattern
- Enhance patient feedback
What are ways to inhibit the diaphragm?
- Manual Inhibition (cuing for upper chest- heel of hand above umbilicus)
- Postural Inhibition (Prone on elbows)
What are ways to facilitate upper chest expansion
- Pec Facilitation - book says hand on pec minor, he says GH joint
- Butterfly technique (losing cobra)
- SCM/Scalene Facilitation
What are techniques for lateral costal facilitation
- “Breathe into my hand” (time to emphasize Ext. Intercostal engagement)
- Sidelying practice one side at a time
What are techniques for posterior chest expansion?
- serrates push-up with inhalation
Hierarchy level that aims to faciliate mucociliary clearance wit the least effect on dynamic airway compression and the fewest cardiovascular effects
active cough techniques Purposes: 1. Therapeutic technique 2. diagnostic signpost 3. social necessity
What are things you need to differentially diagnose to see if a cough is voluntary vs reflexive?
- Sinus infection
- Post-nasal drip
- Bronchogenic Carcinoma - nonproductive cough, but they continue to cough; also, h/o cancer
- Nervousness
- Smoking - 1 cigarette stops the ciliary from moving mucous up for 5-20 minutes
- Eating
- Video Fluoroscopy (cookie swallow) - If, for example, not enough coughing or unable to cough
A cough is a pump. Most effective pumps create [high/ low] flow rates and volumes (force/time). Most effective pumps easy access to ___ (mobilization of secretions to where the cough will be effective).
high; fluids
- a cough itself can move mucus from end of palm tree to corina or facilitate from corina out
Why is a cough not benign?
- Bronchospasm
- [increased] energy expenditure
- dehydration - due to high water content in mucous
- increase BP
- decrease CO
tussive syncope = cough so much that you pass out
What are the stages of coughing?
1) Adequate Inspiration
2) Glottal Closure
3) Intrathoracic and intraabdominal pressure
4) Glottal Opening and Expansion
- 60% FEV1 of vital capacity is an indicator for effective expulsion
- 6th-7th airway branch
What are the different things you look at when evaluating a cough?
- Assess position
- Assess blockers of movement
- “show me how you would cough”—simple straightforward functional assessment
- Detect where breakdown is based on stage
What things should you look at for adequate inspiration?
- Spontaneous vs controlled - spontaneous lacks complete inhalation
- Position- upward eye gaze, trunk extension, shoulder extension to augment inspiration; get max extension for max inspiration prior to cough
- Time? Long enough?
- What are some things that can block this? - Bed position, pain, body position
What are the things you should look at for glottal closure
- Hold of breath at peak of inspiration
- Cough, Huff, or Wheeze?
- What can effect this? - intubation damages vocal cords (swelling from contact) indicated by hoarse voice
What are the things you should look at for proper buildup of intrathoracic and intrabdominal pressure?
- Contractions of stomach, intercostals, neck, chest,
- Movement into flexion?
- Coughing has a low resonant sound (high pitched = ineffective)
- What are some things that block this stage? - Pain, positioning
What are things you should look at for proper glottal opening and expulsion?
- Does the patient appear to gag? - Glottis is off on timing
- Timing is off (hold breath too long or not long enough)
- Coordination on next cough cycle - Normal = 2-3 coughs/ inspiration
Patient population that has problems with forced and prolonged exhalation (expiratory wheeze equals bronchospasm); instruct a pump cough/modified huff cough
asthma
Patient population that has problems with distended lung/flat diaphragm/ exhalation; Use smaller breaths with huff techniques
Emphysema
What are factors to take into consideration for the “art of the cough technique”?
- Position for success
- Maximize inhalation
- Breath hold
- Max intrathoracic and intraabdominal pressure
- Emphasize appropriate timing and trunk movements
- Make procedures as active as possible
What are manually assistive cough techniques (level 8 on hierarchy)?
- Costophrenic—tactile cuing at ribs
- Heimlich (manual assisting of inhalation is not possible) (small area with quick movement with exhalation) (not my favorite)
- Anterior Chest (“V”) Upper and lower
- Counterrotation assist (Sidelying rotation to facilitate inhalation and de-rotation to facilitate exhalation) (like with patients with high-tone)
What are self assisted cough techniques?
- Prone on elbows (head extension during inhalation and head flexion during exhalation) - Need abdominals, don’t need legs
- Long-sitting - poor abdominal control, quadriplegia (requires full elbow ext)
- Short-sitting - tripod position
- Hands and knees (rocking back and forth)
- Can you add manual assistance to a self-assistance cough…or will you be arrested?
Yes, anything to get expulsion
Gentle cough to accelerate airflow while still having glottis open; Burns excessive energy when performed incorrectly, but when performed correctly can manage secretions with conserving energy
huff coughing
- Inhale slowly through nose (pause 3 seconds) then forced exhalation with open glottis to create “huuuuuu, huuuu, huuuuu” or “hhhuuuuwoooo, hhhuuuwooo, hhhuuuwooo” with chin up.
- Not violent: Pause for breath control
- Longer exhalation=mobilize smaller airways
- Shorter exhalation= mobilize larger airways
- Cough to expel secretions is fine
- if you hear a wheeze, cough is too long
Usually used in patients with ineffective coughing that may have neuro disorders that maybe progressive in nature (Guillain Barre, MD, Quadriplegia-2ndary)
Quad coughing
- contraindications: Unstable spines, Rib Fx’s, Abdominal incisions, Cardiovascular instability, Vasovagal reactions
Hierarchy level that aims to facilitate airway clearance using gravitational effects
Postural drainage
- Positioning the pt so that retained secretions in the bronchopulmonary tree can drain by gravity out of the lungs
A rhythmic percussion on the thoracic wall to loosen secretions and assist the mucociliary escalator to rid the lungs of retained secretions
perucussion
- cupped hand
- cyclical tapotment
- wrist primarily, elbow and shoulder minimally
- 30-45 min PD and P can clear lung field secretions
During ACBT, when would you want medium/small vs deep breaths?
Medium small = wanting to move mucus from distal segments; low pressure, low volume; fine crackers; prevents shoving mucus back down
Deep = moving proximal secretions; high volume, high pressure
- ACBT stops when pt no longer has productive cough; moves from fine to coarse crackles
What is the orientation of the bronchopulmonary segment of the apical segment of the upper lobe?
tubes are forward, upward, and lateral
- position standard fowler’s (45-60*)
- percuss at trapezius equal btwn clavicle and scap
What is the orientation of the bronchopulmonary segment of the LUL anterior segment?
Tubes are obliquely upward and forward
- position in semi-fowler (30-45*)
- percuss pec major L side above breast tissue
What is the orientation of the bronchopulmonary segment of the LUL posterior segement?
Posterior and obliquely upward
- prone onto R side with L shoulder pillowed and rotated up and off the bed or short sitting with pillow under L chest and arm
- percuss L scap
What is the orientation of the bronchopulmonary segment of the RUL posterior segment?
Posterior and obliquely upward
- prone on and on left side with R shoulders pillowed and rotated up and off the bed
- percuss over R scap
What is the orientation of the bronchopulmonary segment of the RLL and LLL superior/apical segement?
Posterior
- position prone (comfortable)
- percuss inferior angle of scap on appropriate side
What is the orientation of the bronchopulmonary segment of RLL and LLL posterior basilar segment?
Posterior and obliquely downward
- position prone trendelenburg
- percuss posterior thorax just above the inferior border of the rib cage
What is the orientation of the bronchopulmonary segment of the RUL anterior segment?
Forward
- position supine flat (comfortable)
- percuss pec major on the right side
What is the orientation of the bronchopulmonary segment of the RLL and LLL anterior basilar segment?
Forward and obliquely downward
- position supine trendelenburg
- percuss ribcage on the anterior surface just superior to inferior border (rib flare area)
What is the orientation of the bronchopulmonary segment of the LUL lingular segment?
Lateral and obliquely downward
- position right ¼ sidelying; trendelenburg
- percuss left lateral mid-axillary line
What is the orientation of the bronchopulmonary segment of the LLL lateral basilar segment and RLL cardiac segment?
Lateral and obliquely downward (LB of LLL
Medial and obliquely downward (C of RLL)
- position right sidelying trendelenburg
- perucss(LB of LLL) Left lateral mid-axillary line; C of RLL cannot be auscultated for percussion
What is the orientation of the bronchopulmonary segment of the RML?
Lateral, forward, and obliquely downward
- position half-sidelying on left, trendelenburg
- percuss right thoracic wall slightly anterior to mid-axillary line
What is the orientation of the bronchopulmonary segment of the RLL lateral basilar?
Lateral and obliquely downward
- position left sidelying trendelenburg
- percuss right thoracic wall in mid-axillary line at the border of the ribcage.
