Pulmonary Part 3 - Physical Therapy Flashcards
airway clearance techniques are used for
– COPD: especially chronic bronchitis
– Used in restrictive lung disease only when secretions are present
– Pneumonia: nearly always involves airway plugging
what should you always do before performing an airway clearance technique
- make a baseline assessment
- percussion, auscultation, SpO2, blood gases, Pulmonary
function tests and exercise tolerance
are there lots of studies supporting airway clearance techniques
nope
airway clearance techniques:
– procedures that facilitate clearance of secretions
– should always be done while the therapist is gowned, gloved and masked
* protect patient’s airway from contamination
postural drainage:
positioning the patient such that gravity assists in draining secretions from a segment
– takes advantage of structure of segmental bronchi
look at all them postural drainage positions
absolute contraindications to postural drainage
- Intracranial Pressure (ICP) > 20 mm Hg
- Un-stabilized head or neck injury or recent C/S surgery
- Pulmonary edema or uncontrolled CHF
- Active hemorrhage or hemoptysis
- Massive obesity
- Large plural effusion or massive ascites
- Pulmonary embolism
- Confused/anxious or demented patients
- Rib fractures
- Surgical wound or healing tissue
Relative Contraindications to Postural Drainage/Trendelenburg in adults
- Increased intracranial pressure
- Uncontrolled HTN
- Hemodynamically unstable
- Recent esophageal surgery
- Recent hemoptysis
- Patient at risk for aspiration
- Distended abdomen
Relative Contraindications to Postural Drainage (to Trendelenburg) in children
- Untreated or tension pneumothorax
- Tracheo-esophageal fistula
- Recent eye or intracranial surgery
- Intra-ventricular hemorrhage (grade III or IV)
- Acute heart failure or cor pulmonale
guidelines for airway clearance
- Maintain position as tolerated (5-10 min or >) but depends on position (prone or 1/4 turn from prone positions should be monitored)
- Perform technique before or at least 30 min after meal
- Patients with tube feedings should be checked to insure that there is no aspiration
- Prior Rx w/ bronchodilators maximizes effect
- Provide patient with emesis basin & towel
- Have suction ready if you anticipate heavy mucous
- Vibration & Percussion most effective when performed while patient is in appropriate position
- Encourage patient to take deep breaths & cough during Rx
autogenic drainage
Self-drainage technique that uses diaphragmatic breathing & varied airflow to mobilize secretions
phases of autogenic drainage
– Phase I: breath at very low lung volume: un-stick secretions
– Phase II: breath at tidal volume: collect mucus
– Phase III: breath at high lung volume to evacuate mucus –> Patient is encouraged to cough
Active Cycle of Breathing Technique (ACBT)
- Used to promote airway clearance in COPD and secretion removal
- Consists of cycles of breath control, thoracic expansion and forced expiratory effort
percussion
- Use of sound and vibration to loosen secretions
- Can be performed manually or mechanically
- Mechanical: flutter device & HFCWC
goal of percussion
loosen secretions so they can drain or be coughed up
manual percussion techniques
- Rhythmical clapping of cup hands on the patient’s skin over the involved segment
- Hands should be cupped w/ thumb adducted
- Should produce a hollow or thumping sound
- Allow hands to “fall” at rate of ~ 100 x/ min
- Slapping sound or c/o pain indicates technique is wrong
avoid percussion over:
- bony prominence: clavicle, spinous processes, etc
- surgical incisions: at least until completely closed & w/o discharge
- medical appliances: pacemakers, chest tubes, IV lines, etc
vibration technique
– Two hands are used with thumbs overlapping
– Palmar aspect of therapist’s hand in full contact with patients skin on chest wall or back
– At end of deep inspiration, therapist applies pressure and gently oscillates their hands
– Perform the technique through full expiration
– Keep elbows relatively straight
– tends to promote greater expiration, which is good
Absolute Contraindications to Percussion & Vibration
- Subcutaneous emphysema
- Recent epidural or spinal anesthesia
- Recent skin grafts or flaps on thorax
- Recent burns or open wounds on thorax
- Recent pacemaker implantation
- TB or other serious infection of lung
- Uncontrolled bronchospasm
- Osteomyelitis of ribs
- Rib fracture or osteoporosis
- Metastatic CA involving ribs
- Tumor obstruction of airway
- Excessive anxiety or complaint of chest wall pain
- Coagulopathy
- Treatment intolerance as evidenced by oxygen saturation
positioning for patients with SCI
optimal with patient sitting up or slightly recumbent with head in neutral position and abdominal support
management of patients with SCI
- glossopharyngeal breathing
- vocalization: requires greater TV and respiratory effort, so may be used as a Rx –> work on increasing the syllables per breath
an effective cough depends on:
– achieving at least 60% of predicted vital capacity
– hard, rapid contraction of intercostals & abdominals to significantly increase inter-thoracic pressure
what might affect factors of an effective cough
thoracic surgery, pneumonia, pleuritis or with chronic
lung diseases (COPD and RLD)
costophrenic cough assist technique
–Therapist sits behind or along side (for supine) patient with
hands on the lower, lateral ribs
–Instruct patient to inspire maximally against your hands and then cough forcefully
–As patient begins to cough, press down and in on the ribs with the intent to expel more air out
heimlich cough assist technique
– Sit behind patient with hands open on abdomen
– Instruct patient to inspire maximally against resistance and cough
– press in & up with intent to expel more air out
Mechanical insufflation-exsufflation for mucus clearance:
– Involves periodic build up to super-maximal vital capacity and then a rapid negative pressure.
* Helps maintain ROM of thoracic cage and prevents atelectasis and collapse of lung
* Simulates a cough, improving airway clearance
approved mechanical insufflation/exsufflation device
CoughAssist In-Exsufflator
Pursed lip breathing
– expel air out slowly against resistance from lips
– have patient feel force of air against hand
Huffing
– similar to cough, but don’t close glottis
– expel a volume of air, but at slight lower rate
– helps prepare the patient for normal cough
Sniffing
- Activates the diaphragm primarily
- Used with EMG as a test of diaphragmatic function
- Used to increases inspiratory volume
Upper chest inhibition or facilitation:
– have patient focus on chest movement and quiet accessory muscles in patient breathing from upper chest
– Have patient work on strengthening upper chest
Facilitate diaphragmatic breathing:
– with patient supine, place hand on abdomen and instruct
patient to breath in & out against the resistance of your hand
– deep breathing exercises with focus on diaphragm excursion
respiratory muscle training
- Patients with weakened respiratory muscles as a result of neuromuscular conditions
– strengthening: overload muscles
– endurance: low load training over longer period
– usually applied to diaphragm
cervical SCI
partial or complete preservation of phrenic nerve, but loss of intercostals, accessory mm & abdominals
thoracic and lower SCI
partial loss of intercostals and loss of abdominal muscles
positioning of abdomen for respiration for paralysis
– With weak or absent abdominal muscles, the viscera can’t support the diaphragm
– Abdominal binder can be useful
inspiratory muscle training
- Respironics Threshold IMT
- PN Medical Breather Re-trainer
- Respironics Inc. Threshold pressure threshold trainer and
Gaiam Ltd POWERbreathe pressure threshold - Simple inspiratory spirometer
incentive spirometry
- Provides inspiratory resistance and visual biofeedback
- Decreases “atelectasis” of lung
- Delivered to patients’ bedside by standing order after surgery, but may not be used and patient may not be encouraged to use it
abdominal binder
provides support for the abdominal contents, allowing for better positioning of the diaphragm
suctioning procedure
– Assess oxygenation (SpO2, dyspnea)
– Don sterile gloves and ready equipment
– Give 5-7 breaths (30 seconds) with 100% O2 by Ambubag
– Quickly & gently insert catheter into trach or mouth
– Activate suctioning as catheter is withdraw and rotated
– Reconnect patient to O2 or to vent
can suctioning be performed on patient w/ a trachea tube
yes and patients without
diaphragmatic stimulation or pacing
– E-stimulation of phrenic nerves (invasive) or placement of electrodes over motor points on surface (non-invasive)
– Injury MUST be above C3 for pacing!
flutter device
- Palm-sized device
- User exhales - causing a steel ball to vibrate in the casing
- The vibration travel back into the lungs, where it loosens secretions –> “shaking apples from the branches of a tree” principle
Acapella Vibratory Therapy
- Adjustable vibratory stimulation for secretion removal
- Used with PEEP and can be adapted for vent-dependent pt
when you should use acapella vibratory therapy with caution?
– Inability to tolerate increase WOB
– increased inter-cranial pressure
– Untreated pneumothorax
– Active hemoptysis
– Tympanic membrane rupture or
damage
why might people with restrictive lung disease need chest wall stretching
they may have limitations in rib or diaphragm movement 2 ̊ to soft tissue or bony restrictions
techniques to increase rib excursion:
- Unilateral myofascial release:
– Have pt take deep breath & hold it
– Cross hands and apply pressure to distract ribs - Unilateral hold-inspire technique
- Joint mobilization techniques –> focus on bucket handle or pump handle movement of the particular ribs involved
locations for stretching thoracic cage
- Abdomen
- Ribs
- Sternum
- Back
pulmonary equipment and ventilators
- Intubation/Oral Canulation
- Endotracheal tubes
- Oxygen
- Pulse Oxymeter
need for intubation
– Upper airway obstruction
– Inability to protect lower airway
– Inability to clear secretions from lower airway
– Need for positive pressure ventilation
oral pharyngeal canula
fitted to curve of soft palate
nasal pharyngeal canula
tube fitted to one nares
– better tolerated, but may obstruct sinus drainage
– allow for suctioning & prevents mucosal damage
tracheostomy
- Below vocal cords
- Removable inner cannula
- Universal adapter permits attachment of vent tubing
- Extubation = removal
- Tracheostomy button: valve allowing closure of tube (for
vocalization)
reasons for tracheostomy
– prolonged oral or nasal endotracheal intubation
– minimize tracheal or vocal cord injury
types of tracheostomy
– fenestrated: open at top so upper airway can be used
– button operated: valve allows closure of opening: permits
vocalization
warnings for tracheostomy
caution when inflating:
– over-inflation- necrosis of trachea
– under inflation- aspiration of fluid & air leak
– If cuff is found deflated, ask nursing if it should be inflated or deflated before taking action
positive pressure mechanical ventilation
– Pump forces air into lung, expanding chest wall
– Exhalation is passive, secondary to normal recoil
pressure cycles mechanical ventilation
a max pressure setting signals vent to stop inflation
volume cycled mechanical ventilation
a max volume signals vent to stop inflation
time-cycled mechanical ventilation
inflation continues for fixed period of time
positive pressure ventilators - Circuit
tubing connecting patient with ventilator
positive pressure ventilators - Intermittent mandatory ventilation (IMV) & Synchronized IMV (SIMV)
- Set breaths/min in conjunction with source of O2 (FIO2)
- Setting of IMV 12 = 12 breaths/min
- Setting of SIMV < 12, patient breaths on own between and triggers press ventilations
positive pressure ventilators - pressure support ventilation (PSV)
Augmentation of patient’s own inspiratory effort with preset positive pressure
vent settings
- Controlled ventilation: no patient assistance
- Assist or assist –control: machine does work at set rate, unless patient spontaneously breaths –> pt does some, but not 100% of the work of breathing
positive pressure setting - assist control
patient initiates inspiration and triggers vent
positive pressure setting - synchronized intermittent mandatory ventilation
Vent give + Press after patient’s spontaneous breath
positive pressure setting - pressure control ventilation
100% + press vent
positive pressure setting - pressure support ventilation
patient invitations inspiration and the vent + press
positive pressure setting - Positive end expiratory pressure (PEEP)
note pressure does not return to zero
negative pressure ventilators
- Infrequently used
- Create negative pressure around thoracic cage, causing chest wall to expand
- Similar to old “iron lung”, but newer models are compact
- Chest cuirass
criteria weaning off the vent
– FIO2 of less than 0.5 mmHg
– PEEP < 7.5 cm H2O
– TV = 5 mL/kg BW
– VC = 15 mL/kg BW
– Negative inspiratory effort of 20 mm H2O
– Min Ventilation (VE) < 10 L/min for PaCO2 of 40 mmHg
weaning protocol
control, IMV, or SIMV –> SIMV with press support vent –> assist with press support vent or PEEP –> CPAP w or w/o O2 –> no support
supplemental o2
increased by about 4% with each 1L/min O2
supplemental O2 - nasal canula
useful when pt is breathing through nose
* 0. 2 –6 L/min O2
supplemental o2- face and aerosol mask
- tolerated better
- 5 – 12 L/min O2
supplemental O2 - nebulizer
humidifies inspired gas
* Use when flow > 3 L/min
- For flow rates > 10 L/min, use high output nebulizer
non-invasive ventilation
- Nasal Continuous Positive Airway Press (nCPAP)
- Bi-level Positive Airway Pressure (BPAP)
uses of non-invasive ventilation
– patients with obstructive sleep apnea
– weaning from a vent
– chronic respiratory failure
– Recently been shown to be particularly useful for Covid-19 pts as an alternative to invasive ventilation
pulse oxymeter
- Probe works based on the differential absorption of infrared light by Hb when it is bound to O2 compared to when it is free
- One side emits IR light, and the other side has a photo spectrometer that measures the amount of light of a particular wave-length
factors affecting accuracy of pulse oxymeter
skin color, body temperature, altitude, and movement
normal saturation of Hb with O2
95-100%
< 90% spO2
considered clinically significant and correlates with hypoxemia
can pulse oximeter diagnose anemia
no- it only measures ratio of saturated/unsaturated Hb
when is pulse oxymeter less reliable
during low SpO2 with dark skin pigmentation
when is pulse oxymeter less reliable
during low SpO2 with dark skin pigmentation
when is pulse oxymeter less reliable
during low SpO2 with dark skin pigmentation
when is pulse oxymeter less reliable
during low SpO2 with dark skin pigmentation
- not reliable when SpO2 < 80%
3 areas for outcome measures
- dyspnea
- functional capacity (6 min walk test)
- health related QoL
dyspnea outcome measures
– Modified Medical Research Council Scale (mMRC),
– UCSD Shortness of Breath Questionnaire (USCD SOBQ),
– Baseline and Transition Dyspnea Indices (BDI/TDI)
health related QoL outcome measures
– Chronic Respiratory Disease Questionnaire (CRQ),
– St. George’s Respiratory Questionnaire (SGRQ),
– COPD Assessment Test (CAT)
