Pulmonary Flashcards
Upper airways
nose or mouth: entry point into respiratory system
pharynx: common area used for both respiratory and digestive systems
larynx: connects the pharynx to the trachea, including the epiglottis and vocal cords
lower airways
the conducting airways, trachea to terminal bronchioles, transport air only. No gas exchange occurs.
The respiratory unit: respiratory bronchioles, alveolar ducts, alveolar savs and alveoli. Diffusion of gas occurs through all these structures
R lung
divided into 3 lobes by the oblique and horizontal fissures; each lobe divides into segments- total of 10
L lung
divided into 2 lobes by the oblique fissure; each lobe divides into segments- total of 8
pleura
Parietal pleura covers the inner surface of the thoracic cage, diaphragm and mediastinal border of the lung
visceral pleura: wraps the outside surface of the lung, including the fissure lines
Intracellular space is the potential space between the 2 pleurae that maintains the approximation of the rib cage and lungs, allowing forces to be transmitted from 1 structure to another
primary muscles of inspiration
Primary muscle: diaphragm
- made up of 2 hemidiaphragms, each with a central tendon.
- at rest, the hemidiaphragms are arched high into the thorax
- when the muscle contracts, the central tendon is pulled down, flattening the dome resulting in a protrusion of the abdominal wall during inhalation
Additional primary muscles: portions of the intercostals
Accessory muscles of inspiration
used when a more rapid or deeper inhalation is required or in disease states
upper 2 ribs are raised by the scalenes and SCM
rest of the ribs are are raised by the elevator costar and serrates
by fixing the shoulder girdle- the trap, pecs and serratus can become muscles of inspiration
expiratory muscles of ventilation
resting expiration results from a passive relaxation of the inspiratory muscles and the elastic recoil tendency of the lung
-normal abdominal tone holds the abdominal contents directly under the diaphragm, assisting the return of the diaphragm to the normal high domed position
expiratory muscles are used when a quicker/fuller expiration is desired
-QL, portions of the intercostals, muscles of the abdomen and triangularis sterni
ventilation with patients who lack abdominal musculature (SCI)
have a lower resting position of the diaphragm, decreasing inspiratory reserve
the more upright the body position, the lower the diaphragm and the lower the inspiratory capacity
the more suing the more advantageous the position of the diaphragm
an abdominal binder may be helpful in providing support to the abdominal viscera, assisting ventilation. Care must be taken not to constrict the thorax
Resting end expiratory pressure (REEP)
the point of equilibrium where inspiratory/expiratory forces are balanced
-occurs at end tidal expiration
Forces on the rib cage/breathing mechanics:
- elastic recoil of the lung parenchyma pulls lungs, and bony thorax into a position of exhalation (inward pull)
- bony thorax pulls into a position of inspiration (outward pull)
Tidal volume (TV)
volume of gas inhaled (or exhaled) during a normal resting breath
normal adult: 500mL
normal infant: 20 mL
inspiratory reserve volume (IRV)
volume of gas that can be inhaled beyond a normal resting tidal inhalation
Expiratory reserve volume (ERV)
volume of has that can be exhaled beyond a normal resting tidal expiration
Residual volume (RV)
volume of gas that remains in the lungs after ERV has been exhaled
Inspiratory capacity (IC)
IRV + TV
the amount of air that can be inhaled from REEP
Vital capacity (VC)
IRV + TV + ERV
the amount of air that is under volitional control; conventionally measured as forced expiratory vital capacity (FVC)
Functional residual capacity
ERV + RV
the amount of air that resides in the lungs after a normal resting tidal exhalation
Total lung capacity
IRV + TV + FRV + RV
the total amount of air that is contained within the thorax during a maximum inspiratory effort
Forced expiratory volume (FEV1)
the amount of air exhaled during the 1st second of FVC
in the healthy person, at least 70% of FVC is exhaled within the first second
FEV1/FVC x100 — >70%
ventilation vs. respiration
ventilation= movement of gas in and out of the pulmonary system
respiration= diffusion of gas across the alveolar capillary membrane
arterial oxygenation
=the ability of arterial blood to carry oxygen
PaO2 in the arterial blood
Partial pressure of oxygen in the arterial blood
depends on the integrity of the pulmonary system, the circulatory system and the atmosphere.
95-100% in a young, health person
decreases with age
Hypoxemia 100%
alveolar ventilation
ability to remove CO2 from the pulmonary circulation and maintain pH
pH
indicates the concentration of free floating hydrogen ions within the body
normal range: 7.35-7.45
PaCO2
the partial pressure of CO2 within the arterial blood
normal: 35-45 mmHg
removal or retention of CO2 by the respiratory system alters the pH of the body in an inverse relationship
- increase in the PaCO2 decreases the body’s pH
- decrease in PaCO2 increases pH
hypercapnea
PaCO2 >45 mmHg
increase in the PaCO2 decreases the body’s pH
hypocapnea
PaCO2
HCO3-
amount of bicarbonate ions within the arterial blood
normal: 22-28 mEq/mL
removal or retention of HCI3- alters the pH of the body in a direct relationship
- increase in HCO3- increases body’s pH
- decrease in HCO3- decreases body’s pH
optimal respiration occurs when:
ventilation and perfusion (BF to the lungs) are matched
different ventilation and perfuse relationships exist
dead space
anatomical (conducting airways) or physiological (diseases such as PE)
space that is well ventilated but in which no respiration (gas exchange) occurs
“gravity independent areas”
shunt
no respiration occurs because of a ventilation abnormality
complete atelectasis of a respiratory unit allows the blood to travel through the pulmonary capillary without gas diffusion
“gravity dependent areas”
effects of body position on the ventilation/perfusion relationship:
UPRIGHT POSITION:
- perfusion (Q) is gravity dependent- most pulmonary blood is found at the base of the lung
- ventilation: at the static point of REEP, the apical alveoli are fuller than those at the base. During the dynamic phase of inspiration, more air will be delivered to the less filled alveoli at the bases causing a greater change in Ve at the bases
- V/Q ratio: apices are gravity independent with the lowest blood flow (Q). Although relatively low, there is still more air than blood, resulting in a high V/Q ratio (dead space).
- V/Q of the middle zone of the lung are evenly matched.
- V/Q of the bases are gravity dependent and therefore, have the most Q. Although Ve is relatively high, there is more blood than air, resulting in a (relatively) low V/Q ratio (shunt)
OTHER POSITIONS:
- gravity independent area– dead space
- gravity dependent area– shunt
Ventilation/perfusion ratio (V/Q ratio):
the ratio of pulmonary alveolar ventilation to pulmonary capillary perfusion
central control centers for ventilation
cortex, pons, medulla and ANS
patient interview:
chief complaint
-usually loss of function, ADLs
present illness
- initial onset
- progression
- worsens of improves
history
- occupation and exposures
- PMH- heart disease? long term steroid?
- current meds that can mask (steroids) or alter (BB, bronchodilators) VS
- social habits: smoking, alcohol, drugs
- exercise
- cough/sputum
- family history
tachypnea
RR > 20 bpm
key observations during examine
peripheral edema seen in gravity dependent areas and jugular venous distention indicates possible heart failure
-RV hypertophy and dilation (cor pulmonale) are common sequelae to chronic lung disease
body positions: stabilizing the shoulder girdle places the thorax in the inspiratory position and allows the additional recruitment of muscles for inspiration (pectorals)
color: cyanosis (sign of hypoxemia)
digital clubbing (sign of chronic hypoxemia)
Neck:
- observe the trachea- should be midline
- use of accessory muscles of ventilation
Thorax:
- changes in body thorax- pectus excavate, cranium
- ant-post:lat dimension– 1:2 ratio (With obstructive pulmonary disease, the lung recoil force is decreased, resulting in a barreled chest and increased AP dimension)
- R and L thorax should be symmetrical
- healthy thoracic excursion should be 2-3 inches
lung auscultation: normal lung sounds
intensity of inspiration and expiration is quieter at the bases than the apex
vesicular- normal breath sound: a soft rustling sound heard t/out all of inspiration and the beginning of expiration
Bronchial: a more hollow, echoing sound normally found only over the R superior anterior thorax- corresponds to an area over the R main stem bronchus.
-all of inspiration and most of expiration are heard with bronchial breath sounds
*Decreased: a very distant sound not normally heard over a healthy thorax; allows only some of the inspiration to be heard. often associated with obstructive lung diseases
adventitious (extra) lung sounds:
Crackles: “rales, crepitations”
- crackling sound heard usually during inspiration that indicates pathology
- could be result of air bubbles in secretions or movement of fibrotic tissue during breathing
- atelectasis, fibrosis, pulmonary edema, LV CHF
Wheezes/rhonci: a musically pitched sound, usually heard during expiration, caused by airway obstruction (asthma, COPD, foreign body aspiration)
-with severe airway constriction, as with croup, wheezes may be heard on inspiration as well
vocal sounds
normal:
- loudest near trachea and main stem bronchi
- softer and less clear at more distal areas
abnormal:
- may be heard through fluid-filled areas of consolidation, cavitation lesions or pleural effusions
- Egophony
- bronchopony
- whispered pectoriloquy
egophony
nasal or bleating sound heard during auscultation
“E” sounds are transmitted to sound like “A”
-may be heard through fluid-filled areas of consolidation, cavitation lesions or pleural effusions
Bronchophony
characterized by an intense, clear sound during auscultation, even at the lung bases
“99” “66”
-may be heard through fluid-filled areas of consolidation, cavitation lesions or pleural effusions
Whispered pectoriloquy
occurs when whispered sounds are heard clearly during auscultation
-may be heard through fluid-filled areas of consolidation, cavitation lesions or pleural effusions
pulmonary radiographic exam
chest x-ray: 2D radiographic film to detect presence of abnormal material (exudate, blood) or a change in pulmonary parenchyma (fibrosis, collapse)
CT: cross sectional plane
MRI
Ventilation perfusion (V/Q) scan: matches the ventilation pattern of the lung to the perfusion pattern to identify the presence of PE
Fluroscopy: continuous x ray beam allows observation of diaphragmatic excursion
Respiratory alkalosis
high pH
low PaCO2
normal HCO3-
causes: alveolar hyperventilation
S&S:
- dizzy
- syncope
- tingling
- numbness
- early tetany
respiratory acidosis
low pH
high PaCO2
normal HCO3-
causes: alveolar hypoventilation
S&S
- Early: anxiety, restless, SOB, HA
- Late: confusion, drowsy, coma
metabolic alkalosis
high pH
normal PaCO2
high HCO3-
causes:
- bicarbonate ingestion
- vomiting
- diuretics
- steroids
- adrenal disease
S&S
- weakness
- mental dullness
- possibly early tetany
metabolic acidosis
low pH
normal PaCO2
high HCO3-
causes:
- diabetic, lactic or uremic acidosis
- prolonged diarrhea
S&S:
- secondary hyperventilation
- nausea
- lethargy
- coma
pulmonary function tests
evaluate lung volumes, capacities and flow rates
used to diagnose disease, monitor progression and determine the benefits of medical management
bronchoscopy
endoscope used to view, biopsy, wash, suction and/or brush the interior aspects of the tracheobronchial tree
list of acute pulmonary diseases
bacterial pneumonia
viral pneumonia
aspiration pneumonia
tuberculosis (TB)
pneumocystis pneumonia
SARS (severe acute respiratory syndrome)
bacterial pneumonia
an intra-alveolar bacterial infection
gram-positive bacteria usually acquired in the community: streptococcal
gram-negative bacteria usually develop in a host with underlying, chronic, debilitating conditions, severe acute illness and recent antibiotic therapy
-result in early tissue necrosis and abscess formation
pertinent physical findings:
- shaking chills
- fever
- chest pain if pleuritic involvement
- cough becoming productive or purulent, blood streaked or rusty sputum
- decreased or bronchial break sounds and/or crackles
- tachypnea
- increased WBC count
- hypoxemia
- hypocapnea, initially, hypercapnia with increasing severity
- CXR confirmation of infiltrate
Viral pneumonia
an interstitial or intra-alveolar inflammatory process caused by viral agents (influenza, adenovirus, cytomegalovirus, herpes, parainfluenza respiratory syncytial virus, measles)
Pertinent physical findings:
- recent hx of upper respiratory infection
- fever
- chills
- dry cough
- headaches
- decreased breath sounds and/or crackles
- hypoxemia and hypercapnea
- normal WBC count
- CXR confirmation of interstitial infiltrate
aspiration pneumonia
aspirated material causes an acute inflammatory reaction within the lungs
-usually found in patients with impaired swelling (dysphagia), fixed neck extension, intoxication, impaired consciousness, neuromuscular disease, recent anesthesia
Pertinent physical findings:
- symptoms begin shortly after aspiration event (hours)
- cough may be dry at the onset, progresses to produce putrid secretions
- dyspnea
- tachypnea
- cyanosis
- tachycardia
- wheezes and crackles with decreased breath sounds
- hypoxemia, hypercapnea in severe cases
- chest pain over the involved area
- fever
- WBC count shows varying degrees of leukocytosis
- CXR initially shows pneumonitis; chronic aspiration shows necrotizing pneumonia with cavitation
Tuberculosis (TB)
mycobacterium tuberculosis infection spread by aerosolized droplets from an untreated infected host
- incubation period: 2-10 weeks
- primary disease lasts 10 days to 2 weeks
post primary infection is reactivation of dormant TB bacillus, which can occur years after primary infection
2 weeks on appropriate anti tuberculin drugs renders the host noninfectious.
- during infectious stage, patient must be isolated from others in a negative-pressure room
- anyone else must wear TB mask and follow universal precautions
- if patient leaves the room they wear mask
meds taken for prolonged periods: 3-12 months
increased incidence of TB in patients with HIV
Pertinent findings of primary disease: can go unnoticed, as it causes only mild symptoms:
- slight nonproductive cough
- low grade fever
- possible CXR changes consistent with primary disease
Pertinent findings of post primary infection:
- fever
- weight loss
- cough
- hilar adenopathy: enlargement of the lymph nodes surrounding the hilum
- night sweat
- crackles
- hemoptysis: blood streaked sputum
- WBC - increased lymphocytes
- CXR shows upper lobe involvement with air space densities, cavitation, pleural involvement, and parenchymal fibrosis
pneumocystis pneumonia (PCP)
pulmonary infection caused by a fungus in immunocompromised hosts
-patients with transplantation, neonates or HIV
Pertinent physical findings:
- insidious progressive SOB
- nonproductive cough
- crackles
- weakness
- fever
- CXR shows interstitial infiltrates
- CBC shows no incidence of infection
hemoptysis
blood streaked sputum
SARS
severe acute respiratory syndrome
an atypical respiratory illness caused by a corono-virus
initial outbreak in southern mainland China with worldwide spread
Pertinent physical findings:
- high temperature
- dry cough
- decreased WBC, platelets, lymphocytes
- increased liver function tests
- abnormal CXR with borderline breath sound changes
List of chronic obstructive diseases
Chronic obstructive pulmonary disease (COPD)
Asthma
Cystic fibrosis
Bronchiectasis
Respiratory distress syndrome (RDS)
Bronchopulmonary dysplasia
bronchitis
emphysema
COPD
chronic obstructive pulmonary disease
characterized by airflow limitation that is not fully reversible
-usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases
Physical findings: increase in severity as the stages of disease advance
- cough/sputum production/hemoptysis
- dyspnea on exertion
- breath sounds decreased with adventitious sounds
- increased RR
- weight loss/anorexia
- increased AP diameter of chest wall
- cyanosis
- clubbing
- postures to structurally elevate shoulder girdle
- ABG changes of hypoxemia, hypercapnea
- PFT showing obstructive disease (decreased FEV1, FVC, FEV1/FVC ratio; increased FRC and RV)
stages of COPD
stage 1 (mild)
- FEV1/FVC 80% predicted
- with or without chronic symptoms
Stage 2 (moderate) -FEV1/FVC
Asthma
increased reactivity of the trachea and bronchi to various stimuli (allergens, exercise, cold); reversible in nature
manifests by widespread narrowing of the airways due to inflammation, smooth muscle constriction and increased secretions
even during remission, some degree of airway inflammation is present
Physical findings during exacerbation:
- wheezing, possible crackles and decreased breath sounds
- increased secretions of variable amounts
- dyspnea
- increased accessory muscle use
- anxiety
- tachycardia
- tachypnea
- hypoxemia
- hypocapnea: responding to hypoxemia, there is an increased RR and minute ventilation. This will decrease PaCO2. with severe airway constriction- an increase in minute ventilation can’t occur and hypercapnia can be found
- cyanosis
- PFTs show impaired flow rates
- CXR shows hyper lucency and flattened diaphragms during exacerbation
Cystic fibrosis
a genetically inherited disease characterized by thickening of secretions of all exocrine glands, leading to obstruction (pancreatic, pulmonic, gastrointestinal)
may present as an obstructive, restrictive or mixed disease
clinical signs: meconium, ileus, frequent respiratory infections, (especially staphylococcus), and inability to gain weight despite adequate caloric intake.
Diagnosis made postnatally by a blood test indicating trypsinogen or later by a positive sweat electrolyte test
Pertinent physical findings:
- onset of symptoms in early childhood
- dyspnea, especially on exertion
- productive cough
- hypoxemia, hypercapnea
- cyanosis
- clubbing
- use of accessory muscles
- tachypnea
- crackles, wheezes and/or decreased breath sounds
- abnormal PFTs showing an obstructive pattern, restrictive pattern or both
- CXR shows increased markings, findings of bronchiectasis and or pneumonitis
bronchectasis
a chronic congenital or acquired disease characterized by abnormal dilation of the bronchi and excessive sputum production
pertinent physical findings:
- cough and expectoration of large amounts of mucopurulent secretions
- frequent secondary infections
- hemoptysis
- crackles, decreased breath sounds
- cyanosis
- clubbing
- hypoxemia
- dyspnea
- CXR shows increased bronchial markings with interstitial changes.
- bronchograms can outline bronchial dilation, but rarely needed
respiratory distress syndrome (RDS)
formerly known as “hyaline membrane disease”
alveolar collapse in a premature infant resulting from lung immaturity, inadequate level of pulmonary surfactant
Physical findings:
- respiratory distress
- crackles
- tachypnea
- hypoxemia
- cyanosis
- accessory muscle use
- expiratory grunting, flaring nares
- CXR shows a classic granola pattern (“ground glass”) caused by distended terminal airways and alveolar collapse
PT considerations:
-increased breathing effort caused by handling a premature infant must be carefully weight against possible benefits of PT
Bronchopulmonary dysplasia
obstructive pulmonary disease, often a sequela of premature infants with RDS
results from high pressures of mechanical ventilation, high fractions of inspired oxygen (FiO2) and/or infection
lungs show areas of pulmonary immaturity and dysfunction due to hyperinflation
Physical findings:
- hypoxemia, hypercapnea
- crackles, wheezing and/or decreased breath sounds
- increased bronchial secretions
- hyperinflation
- frequent lower respiratory infections
- delayed growth and development
- cor pulmonale
- CXR shows hyperinflation, low diaphragms, atelectasis and/or cystic changes
chronic restrictive diseases
typified by difficulty expanding the lungs, causing a reduction in lung volumes
restrictive disease due to alterations in lung parenchyma and pleura
fibrotic changes within the pulmonary parenchyma or pleura due to idiopathic pulmonary fibrosis, asbestosis, radiation pneumonitis, oxygen toxicity
Physical findings:
- dyspnea
- hypoxemia, hypocapnea (hypercapnea with severity)
- crackles
- clubbing
- cyanosis
- PFTs reveal a reduction in vital capacity, functional residual capacity and total lung capacity
- CXR shows reduced lung volumes, diffuse interstitial infiltrates and/or pleural thickening
restrictive disease due to alterations in the chest wall
restricted motion of bony thorax, with diseases such as ankylosing spondylitis, arthritis, scoliosis, pectus excavate, arthrogryposis or integumentary changes of the chest wall such as thoracic burns or scleroderma
Physical findings:
- shallow, rapid breathing
- dyspnea
- hypoxemia, hypocapnea (hypercapnia with increasing severity)
- cyanosis
- clubbing
- crackles
- reduced cough effectiveness
- PFTs show reduced VC, FRV, and TLV
- CXR shows reduced lung volumes, atelectasis
Restrictive disease due to alterations in the neuromuscular apparatus:
decreased muscular strength results in an inability to expand the rib cage
-seen in MS, MD, PD, SCI or CVA
Physical findings:
- dyspnea
- hypoxemia
- hypocapnea (hypercapnea with severity)
- decreased breath sounds, crackles
- PFTs show reduced VC, and TLC
- CXR shows reduced lung volumes, atelectasis
Bronchogenic carcinoma
tumor arising from the bronchial mucosa
smoking and occupational exposures most frequent causal agents
secondary changes due to tumor: obstruction or compression of an airway, blood vessel or nerve
local metastases in the pleura, chest wall, mediastinal structures
-distant metastases in lymph nodes, liver, bone, brain and adrenals
Physical findings:
- chest pain
- dyspnea
- tracheal and mediastinal shift away from injured side
- absent or decreased breath sounds
- increased tympany with mediate percussion
- cyanosis
- respiratory distress
- confirmation by CXR
Management:
-chemo, radiation, surgery
PT considerations
- pneumonias that develop behind a completely obstructed bronchus can’t be cleared with PT techniques. Hold tx until palliative therapy reduces tumor size and relieves bronchial obstruction
- possible fractures from thoracic bone metatasis with chest compressive maneuvers and coughing
- ecchymosis (bruising) in patients with low platelet count
- fatigue that restricts necessary activities
list of trauma conditions
rib fracture, flail chest
pleural injury
- pneumothorax
- hemothorax
lung contusion
rib fracture
usually due to blunt trauma
flail chest= 2 or more fractures in 2 or more adjacent ribs
physical findings:
- shallow breathing
- splinting due to pain-especially with deep inspiration or cough
- crepitation may be felt during ventilatory cycle over fracture site
- paradoxical movement of a flail section during ventilatory cycle (inspiration-pulls in, expiration-pulls out)
- confirmation by CXR
pneumothorax
air in the pleural space
- usually through a lacerated visceral pleura from a rib fracture or ruptured bull
- causes lung to collapse due to loss of negative pressure
Physical findings: (increase with severity)
- chest pain
- dyspnea
- tracheal and mediastinal shift away from injured site
- absent or decreased breath sounds
- increased tympany with mediate perfusion
- cyanosis
- respiratory distress
- confirmation by CXR
TX: chest tube:
- pulls air/fluid out of pleural space
- restores negative pressure and allows the lung to inflate
- chest PT is a precaution in the area of the tube
hemothorax
blood in the pleural space
-usually from a laceration of the parietal pleura
Physical findings: (increase with severity)
- chest pain
- dyspnea
- tracheal and mediastinal shift away from side of injury
- absent or decreased breath sounds
- cyanosis
- respiratory distress
- confirmation by CXR
- possible signs of blood loss
lung contusion
blood and edema within the alveoli and interstitial space due to blunt chest trauma with or without rib fractures
Physical findings:
- cough with hemoptysis
- dyspnea
- decreased breath sounds and/or crackles
- cyanosis
- confirmation by CXR of ill-defined patchy densities
pulmonary edema
excessive seepage of fluid from the pulmonary vascular system into the interstitial space; may eventually cause alveolar edema
cardiogenic: results from increased pressure in pulmonary capillaries associated with LV failure, aortic valvular disease or mitral valvular disease
non-cardiogenic: results from increased permeability of the alveolar capillary membranes due to inhalation of toxic fumes, hypervolemia, narcotic overdose or adult respiratory distress syndrome (ARDS)
Physical findings:
- crackles
- tachypnea
- dyspnea
- hypoxemia
- peripheral edema if cardiogenic
- cough with pink, frothy secretions
- CXR shows increased vascular markings, hazy opacities in gravity dependent areas of the lung in a typical butterfly pattern. Atelectasis is possible if the surfactant lining is removed by alveolar edema
TX:
- meds- O2 and diuretics
- reduction of salt intake
- bed rest (head elevated)
Pulmonary emboli
a thrombus from the peripheral venous circulation becomes embolic and lodges in the pulmonary circulation
-small emboli don’t necessarily cause infarction
Physical findings without infarction:
- history consistent with PE: DVT, oral contraceptives, recent abdominal or hip surgery, polycythemia, prolonged bed rest
- sudden onset of dyspnea
- tachycardia
- hypoxemia
- cyanosis
- anxiety, restlessness
- auscultatory findings: may be normal or show crackles and decreased breath sounds
- V/Q scan shows perfusion defects with concomitant normal ventilation
Added physical findings consistent with pulmonary infarction:
- chest pain
- hemoptysis
- fever
- CXR shows decreased vascular markings, high diaphragm, pulmonary infiltrate and/or pleural effusion
TX:
- low dose heparin
- analgesics
- pulmonary vasodilators
pleural effusion
excessive fluid between the visceral and parietal pleura caused mainly by:
- increased pleural permeability to proteins from inflammatory diseases (pneumonia, RA, systemic lupus)
- neoplastic disease
- increased hydrostatic pressure within pleural space (CHF)
- decrease in osmotic pressure (hypoproteinemia)
- peritoneal fluid within the pleural space (ascites, cirrhosis)
- interferene of pleural reabsorption from a tumor invading pleural lymphatics
Physical findings:
- decreased breath sounds over effusion; bronchial breath sounds around the perimeter. Pleural friction rub may be possible with inflammatory process
- mediastinal shift away from large effusion
- breathlessness with large effusions
- CXR shows fluid in the pleural space in gravity-dependent areas of the thorax if >300mL
- pain and fever only if the pleural fluid is infected (empyema)
Atelectasis
collapsed or airless alveolar unit caused by:
- hypoventilation secondary to pain during the ventilatory cycle (pleuritis, post-op pain, or rib fracture)
- internal bronchial obstruction (aspiration, mucus plugging)
- external bronchial compression (tumor or enlarged lymph nodes)
- low tidal volumes (narcotic overdose, inappropriately low ventilator settings)
- neuralgic insult
Physical findings:
- decreased breath sounds
- dyspnea
- tachycardia
- increased temp
- CXR with platelike streaks
list of manual secretion removal techniques
postural drainage
percussion
vibration/shaking
airway clearance techniques:
- cough
- huff
- assisted cough
- tracheal stimulation
- endotracheal suctioning
postural drainage
placing patient in varying positions for optimal gravity drainage of secretions and increased expansion of the involved segment
indications:
- increased pulmonary secretions
- aspiration
- atelectasis or collapse
duration up to 20 minutes
percussion
a rhythmic force applied with cupped hands to the specific area of the chest wall that corresponds to the involved lung segment
used to increase the amount of secretions cleared from tracheobronchial tree
used in conjunction with postural drainage
indications:
- increased pulmonary secretions
- aspiration
- atelectasis or collapse due to mucous plugging obstructing airways
3-5 minutes
force of percussion causes the patient’s voice to quiver
vibration/shaking
following a deep inhalation, a bounding maneuver is applied to the rib cage throughout exhalation; to hasten the removal of secretions from the tracheobronchial tree
commonly used following percussion in appropriate postural drainage position
indications:
- increased pulmonary secretions
- aspiration
- atelectasis or collapse of an airway from mucous plugging
as patient inhales deeply, PT’s hands are placed with fingers parallel to ribs
as patient exhales, PT hands provide a jarring, bouncing motion to rib cage below
duration: 5-10 minutes
- >10 risks hyperventilation (increased Ve resulting in hypocapnea)
airway clearance techniques
COUGH:
- upright sitting after each area has been treated
- clears secretions from major central airways
HUFFING:
- more effective in patients with collapsible airways (COPD)
- prevents high intrathoracic pressure that causes premature airway closure
- ask patient to deeply inhale, immediately forcibly expel the air saying “HA”
ASSISTED COUGH:
- used when pt’s abdominal muscles can’t generate an effective cough (SCI)
- PT’s fist becomes the force; force depends on patient tolerance and abdominal sensation
- hand placed below subcostal angle (similar to Heimlich)
- patient inhales; as patient attempts to cough, hand pushes inward and upward, assisting the rapid exhalation of air
TRACHEAL STIMULATION:
- used with patients unable to cough on command (infants, TBI, CVA)
- finger placed just above suprasternal notch; quick inward and downward pressure on the trachea elicits cough reflex
ENDOTRACHEAL SUCTIONING
- used only when above techniques fail
- suctioning time: 10-15 seconds- intermittent so not to damage inner lining of trachea
- complications: hypoxemia, bradycardia, HTN , increased intracranial pressure, atelectasis, tracheal damage, infections
considerations prior to use of percussion or shaking
pain made worse by technique
circulatory system: aneurysm precautions, hemoptysis
coagulation disorders or meds that interfere with coagulation
MS system: fractured ribs, DJD, bone metastases
considerations prior to use of postural drainage
TRENDELENBURG PRECAUTIONS 1-Circulatory: -pulmonary edema -CHF -HTN
2-Abdominal problems:
- obesity
- ascites
- pregnancy
- hiatal hernia
- nausea/vomiting
- recent food consumption
3-Neurologic system:
- recent neurosurgery
- increased intracranial pressure
- aneurysm precautions
4- Pulmonary system:
-SOB
SIDELYING PRECAUTIONS
1-Circulatory
-axillo-femoral bypass graft
2- MS system:
- humeral fractures
- need for hip ABD brace
independent secretion removal techniques
active cycle of breathing
autogenic drainage
FLUTTER or acapella device
low pressure positive expiratory pressure (PEP) mask
high pressure positive expiratory pressure (PEP) mask
active cycle of breathing
independent program to assist in the removal of more peripheral secretions that coughing may not clear
1-breathe in controlled, diaphragmatic fashion
2-deep inhalations with a hold at the top
3-if no secretions seem to be mobilized, the patient returns to step 1 &2 and reassess. Continue if secretions can be cleared.
4- inhale at a resting tidal volume- contract the abdominal muscles to produce 1 or 2 forced expiratory huffs from mid to low lung volume to raise secretions
5- huff from high lung volume or cough to clear
6- controlled diaphragmatic breathing
7- repeat
autogenic drainage
used to sense peripheral secretions and clear them without the tracheobronchial irritation from coughing
amount of time spent in each of the following stages determined by patient feels with secretions
1-unstick phase: quiet breathing at low lung volumes to effect peripheral secretions
2- collect phase: breathing at mid lung volumes to affect secretions in the middle airways
3- evacuation phase: breathing from mid to high lung volumes to clear secretions from central airways; replaces coughing
4- repeat
FLUTTER or acapella device
external device that vibrates the airways on exhalation to improve airway clearance with intermittent, positive expiratory pressure
1-inhale normal through nose or without device
2- exhales through device, setting a vibration within airways. 5-10 times
3- full inhalation, 3 second hold
4- rapid, forced exhalations through flutter 2-3x
5- huff or cough to clear
PEP mask
positive expiratory pressure mask
low pressure: 10-20 cm H20
high pressure: 50-120 cm H20
normal tidal volume breaths; after ~ 10 breaths, mask is removed for coughing/huffing
diaphragmatic breathing
used to:
- increase ventilation
- improve gas exchange
- decrease work of breathing
- facilitate relaxation
- maintain or improve mobility of chest wall
- patients post-op, post-trauma, pulmonary diseases
semi fowler position (to start)
hand gently over subcostal angle
- apply pressure t/o exhalation; firm pressure at the end
- inhale against resistance; release to allow full inhalation
progress to independent
segmental breathing
used to:
- improve ventilation to hyperventilated lung segments
- alter regional distribution of gas
- maintain or restore functional residual capacity
- maintain or improve chest wall mobility
- prevent pulmonary compromise
used for patients with pleuritic, incisional or postpartum pain that causes decreased movement in the portion of the thorax (splinting) and those at risk of developing atelectasis
postural drainage positions
apply gentle pressure to thorax over area of hypoventilation during exhalation
- increase to firm pressure just prior to inspiration
- inhale against resistance
- release to allow full inspiration
sustained maximal inspiration
used to:
- increase inhaled volume
- sustain or improve alveolar inflation
- maintain or restore functional residual capacity
used in acute situations: post-trauma pain, post-op, acute lobar collapse
inspire slowly through nose or pursed lips to max inspiration
- hold 3 seances
- passively exhale
Incentive spirometes
pursed lip breathing
used to:
- reduce respiratory rate
- increase TV
- reduce dyspnea
- decrease mechanical disadvantages of impaired ventilatory pump
- improve gas mixing at rest for patients with COPD
- facilitate relaxation
primarily used for patients with obstructive disease who experience dyspnea at rest or with minimal activity, or with ineffective breathing patterns during activity
inhale through mouth or nose
exhale through pursed lips (prolong)
paced breathing
activity pacing
usd to spread out the metabolic demands of an activity over time by slowing its performance
used for patients who become dyspneic during activity
break down any activity into manageable components
- inhale at rest
- exhale with pursed lips, complete the 1st component of activity
- stop and inhale at rest
- repeat
ex: ascend 1 stair with exhalation, pause and inhale
pneumonectomy:
lobectomy:
segmental resection:
wedge resection:
pneumoectomy: lung removal
lobectomy: removal of a lobe of a lung
segmental resection: removal of a segment of a lobe
wedge resection: removal of a portion of a lung without anatomical divisions
midsternotomy:
Thoracotomy:
midsternotomy: sternum is cut in half lengthwise and rib cage is retracted
- used in most heart surgery
thoracotomy: used for most lung resections; incision of 4th intercostal space
rescue drugs
used for immediate relief of breakthrough symptoms: tightness, wheezing, SOB
Short acting beta 2 agonists: sympathomimetics
- mimic activity of SNS that produce bronchodilation
- can increase HR and BP
- topically through inhaler
ex:
ventolin (albuterol)
alupent (metaproterenol)
maxair (pirbuterol)
maintenance drugs
regular schedule to maintain optimal airway diameter
1- long acting beta 2 agonists
2- anticholinergics
3- methylxanthines
4- leukotriene receptor antagonists
5- cromolyn sodium
6- anti-inflammatory agents
7- vaccinations
long acting beta 2 agonists
(sympathomimetics)
- mimic SNS, allow bronchodilation
- may decrease need for rescue drugs and inhaled anti inflammatories
- ex: serevent (salmeterol)
anti-cholinergics
inhibit the PSNS
increase HR, BP and bronchodilation
side effects:
- lack of sweating
- dry mouth
- delusions
atrovent
methylxanthines
reduce smooth muscle relaxation
but use is limited due to serious toxicity, increased BP, HR, arrhythmias, GI distress, nervousness, headache and seizures
leukotriene receptor antagonists
block leukotrienes released in allergic reactions
inhibit airway edema and smooth muscle contraction
mechanical ventilation
maintains adequate Ve for patients who can’t independently
endotracheal (oral)
nasotracheal (nasal)
tracheal (through tracheostomy directly into trachea)
no contraindications for PT
chest tubes
used to evacuate air or fluid trapped in intracellular space
sutured in place
no contraindications to PT
IVs
intravenous catheters used to deliver meds
no PT contraindications
-UE should not be raised above level of IV or back flow may occur
supplemental oxygen
if SaO2
sputum characteristics
foul smell– indicates anaerobic infection
purulent (yellow or green) – indicates infection
frothy– usually pulmonary edema
mucoid (clear, thick)– indicates cystic fibrosis or conditions with a chronic cough
hemoptysis – blood in the sputum
Valsalva’s maneuver
attempting to forcibly exhale with the glottis, nose and mouth closed
causes increased intrathoracic pressure and decreased return of blood to the heart
bronchodilator meds
epinephrine
alupent (metaproterenol)
ventolin (albuterol)
proventil
relax smooth muscle and open airway lumen to assist in breathing
corticosteroids
prednisone
cortisol
decrease edema and inflammation associated with COPD
side effects:
- osteoporosis
- muscle wasting
- slow wound healing
bronchitis
chornic inflammation of the tracheobronchial tree with cough and sputum production lasting 3 months-2 consecutive years
S&S
- wheezing or rhonchi breath sounds
- productive mucoid or purulent sputum with infection
- may have fever
Tx:
- bronchopulmonary hygiene
- positions of relax
- paced breathing
- endurance exercise
- education
emphysema
permanent abnormal enlargement and destruction of air spaces distal to terminal bronchioles
may develop following smoking history with chronic cough and sputum production
S&S
- barreled chest
- use of accessory muscles
- decreased breath sounds
- wheezing
- dyspnea
TX:
- pursed lip breathing-exhalation
- education
- endurance
SaO2
arterial oxygen saturation
the ratio of the amount of O2 present in a known volume of blood to the amount of oxygen that could be carried by that volume of blood
measured by pulse oximeter
