Pulmonary Interventions & ACTs

Question 1

what does diaphragmatic breathing optimize?
what is it?

Answer 1

the use of diaphragm to breathe deeper than normal
conscious use of diaphragm to take deep breaths to use more lung capacity compared to resting tidal volume breathing

Question 2

what are some benefits of diaphragmatic breathing?

Answer 2

strengthens diaphragm
improves ventilation and respiration
increases PaO2 and SpO2
activates parasympathetic and suppresses sympathetic
increases venous return, lowers BP
lowers stress and cortisol levels
facilitates relaxation

Question 3

what position should your patient be in for proper diaphragmatic breathing?

Answer 3

lie in hooklying or with pillow under knees
- posterior pelvic tilt will encourage diaphragmatic breathing pattern

Question 4

where should our patients put their hands on for diaphragmatic breathing?
– when should hands move?

Answer 4

place one hand on chest, one on abdomen
– hand on chest should remain still, hand on abdomen should rise

Question 5

how should your breathing be during diaphragmatic breathing?

Answer 5

breathe in slowly –> fully inhaling and expanding abdomen
slowly let the abdomen down while breathing out

Question 6

what is the benefit of pursed lip breathing?

Answer 6

pursed lips provide back pressure to small airways that maintain opening = improved gas exchange
by keeping airways open longer, air can be exhaled easier

Question 7

pursed lip breathing promotes =
pursed lip breathing reduces =
pursed lip breathing facilitates =

Answer 7

RR
effort of breathing
relaxation, reduced stress response

Question 8

what is the I:E ratio with pursed lip breathing?

Answer 8

1:2
exhale 2x longer than inhale

Question 9

incentive spirometry can be used for:

Answer 9

assessment
intervention
education

Question 10

incentive spirometry:
– prevents =
– practices =
– stimulates =

Answer 10

– passive atelectasis that can turn into PNA
– diaphragmatic breathing
– a cough

Question 11

inhalation should be paired with:
– shoulder ___, ____, ____
– thoracic and cervical _____
– _____ eye gaze

Answer 11

– flexion, abduction, external rotation
– extension
– upward

Question 12

exhalation should be paired with:
– shoulder ____, _____, ______
– thoracic and cervical ______
– _____ eye gaze

Answer 12

– extension, adduction, internal rotation
– flexion
– downward

Question 13

what positions are useful in relieving dyspnea?

Answer 13

tripoding
trunk extension
sidelying
trunk elevation/sitting

Question 14

why does tripoding work to relieve SOB?

Answer 14

anchoring distal muscle attachments allows proximal attachments to assist more effectively in thoracic cavity expansion

Question 15

forward leaning tripoding can increase:

Answer 15

intraabdominal pressure and push diaphragm into a more lengthened position = stronger contraction

Question 16

why does trunk extension work to relieve dyspnea?

Answer 16

allows for more effective thoracic cavity expansion

Question 17

why does sidelying work to relieve dyspnea?

Answer 17

assists in superior lung expansion
not as restricting to the spine as supine may be

Question 18

why does trunk elevation/sitting work to relieve dyspnea?

Answer 18

more upright position allows gravity to naturally pull the diaphragm down to create more space in the thoracic cavity

Question 19

what are airway clearance techniques (ACTs)?

Answer 19

manual or mechanical procedures that facilitate mobilization of secretions from airways

Question 20

what is our goal in performance of ACTs?

Answer 20

improved O2 transport –> critical for the patient to be able to progress towards any other functional goals

Question 21

what things are the technique of ACTs based on?

Answer 21

pathophysiology and symptoms
medical stability
pt cooperation and adherence to techniques

Question 22

what are the specific goals of ACTs?

Answer 22

optimize airway patency
increase V/Q matching
promote alveolar expansion and ventilation
increase or improve gas exchange

Question 23

what are indications to use ACTs?

Answer 23

excessive pulmonary secretions
impaired mucociliary transport
ineffective or absent cough

Question 24

when should ACTs be performed?

Answer 24

before or at least 30 minutes after the patient eats

Question 25

what should be given before ACTs?

Answer 25

inhaled bronchodilators

Question 26

what should be given after ACTs?

Answer 26

inhaled antibiotics, steroids --> better deposition if after

Question 27

what is an ACT for increased ventilation during activity that enhances mucociliary transport?

Answer 27

exercise! - it is an ACT

Question 28

what is postural drainage (PD)?

Answer 28

assuming one or more body positions that allow gravity to assist with draining secretions from individual lung segments

Question 29

the segmental bronchus of the segment to be drained must be positioned ______ to the floor

Answer 29

perpendicular

Question 30

how long should each position be maintained during postural drainage?

Answer 30

>/= 5-10 minutes

Question 31

a child with CF has the worst consolidation of fluid in the left lateral lobe, which lobe should you treat first?

Answer 31

left lateral lobe --> segment with worst airway clearance should be drained first

Question 32

what are precautions to postural drainage?

Answer 32

pulmonary edema hemoptysis massive obesity pleural effusion thoracic cavity structural deficits ascites GERD cognition/behavior ability to follow instructions

Question 33

what are contraindications to postural drainage?

Answer 33

increased ICP hemodynamically unstable recent esophageal anastomosis or surgery recent spinal fusion or injury recent head trauma diaphragmatic or hiatal hernia recent eye surgery

Question 34

if a patient has a contraindication or precaution to postural drainage, how do you BEST proceed? a. don't do it b. modify the position c. you don't need to change anything

Answer 34

b. modify the position

Question 35

a PT suspects involvement in the posterior basal segment of lower lobes for an obese patient. which of the following is a BEST position to consider? a. positioned on abdomen, with head down, with 2 pillows under hips with foot of table elevated 20 inches b. positioned on abdomen, with head down, with no pillow under hips with table flat c. positioned on abdomen, with head down, with 1 pillow under hips with table flat d. positioned on abdomen, with head down, with 1 pillow under hips with foot of table elevated 20 inches

Answer 35

c. -- because they are obese, you have to modify their position

Question 36

what is percussion?

Answer 36

loosening retained secretions performed manually or with device via rhythmical clapping with cupped hands

Question 37

what is vibration?

Answer 37

loosening retained secretions via exertion of pressure and oscillation during exhalation

Question 38

which technique can be used as an alternative if needed due to discomfort?

Answer 38

vibration

Question 39

what is the goal of vibration/percussion?

Answer 39

loosen secretions enough that the pt can expectorate them or they can be drained via PD

Question 40

what are precautions of percussion and vibration?

Answer 40

uncontrolled bronchospasm osteoporosis/osteomyelitis rib fractures spinal or rib metastases tumor obstruction of airway anxiety coagulopathy seizure disorder cognition/behavior/cooperation recent pacemaker other recent invasive line placement

Question 41

what are contraindications of percussion and vibration?

Answer 41

hemoptysis tension PNX thrombocytopenia < 20 hemodynamically unstable thoracic burns or wounds pulmonary embolism subcutaneous emphysema skin grafts or surgical flaps to thorax

Question 42

what is the first-line intervention to promote effective cough to address positioning and teaching proper cough techniques?

Answer 42

assisted cough

Question 43

what are the 4 stages of an effective cough?

Answer 43

1. inhalation greater than tidal volume (> 60% of VC) 2. closure of the glottis 3. contraction of abdominal and internal IC muscles to provide a positive intrathoracic pressure 4. sudden opening of the glottis and forceful expulsion of the inspired air

Question 44

what is the glottis?

Answer 44

opening between the vocal cords in the larynx

Question 45

what does the glottis do?

Answer 45

open and close with talking, coughing, breathing, swallowing, etc.

Question 46

how should you position your patient during an assisted cough strategy?

Answer 46

facilitate trunk extension --> inhalation facilitate trunk flexion --> exhalation

Question 47

how can you maximize inspiratory phase during assisted cough strategies?

Answer 47

verbal cues upright positioning upward eye gaze UE AROM thoracic extension

Question 48

for exhalation during an assisted cough, what do you want to maximize?

Answer 48

intraabdominal and intrathoracic pressure via positioning or muscle contraction

Question 49

for increased cough strength, what should you tell your patient to do?

Answer 49

brace or splint abdomen

Question 50

what is an alternative to coughing?

Answer 50

huffing technique

Question 51

what does the huffing technique help do?

Answer 51

prevent bronchoconstriction or collapse of weak airways stabilizes bronchial walls and support structures

Question 52

what is the huffing technique?

Answer 52

mouth open throughout, O shaped glottis doesn't close over the trachea chest and abdominal muscle contraction forced exhalation that sounds like a loud forced sigh

Question 53

huffing technique: long and slow forced exhalation moves secretions: short and strong forced exhalation moves secretions:

Answer 53

in from the distal periphery more proximally to cough

Question 54

what is the active cycle of breathing?

Answer 54

series of maneuvers to emphasize independent secretion clearance from distal to proximal and thoracic extension

Question 55

the active cycle of breathing incorporates what 3 things?

Answer 55

normal breathing deep inhalation huffing

Question 56

what does the active cycle of breathing help prevent?

Answer 56

bronchospasm

Question 57

what does huffing help stabilize?

Answer 57

bronchial walls

Question 58

what position is the active cycle of breathing performed in? why?

Answer 58

sitting helps avoid GERD

Question 59

focused thoracic expansion increases _____ and promotes ______ but allows air behind secretions to help ______

Answer 59

volume ; ventilation ; force them more proximally

Question 60

describe the 3 steps to active cycle of breathing:

Answer 60

1. breathing control: -- normal tidal volume breathing (in through the nose, out through the mouth) 2. thoracic expansion: -- 4-5 inhalations with hands on lower ribs to feel expansion -- percussion/vibration with exhalation 3. forced expiratory technique: -- 1-2 deep huff cough techniques with strong abdominal contraction