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
