Pulmonary Interventions Flashcards
list primary and secondary muscles of inspiration
- Primary
- diaphragm
- external intercostals
- Secondary
- SCM
- scalenes
- pec major/minor
- serratus anterior
list muscles of expiration
- quiet breathing → passive recoil of lungs and rib cage
- forceful breathing
- Rectus abdominus
- external oblique
- transverse abdomnius
- internal intercostals
describe the rhythm, rate, depth and character that make up the normal breathing pattern
- Rate → 12-20 bpm
- Rhythm → I:E ration is 1:2
- Depth → deeper or shallower than normal tidal volume
- Character → quiet and effortless
how is rhythm different in disorders like COPD?
I:E ratio is 1:3 or 1:4 due to trapped air, increased residual volume, and increased work
describe an abnormal breathing pattern’s character
- labored breathing
- use of accessory muscles
- audible wheezes and crackles
describe the diaphragm
- what type of muscle fibers make it up?*
- what ways does it expand?*
- aids in inspiration (C3-5)
- expands vertically and horizontally
- type 1 muscle fiber
- dome shaped
diaphragm position and ROM are affected by ____________
- body position and posture
- stomach contents (distension)
- size of intestines
- size of liver
- ascites
- abdominal muscles
- obesity
when is diaphragmatic breathing training indicated? (3)
- post-surgical patients
- dyspnea at rest
- inefficiency with breathing/SOB during ADLs
precautions/contraindications for diaphragmatic breathing training (3)
- moderate/severe COPD w/related hyperinflation of the lungs
- pts with paradoxical breathing patterns
- pts with increased dyspnea during diaphragmatic breathing
describe the procedure for diaphragmatic breathing training
- start in supine or with HOB elevated 30-45
- pts places one hand on the upper chest and the other just below the rib cage
- PT then instructs:
- “breath in slowly through your nose so that your stomach moves out against your hand.
- The hand on the chest should remain relatively still.
- Fell your abdomen gently rise into your hand
- exhale through pursed lips, let the hand on your abdomen descend, while the hand on your upper chest remains still”
list the expected outcomes for diaphragmatic breathing training
- decreased respiratory rate
- decreased reliance on accessory muscles of inspiration
- increased tidal volume
- subjective improvement of dyspnea
- improved activity tolerance
what is pursed-lip breathing
a technique utilized to reduce respiratory rate and decrease dyspnea by maintaining positive pressure in the bronchioles.
this can help prevent airway collapse in pts with emphysema and helps trapped air escape in pts with COPD
indications for pursed lip breathing (2)
- tachypnea
- dyspnea
precautions/contraindications for pursed lip breathing
forcing exhalation
describe the procedure for pursed lip breathing
- start in supine or seated position
- PT then instructs
- breath in slowly through your nose with the mouth closed for 2 seconds
- pucker or purse your lips as if you were blowing out a candle, then gently breathe out through pursed lips, as if trying to make the candle flame flicker for a four count
- do not blow with force
list expected outcomes for pursed lip breathing
- decreased RR
- decrease dyspnea
- reduce PaCO2
- improve tidal volume
- improve O2 sats
- prevent airway collapse in pts with emphysema
- increase activity tolerance
what is segmental breathing?
what is the main goal?
- a technique intended to improve regional ventilation and treat pulmonary complications after surgery
- goal is to facilitate or inhibit chest wall movement through:
- proper hand placements
- verbal cues
- coordination of breathing
list indications for segmental breathing (3)
- decreased lung volumes
- decreased chest wall compliance
- VQ mismatch
precautions for segmental breathing
none
but be careful with pain or tenerness
when would you use segmental breathing?
when you notice that a pt has one side restricted during respiration
describe the pt position for segmental breathing
- sitting position for basal atelectasis
- sidelying with affected lung uppermost
- supine or sitting for bilateral expansion
- postural drainage positions
describe the procedure for segmental breathing
- therapist applies firm pressure at the end of exhalation over the area that needs more expansion
- pt inhales deeply and slowly expanding the rib cage under the therapist’s hand utilizing the tactile cue
T/F: segmental breathing is a muscle training technique
FALSE
you are not actively pushing against the rib cage, rather you are providing a quick stretch like PNF
list the expected outcomes for segmental breathing
- increased chest wall mobility
- expand collapsed alveoli
- secretion loosening and clearance
what is the purpose of a cough?
very important to aid in airway clearance and help reduce risk of pneumonia
when would you need to teach compensatory techniques for a cough?
if unable to cough effectively for a variety of reasons such as:
- post-surgical pain
- SCI with lack of innervation to forced expiratory muscles
- progressive weakness
list the stages and components of a cough
- deep inhalation
- glottis closes
- increased pressure gradient
- glottis opens
- forceful movement of air
what can stimulate a cough?
reflexively by a mechanical/chemical stimulus to the larynx, trachea, carina, or lower bronchi
what is the purpose of a directed cough?
can compensate for pt’s inability to elicit max forced exhalation
describe the procedure for a directed cough
- inhale maximally, close glottis and hold breath for 2-3 seconds
- contract the expiratory muscles to produce increased intrathoracic pressure against the closed glottis
- cough strongly 2-3x through slightly open mouth
*post surgical pts may need to splint the chest/abdomen by applying pressure over incision with a pillow or soft blanket roll
what is the purpose of splinting during coughing in post-surgical pts?
can help absorb all the vibrations which will reduce pain during coughing
what is a huff cough?
utilizes forced expiratory maneuver with glottis open
although it does not produce the airflow velocity a cough, it helps decrease the risk of airway collapse
describe the procedure of a huff cough
- inhale deeply through an open mouth
- contract abdominal muscles during a rapid exhalation with glottis open saying “Ha Ha Ha”
precautions/contraindications for Huff Cough
- droplet precautions with inability to control secretions
- elevated ICP
- Acute MI
- unstable head/neck injury
- potential aspiration
- untreated pneumothorax
- osteoporosis
- flail chest
describe percussion/vibration
- consist of positioning the pt properly so that gravity aids in drainage of bronchial secretions
- followed by mechanical assistance to loosen secretions
- after completion, pt is encouraged to cough/huff to clear airway
important things to remember with percussion
- skin must be covered (towel, t-shirt, hospital gown)
- therapist rhythmically strikes the chest with a cupped hand for 2-3 minutes per affected lung segment.
- can be done mechanically as well
- cough!
important things to remember with vibration
- same positions as percussion
- therapist places one hand over the affected area on each side of the rib cage
- or hand over hand over affected segment
- therapist vibrates the chest wall as the pt exhales rhythmically and with downward pressure
- vibration in direction of rib movements during expiration
- cough!
list precautions/contraindications for percussion/vibration
- elevated ICP
- unstable head/neck injury
- acute spinal injury
- PE associated with CHF
- PE
- Rib fracture
- osteoporosis
- prolonged use of corticosteroids
- suspected TB
- bronchospasm
describe active cycle of breathing techniques
- start with relaxed diaphragmatic breathing (20-30 seconds) in sitting
- perform 3-4 deep breaths with added thoracic expansion
- may add inspiratory hold of 1-3 seconds
- relaxed exhalation
- may follow with huffs or FET as secretions move into large airways
- relaxed, controlled breathing
- repeat cycle 2-4x
- cough at end of 3 cycles
list outcomes of active cycle of breathing technique
- loosen and clear secretions from the lungs
- improve ventilation in the lungs
- improve the effectiveness of a cough
describe autogenic drainage
- staged breathing at different lung volumes
- start with small tidal breaths from ERV in sitting
- repeated until secretions are felt gathering in the airways (10-20 breaths)
- the cough is suppressed
- a larger tidal volume is taken for another series of 10-20 breaths
- followed by a series of larger (approaching VC breaths)
- followed by several huff or coughs to expectorate sputum
- start with small tidal breaths from ERV in sitting
T/F: if you have to cough early in autogenic drainage do so
FALSE
try to hold cough to the very end if possible
list the outcomes of autogenic drainge
- mobilize secretions by creating shearing forces induced by airflow
- speed of expiratory flow helps mobilize secretions by shearing them from bronchial walls
- once mobilized, secretions are transported from the periphery of the airways to the central airways to be cleared
describe how to use an incentive spirometer
- maximizes alveolar expansion utilizing sustained maximal inspiration
- gives visual feedback to encourage the pt to take long, slow, deep inhalations
- very important in post surgical pts or those on prolonged bedrest (atelectasis)
- 5-10 breaths per hour when awake
what is an Acapella Flutter Device?
- positive expiratory pressure device with mechanical oscillation
- creates circuit with lungs to allow for secretion mobilization
- most allow for inhalation/exhalation without need to remove device
- end with cough
describe The Vest
- great for children along with those in need of more regular airway clearance (CF, COPD exacerbation, etc.)
- provides percussion over surface area of all bronchopulmonary segments
- secretions are removed as they loosen