Pulmonary Flashcards
Goals of cardiovascular pulmonary PT
- Prevent airway obstruction/ accumulation of secretions that interfere with normal respiration
- Improve airway clearance, cough effectiveness, ventilation through mobilization and drainage of secretions
- Improve endurance, general exercise tolerance
- Reduce energy costs during respiration through breathing retraining
- Prevent, correct postural deformities associated with pulmonary or extrapulmonary disorders
- Maintain or improve chest mobility
Anatomy of the respiratory tract
- trachea
- 2 mainstem bronchi
- 5 lobar bronchi (3 upper, middle, lower) on right; (2 upper and lower and a lingula on the left
- 18 segmental bronchi
- bronchioles
- alveolar ducts and sacs
Primary ventilatory muscles
Inspiration: •Diaphragm •Scalenes •Parasternals Expiration: •none active during tidal (resting) expiration-passive recoil
Accessory ventilatory muscles
Inspiration: • SCMs • upper traps •pecs •possible external intercostals Expiration: • abdonminals • pec major •possibly internal intercostals
Compliance
distensibility of tissue- how easily the lungs inflate during respiration
Airway resistance
amount of resistance to flow of air- depends on: bifurction/ branching of airways, size of lumen- diameter may be decreased by mucus or edema.
Flow rates
- measurements of amount of air moved in and out of airway over a period of time.ie. With COPD flow rate is decreased- takes longer than normal to exhale a specific volume of air
Total lung capacity
the total amount of air contained in the lunges after a maximal inspiration
•approx 6,000 mL
Tidal volume
the amount of air exchanged during a relaxed inspiration followed by a relaxed expiration (quiet/resting breathing)
•approx 500 mL
Residual volume
the amount of air left in the lungs after a max expiration
• approx 1500 mL
•RV increases with restrictive and obstructive pulmonary disease
Vital capacity
measured by max inspiration followed by max expiration
•approx 4500 mL
•decreases with age, restrictive and obstructive diseases, and is less in supine than erect sitting or standing
normal respiration rates for adults
12-20 breaths per minute
normal ratio of inspiration/expiration
at rest= 1:2
with activity= 1:1
*patient with COPD may have a ratio of 1:4 at rest- reflects this patient types difficulty with expiratory phase of breathing
ausculation- normal and adventitious
Normal: vesicular, bronchiol, bronchovesivular
Adventitious: crackles (rales), wheezes (rhonchi)
thin, frothy, and white consistency of cough production indicates…
pulmonary edema and heart failure
Restrictive lung diseases
Difficulty with INHALATION
Pulmonary causes:
•pneumonia
•TB
•asbestosis (a lung disease resulting from the inhalation of asbestos particles, marked by severe fibrosis and a high risk of mesothelioma- cancer of the pleura)
•atelectasis
•tumor
•pulmonary fibrosis
•pulmonary edema
•PE
•ARDS (adult or acute respiratory distress syndrome caused by fluid build up in the alveoli)
•bronchopulmonary dysplasia (Chronic lung disease of premature babies)
• advanced age
•pneumothorax (A collapsed lung. A pneumothorax occurs when air leaks into the space between the two pleural membranes surrounding each lung, space is called the pleural cavity)
•hemothorax (an accumulation of blood within the pleural cavity- space between the pleural membranes surrounding each lung)
Extrapulmonary causes:
• chest wall pain due to trauma or surgery
•chest wall stiffness due to disease- scleroderma (autoimmune disease- hardening of the skin), ankylosing spondylitis
•postural deformity- scoliosis, kyphosis
• Ventilatory muscle weakness- SCI, CP, MD, Parkinson disease
•pleural disease
• decreased diaphragmatic excursion due to ascites (fluid build up in the abdominal cavity) or obesity
Pulmonary HTN
can be caused by a number of factors, all of which force the heart’s right side to work harder to pump blood to the lungs. The right chambers may enlarge as they struggle to function, and the blood is often forced backwards through the tricuspid valve
lobectomy
removal of a lobe of a lung- often for removal of CA
COPD chronic obstructive pulmonary disease
- peripheral airway disease
- chronic bronchitis (inflammation (swelling) and irritation of the bronchial tubes. The irritation of the tubes causes mucus to build up)
- Emphysema (In people with emphysema, the air sacs in the lungs (alveoli) are damaged. Over time, the inner walls of the air sacs weaken and rupture — creating larger often mucus filled air spaces called bullae- instead of many small ones)
- asthma (marked by spasms in the bronchi of the lungs, causing difficulty in breathing. It usually results from an allergic reaction or other forms of hypersensitivity- airways narrow and swell and may produce extra mucus)
- bronchiectasis (a condition where the bronchial tubes of your lungs are permanently damaged, widened, and thickened. These damaged air passages allow bacteria and mucus to build up and pool in your lungs- leading to frequent infection and general obstruction)
- cystic fibrosis (hereditary disease that affects the lungs and digestive system. The body produces thick and sticky mucus that can clog the lungs and obstruct the pancreas)
- bronchopulmonary dysplasia (Chronic lung disease of premature babies- lungs don’t develop normally)
Types of breathing:
- diaphragmatic
- segmental: lateral costal expansion and posterior basal expansion
- pursed lip breathing- avoid forceful expiration- there should be no contraction of abdominals
- Glossapharyngeal breathing: for high SCI or other neuromuscular disorders- usually ventilator dependent because of absent or incompetent innervation to diaphragm (gulping air)
Pulmonary A&P Dr.B
•Involuntarily controlled by brainstem. Voluntarily by cerebral cortex.
•Primary inspiratory muscles: Diaphragm External intercostals Internal intercostals •Accessory: trap, SCM, scalenes, pectorals, serratus ant, lat dorsi
•Primary expiratory: Rectus abdominus External oblique Internal oblique. •Accessory exp: Latissimus dorsi Tripod position allows for accessory muscles to be used more effectively
Respiratory flow chart
nose -> nasal cavities -> pharynx (adenoids & tonsils) -> larynx (epiglottis) -> trachea -> bronchi -> bronchioles -> alveoli -> lung capillaries
Gas exchange
Occurs across the alveolar-capillary membrane. Factors involved: Concentration gradient: Alveolar O2 100mmHg to capillary 40mmHg Surface area of the A-C interface. Thickness of membrane (phlegm) Solubility of the gas
Ventilation/Perfusion
- Close as possible to 1:1 is ideal
- Air present and ready to exchange (V) and blood present and ready for exchange (Q)
- Really is 0.8
- V/Q depends on position
- Dead space: perfusion is lacking
- Shunt: ventilation is lacking
Obstructive disorders
- Asthma
- Chronic bronchitis
- Emphysema
- Cystic Fibrosis
- Bronchiectasis
- COPD: a combination of chronic bronchitis, emphysema, small airway obstruction.
COPD
- Progressive airflow limitation caused by airway inflammation due to noxious particles/gases
- Mucous membranes hyperplastic (narrow)
- Cilia function decreases (hard to clear)
- Chest wall flexibility decreases, no recoil
- Elevated TLC, FRC, RV
- Decreased IRV, VC, IC, ERV
COPD what can you do
What can you do?
•Teach patient positioning: upright or postural drainage
•Pursed lip breathing (tissue trick)
•Effective coughing with tactile cues
•Give rest breaks
•Use Borg scale
** don’t increase oxygen without permission**
Asthma: exacerbation
•S&S: Tachypnea, fatigue, anxiety, pursed lip breathing, active expiration, cyanosis, accessory muscle use
•if severe: both BP and pulse will decrease on inspiration
polyphonic wheezing on expiration>inspiration
diminished breath sounds
Asthma: tx
Remove of trigger Bronchodilator Corticosteriods Supplemental oxygen IV fluids PT: pt should bring inhaler to tx, stop exertion if wheezing noted, triggers should be noted on the chart (cold/allergen)
Chronic Bronchitis
- S&S: tripod breathing, barrel chest, anxiety, fatigue, ^RR, prolonged expiration, stocky build, dependent edema, “blue bloater”, cyanosis due to cor pulmonale, edema, ^HR, BP, ^Hbg, ^CO2
- Rhonchi, diminished breath sounds, crackles, productive cough in morning, clear to purulent sputum
- Xray: flat diaphragms, cardiomegaly (cor pulmonale)
Chronic bronchitis tx
Smoking cessation, bronchodilator, steroids, expectorant, O2, ventilation if severe
PT: airway clearance techniques, pulmonary rehab
Emphysema
•S&S: cachexia, accessory muscle use, fatigue, anxiety, “Pink puffer-tachypnea, pursed lips & flushed skin”, muscle atrophy, air trapping
Very diminished breath sounds, wheeze, crackles
• No cough
•Xray: bullae, heart appears smaller, flat diaphragms
Emphysema tx
- Bronchodilators,
- O2
- Nutrition support
- Pulmonary rehab.
- Be on the look out for spontaneous pneumothorax as bullae can burst
Cystic fibrosis
•S&S: tachypnea, fatigue, accessory muscle use, barrel chest, cachexia, clubbing
^BP, HR, diminished breath sounds, rhonchi, crackles, chronic cough, thick green/red streaked sputum
•Xray: flat diaphragms, fibrosis, atelectasis, linear opacities, large R ventricle
Cystic fibrosis tx
- Antibiotics, Bronchodilators, Mucolytics
- O2
- PT: Airway clearance techniques & aerobic exercise
- nutritional support
- Psychosocial
- lung transplant
Airway clearance techniques
- Breathing control
- Thoracic expansion
- Forced expiratory
- Directed cough and huffing
- Postural drainage
Breathing techniques
- Diaphragmatic breathing
- Inspiratory muscle training
- Paced breathing and exhale effort
- Pursed-lip breathing
- Segmental breathing
- Sustained maximal inhalation with incentive spirometer
Bronchiectasis (bronchial dilation)
- S&S: tachypnea, fatigue, accessory muscle use, barrel chest, cachexia, clubbing, ^BP & HR, pleuritic pain
- Crackles, diminished breath sounds, rhonchi
- Sputum: purulent, odorous, may have hemoptysis
- Xray: infiltrates, atelectasis, honeycomb
Bronchiectasis tx
- Antibiotics, bronchodilators, corticosteroids, O2, IV fluid, nutritition, pain control, lung transplant
- PT: bronchopulmonary hygiene
Pulmonary function testing
- Tests inspiration & expiration volumes and speeds.
- Determines obstructive vs restrictive
- Determines progress of condition
- Obstructive: reduced expiratory flows, retained air leads to d/c inspiration
- Restrictive: reduced lung volumes, normal expiration.
Restrictive lung diseases
- Atelectasis
- Pulmonary Embolism (PE)
- Adult Respiratory Distress Syndrome (ARDS)
- Pneumonia
- Pulmonary fibrosis/ Interstitial lung disease
- Pulmonary edema
Atelectasis
- Partial or total collapse of alveoli, lung segments or lobes.
- Caused by: inactivity, pain with deep breathing (hint…surgery patients), diaphragm weakness (ICU and SCI patients), foreign body
- PT:Incentive spirometer, deep breathing and coughing, OOB, ambulate
PE
- A clot within the arterial pulmonary circulation. (90% of the time from the lower extremity)
- No blood flow beyond the clot. No gas exchange beyond the clot.
- PT should be ceased until cleared by MD, very close monitoring upon resumption of activity.
- Sx: Sudden dyspnea, chest pain, tachypnea, tachycardia, severity varies
ARDS
- Acute lung inflammation
- S&S: dyspnea, AMS, ^RR, ^PA pressure, hypotension, decreased chest wall expansion, d/c breath sounds, crackles, wheeze.
- Xray: pulmonary edema, patchy opacities, “ground glass”
- Tx: vent, IV fluid, prone, glucocorticoids,
- PT will start when pt is stable, 30% mortality
Pneumonia
•Distal airway inflammation with alveolar exudate formation.
•May be one lobe or many.
Fever, increased WBC, dyspnea
•Resolution may take 6 weeks (prolonged in advanced age, smoking hx, poor nutrition, co-morbidities)
Pulmonary fibrosis/interstitial lung disease (ILD)
- Destruction of respiratory membranes in multi locations
- 1st phase inflammatory, 2nd phase fibrotic
- S&S: exertional dyspnea, non productive cough, dry crackles (Velcro sound),
- Xray: diffuse, bilateral changes
Pulmonary edema
- Fluid moves from capillaries into alveoli.
- S&S: tachypnea, orthopnea, anxiety, accessory muscle use, wet crackles at bases, may have wheeze.
- Sputum frothy, white, clear, pink**
- ^ Hilar vascular markings, ^cardiomegaly, fluffy opacity
- Tx: diuretics, O2, hold PT until stable
Red flag signs of acute pulmonary edema
- Extreme dyspnea
- Diaphoresis
- Bubbly/wheezing/gasping breath sounds
- Frothy or blood tinged sputum
- Cyanosis
- Rapid, irregular HR
- Severe drop in BP
Extrapulmonary restriction
- Pleural effusion, •Hemothorax
- Pneumothorax (PTX)
- Flail chest (rib cage breaks and moves)
- Empyema
- Kyphoscoliosis, ankylosing spondylitis, RA
- Obesity/pregnancy
Plueral effusion/hemothorax
- Fluid gathered between the lung tissue and the pleural sac.
- Prevents full expansion
- Hemothorax indicates this fluid is blood
- Empyema indicates this fluid is purulent.
Pneumothorax
- Pneumothorax: Air gathers in the pleural cavity
- Can be due to trauma, tension, bleb/bulla, central line insertion, thoracentesis, atelectasis.
- S&S: tachypnea, pleural pain, d/c expansion, d/c breath sounds
Thoracentesis and chest tube
- Thoracentesis: surgical puncture to remove fluid from pleural space
- Chest tube: tube placed in the intercostal space to remove fluid/air/blood from pleural space, drains to pleurovac container, or pleurax is drained intermittently. sutured in place
tracheostomy
Surgical creation of opening into the trachea through the neck
lung surgeries and PT
Lung surgeries tend to be quite painful for several days, especially when a chest tube is present. Plan for premedication, splinted coughing, don’t roll on to the incision or chest tube if possible, be very careful not to pull on the chest tube, gait belt may be contraindicated. Don’t knock over Pleurevac.
ABG (arterial blood gas)
- Blood sample from (radial) artery
- Detects acid/base balance, how well body is removing
- CO2 and bringing in O2
- pH: 7.35-7.45
- PaCO2: 35-45 mmHG
- PaO2: 80-100 mmHG. •Hypoxemia: <80
- HCO3: 22-26 mEq/L
- SaO2: 95-98%
Normal lung sounds
Depend on the area:
•Tracheal/bronchial: over the trachea or bronchi. Loud, inspiration shorter.
-heard over tubual structures, abnormal if over lung tissue
•Vesicular: breezy, inspiration longer
-Heard over lung tissue
Abnormal lung sounds
- Wheeze
- Stridor (a high-pitched, wheezing sound caused by disrupted airflow)
- Rhonchi (continuous low pitched, rattling lung sounds that often resemble snoring)
- Crackles (fine, short, high-pitched, intermittently crackling sounds. The cause of crackles can be from air passing through fluid, pus or mucus)
- Pleural friction rub
Cheyne- Stokes respirations
a cycle of abnormal breathing that lasts between 30 seconds and 2 minutes, the patient’s breathing will become really deep and then gradually get very shallow and some may experience a period of apnea. This condition is associated with heart failure and stroke, as well as airway obstruction.
Kussmaul’s respirations
deep and rapid breathing pattern, a form of hyperventilation that is one of the body’s responses to excessive internal acidity. This breathing pattern commonly occurs with severe metabolic asidosis (experienced by those with DM) including keto acidosis as well with renal failure
Biot’s respirations
clusters of rapid and shallow breathing, unlike Cheyne-Stokes this breathing abnormality wont come on gradually and there are no periods of deep breathing. This condition is caused by pressure on or damage to the brainstem due to CVA or problems such as meningitis.
Hyperventilation
period of rapid and deep breathing, generally associated with extreme stress or panic attacks, but sometimes with a more serious underlying cause such as heart problems, COPD, and pulmonary infections
Hypoventilation
period of slow and shallow breathing, associated with lung issues like cystic fibrosis and emphysema as well as metabolic alkalosis
tracheal breath sounds
- Normal
* loud and tubal, heard over proximal airways, such as the trachea and main stem.
Bronchial breath sounds
- Normal
* loud and tubal, heard over proximal airways, heard near the manubrium
Vesicular breath sounds
- Normal
* soft and rustling sound, heard over more distal lung areas (parenchyma)
Wheezing breath sounds
- Abnormal
* airway obstructions or retained secretion, heard during expiration
Stridor breath sounds
- Abnormal
* very high pitched wheezing occurring during inhalation, usually associated with an upper obstruction
Rhonchi breath sounds
- Abnormal
* low pitched sound (similar to snoring) caused by large obstructions, usually in the form of secretions
Discontinuous breath sounds
- abnormal
- crackling and bubbling or popping sounds, usually indicates presence of fluid secretions or sudden opening and closure of airway
breath sounds from fluid
such as pneumonia or pulmonary edema- the sound is wet
breath sounds from atelectasis
sound is dry
Resonant breath sounds
occurs over normal lung tissue
Hyper-resonant lung sounds
occurs with emphysema or a pneumothorax
Dull breath sounds
occurs with increased lung tissue density, or decreased air content
TLC total lung capacity
the volume of air contained in the lungs after a maximal inspiration. Increase in this volume indicates an obstructive disorder, while a significant decrease indicates a restrictive disorder
FEV forced expiratory volume
forced expiratory volume is the amount of air that can be expired within a certain time frame. A significant decrease in this volume indicates a restrictive disorder, while a decrease in FEV1/FVC indicates an obstructive disorder
Asthma
Classification: obstructive
Observations: tachypnea, fatigue, and anxiety
Management: removal of causative agents, corticosteroids, bronchodilators
Cystic fibrosis
Classification: obstructive
Observations: tachypnea, fatigue, digital clubbing, and barrel chest
Management: antibiotics, bronchodilators, nutritional support
Emphysema
Classification: obstructive
Observations: wheezing, pink puffer, and cachexia
Management: bronchodilators, supplemental O2, nutritional support
Chronic bronchitis
Classification: obstructive
Observations: blue bloater, tachypnea, barrel chest, fatigue
Management: supplemental O2, stop smoking, brochodilators
Bronchiectasis
Classification: obstructive
Observations: accessory muscle use, fatigue, clubbing
Management: supplemental O2, antibiotics, bronchodilators
Atelectasis
Classification: restrictive
Observations: dry or wet sputum, shallow breathing, tachypnea
Management: incentive spirometer, supplemental O2, functional mobilization
Pneumonia
Classification: restrictive lung disease
Observations: fatigue, decreased chest wall expansion, crackles
Management: antibiotics, supplemental O2, bronchopulmonary hygiene
Pulmonary edema
Classification: restrictive
Observations: tachypnea, orthopnea, accessory muscle use
Management: diuretics, supplemental O2, hemodynamic monitoring
Adult respiratory syndrome
Classification: restrictive
Observations: labored breathing, altered mental status, tachypnea
Management: prone positioning, hemodynamic monitoring, mechanical ventilation
PE
Classification: restrictive
Observations: rapid onset of chest pain, tachypnea, dysrhythmia
Management: anticoagulation, thrombolysis, hemodynamic stabilization
side effect of pulmonary maintenance drugs, rescue drugs, antibiotics, supplemental O2
shaky hands, tachycardia, HA, vomitting, diarrhea, dizziness, abdominal cramping, rash, nasal inflammation, air trapped in the esophagus, tremors
s/s of hyperthyroidism
- tachycardia
- Graves disease (autoimmune disorder that causes hyperthyroidism, or overactive thyroid. With this disease, your immune system attacks the thyroid and causes it to make more thyroid hormone than your body needs)
- increased perspiration
- diarrhea, thirst, weight loss
s/s of hypothyroidism
- cold intolerance
- nonpitting edema of the eyelids, hands, and feet
- Hashimoto’s thyroditis (autoimmune disease that damages the thyroid gland. Hashimoto’s disease affects more women than men. It is the most common cause of hypothyroidism)
- delayed DTR
- dry and cool skin
retained secretions…
- Obstruct airways
- Limit airflow
- Cause VQ mismatch
- Impair gas exchange
- Increases risk of infection
- Secretion clearance is the cornerstone of diseases of hypersecretion
Goals of airway clearance
- Improve ventilation
- Facilitate secretion clearance
- Manage dyspnea & discomfort
- Increase cough effectiveness
Principles of airway clearance: interdependence
deep inhalation expands direct and adjacent collapsed allveoli bringing air into obstructed airways
Principles of airway clearance: collateral ventilation
channels bypass blocked airways using pressure from adjacent segments
Principles of airway clearance: 3 seconds inspiratory hold
allows time for interdependence and collateral ventilation to occur
Cough
•Coughing clears proximal 1/3 bronchial tree
- other techniques move secretions to this area to be cleared by coughing
•Effective cough requires:
- deep inhalation, 1.5x tidal volume to elicit elastic recoil
-closure of glottis, abdominal contraction, add 3 second hold for more effectiveness
- increased expiratory flow rate to shear secretions from bronchial walls
•Can cause bronchospasm
Pharmacology
- Bronchodilators: albuterol
- Mucolytics: reduce viscosity
- inhaled steroids
- inhaled antibiotics
postural drainage contraindications
- intercranial pressure >20 mm Hg
- head/neck injury
- hemorrhage
- recent spinal surgery
- hemoptysis (coughing up of blood or blood-stained mucus)
- surgical wound in area
- empyema (a collection of pus in the pleural cavity)
- bronchopleural fistula
- pulmonary edema
- confusion/anxiety
- rib fx/CA
Trendelenburg specifically contraindicated
•uncontrolled HTN • distended abdomen •esophageal surgery • lung CA with hemoptysis • airway at risk for aspiration -tube feed -recent meal -unable to manage oral secretions
postural draining positions
- anterior apical segments: semi-fowlers
- posterior apical segments: sitting up and leaning forward
- anterior segments (upper lobes): supine
- right posterior segments: prone with the right side propped up on a pillow so that it is superiorly positioned relative to the L (switch sides for L)
- left posterior segment (upper lob): prone with upper body elevated
- right middle lobe: trendelenburg with slight L rotation and right side propped up on pillow
