Pulmonary Management Flashcards
1
Q
Primary muscles in inhalation
A
Diaphragm, Scalenes, Portions of Intercostals
stabilize rib cage and prevent inward mov’t of superior aspect of chest wall
2
Q
Role for pulmonary mx
A
>Prevent airway obstruction and accumulation of secretion ➢ Improve airway clearance, cough effectiveness and ventilation ➢ Improve endurance, gen. exercise tolerance, and overall well being ➢ Reduce energy costs during respiration ➢ Prevent or correct postural deformities ➢ Maintain or improve chest mobility
3
Q
Accessory mm for inspiation (when more rapid or deeper inhalation is needed)
A
SCM (elevate sternum), Upper trapezius(elevate shoulders and ribs), Pectorals,
Subclavius & Ext. Intercostals(expansion of ribs), SA (stabalize the ribs)
4
Q
resting position of the diaphragm is lower in the thorax; dec. IRV
A
Lack of abdominal musculature
5
Q
the
lower the diaphragm and the lower the IC
A
The more upright the body position
6
Q
the more advantageous the position of the
diaphragm
A
more supine
7
Q
helpful in providing
support to the abdominal viscera thereby
assisting ventilation
A
Abdominal binder
8
Q
Primary muscles for exp:
A
Elastic recoils of tissue (diaphragm)
9
Q
Accessory muscles in exp
A
Abdominals (effective in cough sec), Pectoralis major, quadratus lumborum(stabalize ribs), Internal intercostals (dec pressure in chest wall)
10
Q
2 forces s acting upon the ribcage in mechanics in breathimg
A
- Inward pull
2. Outward pull
11
Q
elastic recoil of the lung
parenchyma pulls the lungs, pleura and
bony thorax into a position of exhalation.
A
- Inward pull -
12
Q
bony thorax pulls the
thorax, pleura and lungs into a position of
inhalation
A
- Outward pull –
13
Q
point
of equilibrium; occurs at end of tidal expiration
A
Resting End expiratory Pressure (REEP)
14
Q
Movements of the Thorax during Ventilation
1. Inc. in AP dimensions
A
“pump-handle”
motion
15
Q
Movements of the Thorax during Ventilation
2. Inc. in lateral dimension
A
– “bucket handle”
and “caliper motion”
16
Q
Movements of the Thorax during Ventilation
3. Inc. in vertical dimensions
A
– “piston action”
17
Q
Movements of the Thorax during Ventilation
3. Inc. in vertical dimensions
A
– “piston action”
18
Q
Use for controlled breathing technique
and during postural drainage to mobilize
lung secretions
A
DIAPHRAGMATIC BREATHING
19
Q
Gravity assists the diaphragm (semi-fowlers )
A
Position DIAPHRAGMATIC BREATHING
20
Q
Instructions for DIAPHRAGMATIC BREATHING
A
Inhale through your nose slowly, exhale through your mouth
21
Q
SEGMENTAL BREATHING
Impt. to px
w/ stiff lower rib cage (chronic bronchitis,
emphysema, or asthma)
A
Lateral Costal Expansion
22
Q
Instructions for Lateral Costal Expansion
A
Ask the patient to breathe out and feel the rib cage move downward and inward. As the patient breathes out, place pressure into the ribs with the palms of your hand ■ Just prior to inspiration, apply a quick and inward stretch to chest ■ Apply light manual resistance to lower ribs to increase sensory awareness as the patient breathes in deeply and the chest expands and the ribs flare. Then as the patient breathes out, assist by gently squeezing the ribcage in a downward and inward direction ■ Teach the patient how to perform the maneuver independently by placing his hands over the ribs or applying resistance with a towel or belt around the lower ribs
23
Q
impt. to
postsurgical patients who are confined to
bed in semi-reclining for an extended
period of time
A
Posterior Costal Expansion
24
Q
Instructions for Posterior Costal Expansion
A
■ Have the patient sit and lean forward on a pillow, slightly bending the hips ■ Place your hand over the posterior aspect of lower ribs, and follow the same procedure aspect of the lower ribs for lateral costal expansion
25
Indications for PURSED LIP BREATHING
COPD pts during dyspneic
| attacks/ SOB
26
```
○ Spontaneously adopted by patients with
COPD to reduce the respiratory rate
○ Increase the tidal volume
○ Improves exercise tolerance
○ Promotes relaxation
```
PURSED LIP BREATHING
27
```
○ A means of increasing the IC when there
is severe weakness of the muscles of
inspiration
○ Ventilator dependent pt (high SCI, NM/d/o)
○ Can reduce ventilator dependence
(weaning period)
○ Emergency procedure, ventilator
malfunction
Designed to improve or maintain mobility
of the chest wall, trunk, shoulder girdle
when it affects ventilation or postural
alignment.
● Reinforce or emphasize the depth of
inspiration controlled or controlled
expiration.
```
GLOSSOPHARYNGEAL BREATHING
28
how to o mobilize one side of the chest
```
a. Have the patient bend away from
the tight side to lengthen
hypomobile structures and
expand that side of the chest
during inspiration.
b. Have the patient push the fisted
hand into the lateral aspect of the
chest, bend toward the tight side,
and breathe out.
```
29
To mobilize the upper chest and stretch
| pectoralis muscle:
```
a. While the patient is sitting in a
chair with a hand clasped behind
the head, have him or her
horizontally abduct the arms
(elongating the pectoralis major
muscle) during a deep inspiration.
b. Instruct the patient to bring the
elbows together and bend forward
during expiration.
```
30
How to mobilize the upper chest and shoulders
```
While sitting in a chair, have the
patient reach with both arms
overhead (180 degrees bilateral
shoulder flexion and slight
abduction during inspiration and
then bend forward at the hips and
reach for the floor during
expiration.
```
31
```
Used to increase inhaled volume
○ Sustain or improve alveolar inflation
○ Restore functional residual capacity
○ Incentive Spirometer - can assist pt in
achieving sustained maximal expiration
```
SUSTAINED MAXIMAL EXPIRATION
32
What is INCENTIVE RESPIRATORY SPIROMETRY
```
Low-level resistance training that
emphasizes SMI using a small handheld
spirometer with a visual or auditory
feedback purpose:
■ Increase volume of air inspired
■ Prevent alveolar collapse and
atelectasis in post-op pts
■ Strengthen weak inspiratory muscle
```
33
```
Designed to improve or maintain mobility
of the chest wall, trunk, shoulder girdle
when it affects ventilation or postural
alignment.
● Reinforce or emphasize the depth of
inspiration controlled or controlled
expiration.
```
Chest mobilization
34
Cough Mechanism:
a. Deep inspiration
b. Glottis closes, and vocal cords
tighten
c. Abdominal muscles contract and
the diaphragm elevates
d. Glottis opens
e. Explosive expiration of air occurs
35
Precautions for cough
```
○ Never allow the pt to gasp air
○ Avoid uncontrolled coughing
spasm
○ Avoid forceful coughing, pts with
Hx of CVA or aneurysm
○ Be sure px coughs while in erect
or side-lying posture
```
36
. Manual Assisted Cough (Therapist/ Self
| assisted)
```
Goal: inc. intra-abdominal
pressure
● Position: supine or sitting
● Hand placement: epigastric area
(similar to Heimlich maneuver)
● Force: inward and upward
compression
```
37
Humidification
| Self-Assisted Techniques
```
Patient Position: Sitting
○ Patient:
■ Places
Interlocked
Hands Below
Xiphoid
Process
■ Or Crosses
Arms Across
Abdomen
○ After Deep Inspiration,
Patient
■ Pushes Inward
And Upward On
Abdomen With
Wrists/
Forearms
```
38
```
➢ Chest wall pain from recent surgery or
trauma
➢ Press the hands or a pillow firmly the
incision to support the painful area with
each cough
```
Splinting
39
```
➢ Facilitate reflexive cough
➢ Place a finger or thumb just above the
suprasternal notch
> Apply a circular motion w/ pressure
downward into the trachea
```
Tracheal Stimulation
40
➢ Only means if unable to cough or huff
voluntarily or after reflex stimulation of the
cough mechanism.
➢ Used for pxs with artificial airways
➢ Follow standard precautions in the
procedure
➢ Catheter is fed through either an artificial
airway, oral or nares up to carina
➢ Applied intermittently for 10-15 seconds
Endotracheal Suctioning
41
Mobilizing secretions in one or more lung
segments to the central airways by placing
the pt in various position so gravity assists
in the drainage process
POSTURAL DRAINAGE
42
Goals for postural drainage
Goals:
1. Prevent accumulation of secretion in pts at
risk for pulmonary complications
2. Remove accumulated secretions
43
Relative Contraindications for postural drainage
a. Severe hemoptysis
b. Untreated acute conditions
c. Cardiovascular instability
d. Recent neurosurgery
➢ Trendelenburg may cause
increased intracranial pressure
44
Consideration prior to postural drainage:
```
Precautions to use of Trendelenburg
position
➢ CV system - Pulmonary edema,
CHF, HTN
➢ Abdominal problems - Ascites,
Hiatal hernia, nausea and
vomiting
➢ Neurological system - recent
neurosurgery, increased ICP,
aneurysm precautions
➢ Pulmonary system - pts w/ SOB
b. Precautions to use of Side Lying position
➢ Circulatory system - axillofemoral
bypass graft
➢ Musculoskeletal system - humeral
fractures, need for hip abduction
brace, arthritis, bursitis
```
45
Manual Techniques used during Postural Drainage:
| a. PERCUSSION
```
➢ Mechanically dislodging viscous
or adherent mucus from the
airways
➢ Rhythmically applied using a
cupped hands to specific areas of
the chest wall
➢ Therapist should try to keep
shoulders, elbows, and wrists
loose and mobile during the
maneuver
➢ Precautions: sensitive skin, over
breast tissue and over bony
prominence
➢ Relative contraindications:
○ Over fracture, spinal
fusion, osteoporotic
bone
○ Over tumor area
○ Pt with low platelet count
or receiving
anticoagulation therapy
```
46
Manual Techniques used during Postural Drainage:
| b. vibration
```
➢ Used in conjunction with
percussion
➢ Applied only during the expiratory
phase
➢ With on hand on top of the other,
gently compress and rapidly
vibrate the chest wall as the
patient breathes out
```
47
Manual Techniques used during Postural Drainage:
| c. SHAKING
```
➢ Following a deep inhalation, it is
an intermittent bouncing
maneuver coupled with wide
movements of the therapist’s
hands
➢ Applied to the rib cage throughout
exhalation
➢ Time of the day:
○ Never administer PD
directly after meal
○ Coordinate treatment
with aerosol therapy
○ Early morning and early
evening
➢ Frequency: depends on the type
nad severity
○ Thick and copious - 2 to
4 times per say
○ Under maintenance -
1/day or few days a
week.
➢ Duration: 45 to 60 minutes
```
48
Preparation for postural drainage:
1. Wear lightweight shirt or gown
2. Have a sputum cup, tissue, pillows.
3. Explain procedures.
4. Teach deep breathing and effective cough
prior to.
5. If producing copious amount of sputum,
instruct to cough few times or have suction
prior to positioning.
49
Proper sequence for postural drainage:
1. Determine the segment of the lungs to be
drained.
2. Check VS, breath sounds.
3. Position px for drainage. Observe his color.
4. Maintain each position to 5-10 mins or as
long as the position is productive.
5. Have the px breath deeply during
drainage.
6. Apply percussion
7. Encourage the px to take a deep, sharp,
double cough. (semi-upright pos’n)
8. If px does not cough spontaneously, take
several deep breaths or huff as you apply
vibration.
9. If not productive after 5-10 mins., go on to
the next position
50
Criteria for discontinuation of postural drainage
1. CXR is clear
2. Afebrile for 24-48 hrs
3. Normal or near normal breath sounds are
heard on auscultation
4. If px is on regular home program
51
Areas of percussion:
| ➢ UPPER lobe
```
○ Apical: between clavicle and top
of scapula
○ Posterior: upper back
○ Anterior: between clavicle and
nipple
➢ (R ) MIDDLE Lobe and (L) Lingula (R)/(L)
nipple area/armpits to beneath breast
```
52
Areas of percussion:
| ➢ LOWER lobe
```
○ Anterior: lower RIBS
○ Lateral: uppermost portion of
lower RIBS
○ Posterior: lower RIBS close to
spine
○ Superior: SCAPULAR tip
```
53
INDEPENDENT SECRETION REMOVAL
| TECHNIQUES
```
➢ Active Cycle
➢ Autogenic Drainage
➢ Flutter Device
➢ Low pressure PEP
➢ High pressure PEP
```
54
Active Cycle procedure
```
a. Controlled diaphragmatic
breathing
b. Thoracic expansion exercise:
deep inhalations with hold at the
top
c. Controlled DB: px determines the
next step
d. Inhale a resting tidal volume.
Contract the abdominal muscles
to produce one or two forced
expiratory huffs from mid to low
lung volume
e. Huff from high lung volumes or
cough out to clear
f. Back to step a., repeat cycles
until secretions are in large
airways
```
55
B. Autogenic Drainage
| Procedure:
```
a. Unstick phase - quiet breathing at
low lung volumes to affect
peripheral secretions
b. Collect phase - breathing at mid
lung volumes to affect middle
airways
c. Evacuation phase - breathing
from mid to high lung volumes - to
affect central airways. (replaces
coughing)
```
56
Flutter Device procedure
```
a. Inhale through the nose or around
the mouthpiece of the device.
b. Hold 3 seconds at top of
inhalation.
c. Rapid force exhalation through
the flutter
d. Repeat 4 to 10 times.
e. Huff or cough to clear secretions.
f. Repeat until all secretions are
removed.
```
57
➢ Uses positive expiratory resistance via face mask resistance: 10-20 cmH2O
Low Pressure PEP
58
Low Pressure PEP Procedure
```
a. Seated, breathe at tidal volumes
with mask in place
b. after 10 breaths: remove mask for
coughing and clearing of
secretions
**Repeat until secretions are
removed
```
59
```
➢ For px with unstable airways
➢ Resistance: 50-120 cm H2O
➢ Same procedure w/ Low pressure PEP
except after 10 breaths huffing from high to
low lung volume with mask in place
```
E. High Pressure PEP
60
```
Prevention and Relief of Dyspnea
➢ Patients with COPD may encounter
episodes of dyspnea
➢ COPD patient will benefit from Dyspnea
relieving and preventing techniques
```
1. Controlled breathing techniques
2. Pacing activities
3. Anticipating activity or situation that
triggers dyspnea
4. Controlled Breathing Techniques
