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Cardiopulmonary > Pulmonary Rehabilitation > Flashcards

Pulmonary Rehabilitation Flashcards

1
Q

Goals of Pulmonary Rehab

A
  • Control and alleviate Sx
  • Improve activity tolerance
  • Promote self-reliance and independence
  • Decrease need for acute resources
  • Improve quality of life

Note: Nothing about pulmonary function! The damage to the lungs is done, but we can try to alleviate symptoms.

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2
Q

Indications for Pulmonary Rehabilitation

A
  • Chronic but stable pulmonary impairment that cannot improve by medical management
  • Stage II, III, IV of GOLD
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3
Q

Classification of COPD

GOLD

A
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4
Q

Pulmonary Rehabilitation in research shows…

A
  • Increased function with less dyspnea
  • Increased endurance using 6 MWT
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5
Q

Pulmonary Rehabilitation programs REQUIRE…

A

Home walking program

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6
Q

Pulmonary Rehabilitation Aerobic Exercise Guidelines

A

Mode:
* Interval OR circuit OR continuous
* Walking strongly encouraged or cycling

Frequency:
* 3-5 days/week (lower function require more days)

Duration:
* Up to 30 minutes continuous duration (start with 5-10 minutes and build)

Intensity:
* No proven optimal intensity
* Ex at intensity near ventilatory threshold
* Ex at approximately 50% VO2max

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7
Q

Pulmonary Rehabilitation - Resistive Training

A
  • Start with a weight that allows for 12-15 repeitions
  • 2-3 sets of each exercise (30-60 seconds minimum between each exercise)
  • RPE should not exceed “Fairly light” to “somewhat hard” during lift (9-13)
  • Avoid holding breath
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8
Q

Primary Outcome Measures Pulmonary Rehabilitation

A
  • 6 Minutes Walk Test
  • Decreased symptoms
  • Vitals
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9
Q

Goal for pulmonary interventions

A
  • Improve breating efficency and effectiveness
  • Reverse or prevent atelectasis
  • Mobilize and clear retained secretions
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10
Q

Atelectasis

A

Complete or partial collapse of the entire lung segment of the lung. It occurs when alveoli within the lung become deflated or filled with fluid.

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11
Q

What is Normal breathing?

A
  • At rest - quiet and shallow, airflow predominantly in upper lobes or zones.
  • Controlled by medulla
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12
Q

Respiration Definition

A

Ventilation to perfusion match gas exchange physiology

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13
Q

Examples of protective reflexes for normal airway clearance

A
  • Cough
  • Gag
  • Mucociliary escalator
  • Smooth muscle contriction or dialation in the airways
  • Macrophages
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14
Q

Apical breathing

A
  • Quiet, tidal breathing, with predominantly upper chest wall expansion, slight rib flare
  • Exhalation is passive, neck, UE and chest wall are collapsed

Normal breathing

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15
Q

Diaphragmatic breathing

A
  • Deeper inhalation with full excursion of the diaphragm(contracts down), some upper chest expansion, increased rib flaring and abdominal wall distention
  • Results in increased inspiratory volume and lung filling in the lower lung zones
  • Exhalation is passive
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16
Q

Abdominal breathing with pursed lip exhalation

A
  • Lips are pursed (whistle like position) to narrow the airway outlet - creating resistance to airflow.
  • Increased air wall pressure helps to prevent collapsing during active exhalation (Allows ability to get more CO2 out)
  • Exhalation time is prolonged, may help to slow and control respiratory rate
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17
Q

Lateral basal expansion

A
  • Muscles are contracted during inspiratory cycle causing increased rib/chest wall expansion
  • Applying manual tactile pressure the quick stretch kicks in and facilitates muscle spindle activation. This creates a stronger contraction of the intercostal muscles due to myosin/actin crossover to become greater.
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18
Q

Segmental Breathing

A
  • Focused breathing to increase expansion of one segment or lobe/zone of the lungs
  • May use hand placement or other sensory stimuli, resistance, or quick stretch at end of exhalation to promotion local expansion
  • Example: Bronchiectasis - can get air behind the puss pocket to help get mucus out to help with breathing.
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19
Q

Incentrive Spirometer - Indications and function

A
  • Function: Increases the volume of air inspired
  • Indication: Used to prevent atelectasos in post op patients (or at risk); Ex: abdominal surgey, thoracic surgery, retained secretions or insufficent ventilation. Pain with breathing.
  • Examples: 10x every waking hour Diaphragmatic breathing
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20
Q

Respiratory Distress: S & S

A
  • Increase or decrease rate or depth of breathing
  • Irregular pattern – gasping, crescendo, apnea
  • Nasal flaring or chest wall retractions
  • Hypertrophied accessory muscles of breathing
  • Hypoxemia - cyanosis, diaphoresis, anxiety, confusion
  • Chest wall dysfunction – paradoxical breathing
  • Excessive secretion production or drooling
  • Audible airway noise
  • Use of accessory muscles to breath, leaning forward
  • Absent or abnormal breath sounds
  • Orthopnea
  • Dyspnea
  • Inability to speak in complete sentences

If we bring up too many fluids too quickly may lead to RD because all major passageways are blocked.

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21
Q

What breathing patterns do we teach patients?

A
  • Abdominal Breathing with pursed lip exhalation
  • Lateral Basal Expansion
  • Segmental Breathing
  • Diaphragmatic
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22
Q

When can/should you teach a change in breathing patterns?

A
  • To prevent or recerse atelectasis (segment or lobe level); Ex: post surgery, pneumonia, pathology, comorbidities
  • Obstructive Lung Disease
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23
Q

How do breathing patterns help with obstructive lung disease?

A
  • Improves efficency of breathing
  • Helps moblilize secretions - if present
  • Reduce air trapping
  • Coordinate breathing with exercise for efficency
  • Decrease accessory muscle use
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24
Q

True or False: You can change the breathing patterns of people with restrictive lung disease.

A

False. Do not try to change them!

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25
Q

Body position determines:

A
  • Effect of gravity on chest wall and abdomen
  • Predominance of airflow and expansion of lung zones
  • Chest wall movement due to weight of body compressing rib movement
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26
Q

Air moves where…

A

blood and mucus isn’t!

Example:
Seated: Upper and Middle Lobes = Air
Supine: Anterior portion of the upper, middle and loweer lungs = Air

27
Q

How does a supine position change the demand on the body in references to gravity, air flow and blood postiion?

A
  • Gravity, chest and abdomen increase the work of the diaphram
  • Airflow increases in the anterior lung zones
  • Blood flow increases in the posterior lung zones
28
Q

How does a seated and leaning forward position change the demand on the body in references to gravity, air flow and blood postiion?

A
  • Decreases the effect of gravity
  • Airflow and volume increases in apices
  • Increased blood flow in lower lung zone
  • Rib motion not confined to table
29
Q

How can prone positioning be beneficial?

A
  • Decreases the stess and strain in lungs
  • Improves arterial oxygenation and demonstrates limited complications
  • Other benefits include preventing contractures
30
Q

Is a cough reflexive or voluntary?

A

Both! Protective mechanism to expel foreign object, irritants and secretions from the airways.

31
Q

Components of an effective cough

A
  • Deep inhalation
  • Hold breath (epiglottis closes)
  • Chest wall and abdominal muscles contract increases thoracic pressure
  • Epiglottis opens and chest wall ans abdominal muscles contract causing forceful, explosive exhalation, usually several times in a series
  • If secretions present, expelled into the airway into the mouth, then spit out or swallowed (Children do not have the motor control to spit)
32
Q

Ways to ellicit a cough to mobilize secretions

A
  • Huff
  • Panting
  • Sips of warm or cold water
  • Tracheal pressure (Thumb on trachea and rub)
  • Stimulation of cough/gag reflex
  • Devices (PEP or Acapella)
  • Active Cycle Breathing Device (Device vibrates)
  • Splinting (minimizes pain)
  • Gentle Cough (start gentle and become more forceful)
33
Q

What are 3 ways you can assist someone into coughing?

A
  • Extension with inspiration and forward flexion with cough - compress chest and abdomen
  • Administer a deep breath with a breathing machine or resuscitaion bag and quickly release
  • Chest wall and/or abdominal compression (“Quad” coughing) after a deep inspiration
34
Q

When and why is a splinted cough used?

A
  • Post surgery
  • Use a pillow or rolled up towel/small blanket
  • Something to brace the sternum to decrease pain
35
Q

When patients are unable to clear secretions, what is used?

A
  • Suction airway to promote mobilization of secretions
36
Q

Signs ans Symptoms of Retained Secretions

A
  • Hypoxemia
  • Abnormal or absent breath sounds
  • Audible airway noise, dyspnea - SOB, respiratory distress
  • CXR - “consolidation” or “white out” of ;ung
  • Spiking Temperature
37
Q

Causes of Retained Secretions

A
  • Ineffective cough
  • Ineffective mucociliary escalator
  • Inspissated (thick) secretions (dehydrated)
  • Increased mucus production (Chronic Bronchitis, Emphysema)
  • Immobilization with one of the above
  • Aspiration (breath in) of foreign body
38
Q

Methods to Mobilize Secretions

A
  • Increased airflow to promote mucociliary escalator
    – Breathing techniques, incentive spirometer.
  • Improve cough effectiveness
  • Hydrate secretions (being hydrated allows for proper movement of muscocilliary)
  • Increased activity
  • Decreased viscosity of secretions (Pulmozyme – inhaled mucolytics)
  • Use P-drainage, percussion, vibration force
    – “catchup bottle theory”
  • Suction
  • Lavage (Take you into surgery and pump water into lungs and drain it out)
39
Q

Sputum - Levels

A
  • Normal: Clear (mucoid or viscous)
  • White: WBC – reaction to infection or inflamm (?)
  • Yellow: Infection – old WBC (pus)
  • Green: Infection – old WBC with necrosis
  • Blood tinged: could be due to irritation – hard coughing
  • Blood clots: need to report
  • Putrid: sometimes coffee ground like – abscess in lung
40
Q

What does it mean when sputum goes from white to yellow to green?

A

The person is getting sicker.

41
Q

What to look at when analyzing sputum?

A
  • Color, Amount, Odor and Consistency
42
Q

What pt. population requires drainage of all the lobes of the lungs?

A

Cystic Fibrosis

43
Q

Hand Placement for Right and Left Upper and Middle Lobes

A
44
Q

Hand Placement for Right and Left Lower Lobes

A
45
Q

What are some ways you can improve air flow

A
  • Teach appropriate breathing technique - based on what type of disease process is causing the retention of secretions
  • Normal lung function with retained secretions or atelectasis (no disease)
    – diaphragmatic breathing or segmental breathing or incentive spirometry
  • Obstructive lung disease
    – abdominal breathing with pursed lip exhalation
  • Accessory muscles of breathing
    – teach relaxation techniques
  • Work on ROM, coughing, splinting
    – appropriate to diagnosis, history, and procedures
46
Q

How does postural drainage work?

A
  • Positioning the body to allow gravity to assist mucociliary action with the movement of secretions toward the CARINA, where coughing or suctioning can clear the airway
47
Q

Indications - Postural Drainage

A
  • Retained secretions that are poorly mobilized
  • COPD characterized by excess mucus production
  • Prophylactically
    – Post-op (Upper abdominal or thoracic surgery)
    – Immobilized or debilitated patients with high pulmonary risks
    – Ineffective cough and ability to clear secretions
  • Can be combined with positional rotation for skin care
48
Q

Right Lobe STRICT Drainage Positioning

A
49
Q

Left Lobe STRICT Drainage Positioning

A
50
Q

How is modified postural drainage positioning different than strict

A

Combinations of positions that are used when multiple segments are involved or accommodations of the position are required for patient tolerance while still promoting secretion drainage

51
Q

What are the 6 modified positions for drainage?

A
52
Q

Precautions - Postural Drainage

A
  • Open wounds, incisions, skin grafts, or burns
  • Unstable cardiovascular status
  • Untreated pneumothorax, flail chest or rib fx
  • Orthopedic procedures
  • Acute head injuries or neurosurgery
  • Pain
  • Dsypnea, cyanosis, anxiety, respiratory distress
  • Tube feeding, nasogastric tube, or after eating
  • Hiatal hernia or gastric reflux
  • Post-op esophagogastrectomy or colon surgery
53
Q

What is a flail chest?

A

When you break multiple ribs near sternum but lateral; skin and bone move in opposite directions when breathing

54
Q

Contraindications to Head Down Positioning

A
  • Frank hemoptysis – stop treatment, sit patient up, notify physician immediately
  • Unstable CV status
  • Unstable hypertension
  • Recent head injuries/surgery
  • Untreated (large) hemo- or pneumo- thorax
  • Untreated diaphragmatic hernia
  • N-G tube
  • COPD with severe SOB (Dyspnea)
  • Premature infants
  • After recent meals or tube feeding
55
Q

Sequence for Pulmonary Rehab

A
  1. Improve Airflow
  2. Cough assessment & Instruction
  3. Postural Drainage
    - If only doing drainage: 20 minutes per position
    - Percussion/drainage 3-5 min with percussion/drainage
    - Major Rule: Work Top to Down
    - Minor Rule: Least to Most involved (End with most congested)
56
Q

How are chest wall percussions performed?

A
  • Rhythmic percussive force on chest wall with a cupped hand (or mechanical device)
  • Purpose: Tuberlence in airflow and vibration to loosen secretions
  • Should be performed for 3-5 minutes or as tolerated; each position consists of 3-5 min (drainage/percussion)
  • Never to be painful or performed over bony prominences
57
Q

Indications - Percussion

A
  • Pt w/ secretions who has an ineffective sough mechanism
  • Pt who has copious amounts of secretions and are acute or chronically unable to manage clearance of secretions independently

Either is indication

58
Q

Precaution - Percussion

A
  • Osteoporosis (or post menapausal women)
  • Asthma
  • Seizure disorders (Epilepsy)
  • Chest wall pain / bruises
  • Severe hypoxemia or compromised cardiac or pulmonary status
  • Untreated hemo- or pneumo- thorax
  • Tube feedings or gastric reflux
  • Acute spinal injuries or surgery
  • Untreated (or possible) tuberculosis (wear respirator mask)
59
Q

Contraindications - percussion

A
  • Over new incisions
  • Directly over rib fx (fracture) or flail chest
  • Hemophilia patients
  • Morbid obesity (percussion gets muted through layer of adipose tissue therefore no point in doing it)
60
Q

Adjunct Devices for Percussion

A
  • Mechanical Percussors
  • Palm Cups
  • Chest Percussion/Vibration Vests
  • Special beds that vobrate and position pt.
  • Vibrator (for infants)
61
Q

How is Chest Wall Vibrations performed?

A
  • Manual oscillation of the chest wall during exhalation only to create turbulence in airflow and to loosen secretions
  • Stimulates coughing so mucus can be coughed up and expectorated
  • 3-5 repetitions of vibration and then cough
  • May be used alone 20-30 minuted while in the drainage position and no percussion
  • Applies Superficial (firm pressure) or Compression (on chest)
62
Q

Precautions with Vibration

A
  • Fracture ribs - Only superficial allowed
  • Split sternum (OHS) - Only superificial alllowed
  • Osteoporosis - Only superficial allowed

All are contraindicated for compression

63
Q

Potential adverse reactions from drainage/percussion or vibration

A
  • Hypoxemia – watch O2 stat (if it changes, they are in respiratory distress); with position changes that increases ventilation/perfusion mismatching
  • Cardiovascular instability with head down positioning
  • Hemorrhage from hemoptysis (cough up blood, stop get help, is bleeding)
  • Rib fractures (metastatic disease)
  • Increased intracranial pressure (<30 degree elevation)
  • Dyspnea
64
Q

Oscillating PEP device

A
  • Brands: Acapella, flutter
  • Combines PEP therapy and airway vibrations to mobilize pulmonary secretions (Creates more air backflow while exhaling)
  • Pt can sit, stand or recline

Cardiopulmonary (21 decks)

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