Pulmonary System Flashcards
Muscles of inspiration include:
External intercostals - (slope forward and downward) SCM Scalenes Serratus Ant Pec minor Pec major Lat dorsi Trapexzius Erector spinae Diaphragm
Muscles of Expiration
Rectus abdominis, TA, Internal/external obliques
The Diaphragm is innervated by what? Moves how in quiet sitting? Changes how between supine, sitting and sidelying? Changes in COPD?
Innervated by the Phrenic n C3-5
Moves 2/3 of an inch during quiet sitting but up to 2.5-4 inches with max ventilator effort.
In supine: the level of the diaphragm rises
In sitting/standing: the dome of the diaphragm is pulled down (gravity)
In sidelying - the uppermost side drops to a lower level and has less excursion.
In COPD - compromised expiration - hyperinflated lungs = flattening of the diaphragm
Respiratory rate for infants
30-45
RR for children
20-35
Bradypnea
<12
Tachypnea
> 20
Hyperpnea/Hypopnea
increased/decreased rate and depth of breathing
Auscultation: Vesicular sounds
Soft rustling all inspiration and the beginning of exp. Normal, unlabored breathing.
Auscultation: Vocal sounds
Loudest near the trachea and mainstem bronchi. Normal.
Auscultation: Bronchovesicular
Heard over 1st and 2nd intercostal spaces and interscapular region. Normal
Auscultation: Bronchial sounds
Hallow echoing all inspiration and expiration. Normally over the manubrium. Normal.
Auscultation: Apneuistic
Abnormal. Gasping inspiration
Auscultation: Biots
Irregular deep and shallow breaths, abrupt pauses. Ataxia.
Cheyne-stokes
Deep followed by shallow breaths
Kussmauls breathing
Distressing dyspnea - increased RR and depth, panting, air hunger
Lateral costal breathing
Ant flattening of chest with excessive flaring of lower ribs.
Paradoxical breathing
Part of the chest wall falls in during inspiration
Auscultation: Crackles
Rattling or bubbling due to excretions/ Atelectasis, fibrosis or pulmonary edema.
Auscultation: stertor
Snoring sound due to partial obstruction
Egophany
Abnormal transmission of vocal sounds, nasal or bleating.
Stridor
Shrill, harsh sound during inspiration in the presence of laryngeal obstruction
Dyspnea on exertion
classic sign of anemia
Proxysmal nocternal dyspnea
Sign of heart failure
Explain muscular activity during normal breathing
Inspiration: diaphragm contracts flattening the dome
Expiration: passive relaxation of inspiratory msucles and elastic recoil - diaphragm returns to normal
Rib cage excursion
Rib 2-4 pump handle - up and down supine for assessment. Increase chest dimension in AP direction
Rib 8-10 bucket handle flop up and down, sidelying for assessment. Increase chest dimension in lateral direction
Asthma
Reversible obstructive lung disease
Atelectasis
Collapse of normally expanded and aerated lung tissue
Bronciectasis
Dilated, inflamed and easily collapsible bronchi due to destruction of the muscle and decrease in elasticity
Bronchitis (acute)
Viral/bacteria. Inflammation of the bronchi
Brochitis (chronic)
Inflammation of bronchi - lasts years. Caused by smoking. Also have COPD
Cystic fibrosis
Disorder of ion transport in the exocrine glands - effects on hepatic, digestive, male reproductive and respiratory systems.
Emphysema
Accumulation of air in the tissues. Part of COPD.
Lofgren’s syndrome
A group of symptoms present at initial onset of sarcoidosis. Fever, arthritis, enlarged lymph nodes, rash.
Pancoast syndrome
Apical lung tumor. Pain in 8th cervical nerve trunk and 1st/2nd thoracic nerve. Weakness/atrophy of hand muscles
Pneumonia
Inflammation affecting the parenchyma of the lungs
Obstructive lung diseases are characterised by... Xray findings: Pulmonary function test findings: Lung volumes: Examples:
Airflow limitation associated with abnormal inflammation.
Decreased elastic recoil, dyspnea on exertion, cough, sputum, hemoptysis, hypoxemia, hypercapnia, decreased breath sounds, increased RR, weight loss, low diaphragm, pursed lip breathing, cyanosis, clubbing.
Xray: hyperinflation, flattened diaphragm, hyperlucency
PFT: decreased FEV and FVC, increased RV and FRV, Decreased FEV1/FVC.
Lung volumes: Decreased vital capacity, increased residual volume and functional residual capacity.
Eg; CF, COPD, Asthma, Bronchiectasis, Bronchopulmonary dysplasia, Emphysema.
Restrictive lung diseases are characterised by... Xray findings: Pulmonary function test findings: Lung volumes: Examples:
Alterations in lung parenchyma and pleura. Difficulty expanding lungs caused by a reduction in lung volumes. Fibrotic changes.
Dyspnea, hypoxemia/hypercapnia, crackles, clubbing, cyanosis, shallow rapid breathing, reduced cough, Chest wall alterations.
Xray: reduced volumes, pleaural thickening, atelectasis.
PFT: reduced vital capacity, reduced FRC and TLC
Lung vol: Reduced VC, residual volume and FRC
Eg: AS, Scolisosis, TB, Pneumonia, Arthrogryposis, burns, Scleroderma, MS, MD, SCI, CVA
Monitor FEV1/FVC ration before during and after exercise - when does exercise need to be slowed and when does it need to be stopped?
Decrease of 10% = Slowing Activity
Drop of 15-20% = cessation of ex
Postural Drainage: Upper lobe Apical
Flat table, lean back 30 degrees on therapist, Clav-scap
Postural Drainage: Upper lobe Post
Flat table - lean forward 30 degrees - upper back bilat
Postural Drainage: Upper lobe Ant
Flat table - supine, pillow under knees. Clav-nipple
Postural Drainage: Middle lobe (R)
Table elevated 16” (L) SL1/4 turn backward
Postural Drainage: (L) Lingular
Table elevated 16” (R) SL1/4 turn backward
Postural Drainage: (L)/(R) anterior basal
Table elevated 20” (L) or (R) Sidelying
Postural Drainage: Lower lobes Lateral basal
Table elevated 20” prone 1/4 turn upward
Postural Drainage: Lower lobes posterior basal
Table elevated 20” Pillow under hips, prone
Postural Drainage: Lower lobes superior segment
Table flat prone with two pillows under hips
Percussion indications and contraindications
Secretion clearance from tracheobronchial tree
Secretions, atelectasis, aspiration, mucous plugging
- C/I - pain increase, aneurysm precautions, hemoptysis, increased PTT, increased PT, decreased platelet count, anticoag medications, fractured ribs, flail chest, degen bone disease, bone ca
Vibrations
Shaking throughout expiration.
Ind and C/I as above. 5-10 inhalations
Endotracheal suctioning - Size and suction pressure of catheters.
failure of other airway clearance techniques. Catheter sizes Adult: 10, Older children 8fr and young children/infants 5-6. Set at 120mmhg suction.
High frequency airway oscillation
Uses high frequency vibration to mobilise secretions.
Inhale slowly 75% full breath, lips sealed Hold 2-3 sec, exhale 3-4 seconds. Repeat 10 x 20 times. Cough/huff
C/I - ICP >20 Skull trauma, sinusitis, nose bleeds, nausea, middle ear pathology, pneumothroax.
Paced breathing
Used for patients who become dyspneic during the performance of an activity or exercise.
Used to spread out the metabolic demands of an activity over time. Breath in at rest, breath out with first component of activity
Inspiratory muscle trainer
Loads muscles of inspiration but breathing through graded apeture openings. Determine max inspiratory pressure and chose 30-50% of that to allow 10-15 minutes of training per session. Maintain usual tidal volume and respiratory rate.
Common lung changes due to age
Chest wall stiffness - increased WOB
loss of lung elastic recoil
Changes in lung parenchyma incuding enlarged alveoli
Pulmonary blood vessels thicken
Declining TLV - RV increases, VC decreases, FEV decreases
Altered pulmonary gas echange - Pa02 at 20 = 90, paO2 at 70 = 75mmHg
Decline in gas exchange
Reduction in gag reflex
Prolonged recovery of respiratory illness
Cuff pressure to prevent ventilator assisted pneumonia must be
25-35mmHG
Cuff pressure must be below tracheal mucosal capillary perfusion pressure. Too low and it will not prevent silent aspiration of pharyngeal secretions.
What is the requirement for confirmation of asthma?
15% improvement post brochnodilator
What is the DLCO
Diffusion capacity for carbon monoxide <60% poor lung cancer prognosis. >15% decline after 6 months - predictor of mortality.
Respiratory acidosis
PH <7.35 and PCO2 >45
Hypoventilation
Confusion, stupor, coma
Respiratory alkalosis
PH > 7.45 PCo2 <35
Hyperventilation
Hyper-reflexia
Dizziness, disorientation
What are the 4 stages of pneumonia
Stage 1 - engorgement. A few days
Stage 2 - red hepatisation, alveoli, leukocytes present
Stage 3 - Grey hepatisation 4-8 days. Build up of dead bacteria and consolidation
Stage 4- Resolution
Auscultation sounds - Hyperresonant
Very low pitch - emphysema
Auscultation sounds - Flat tone
High pitch - over muscle mass
Auscultation sounds - dull note
Low amplitude, med-high pitch, over consolidation
What is Well’s clinical prediction rule for a DVT
\+1 Cancer \+1 paralysis/Cast \+1 Recently bedridden \+1 entire leg swelling \+1 Calf swelling \+1 localised tenderness \+1 Collateral superficial vv. > 3 high prob 1-2 moderate prob 0 low probability
Seek EMS if
- VF
- Asystole
- SOB at rest
- unstable angina not relieved by nitro x 3
- Ventricular standstill + 3rd degree heart block
VT - 3 or more PVCs
Stop exercise if
- Failure of SBP to rise or if it drops >10mmhG
- SPB > 200 or DBP > 110
- Hypotensive
- change in cardiac rhythm
- fatigue, discomfort or asks to stop
- 2nd degree heart lock
- VT - 3 more more PVCs no pwave
- ST elevation >1mm
Unstable angina - couplet/triplet
- signs of poor perfucion
- symptomatic CHF
- Glucose >230 or <70
- uncontrolled tachy or bradycardia
- DVT
- PTT >60sec
What are the physiological differences between UE and LE ex
UE ex has 30% greater rise in sympathetic upregulation causing an increase in HR. Increased blood pressure due to lactate and muscle stress.
Same workload = more stressful to do isolated UE ex than isolated LE ex.
What are the signs of pneumonia
- reduced respiratory movement
- dull note percussion (consolidation)
- insp/exp course creps
- no mediastinal shift
- air bronchograms on radiography
What causes same sided mediastinal shift?
Lung collapse
What causes mediastinal shift to the opposite side?
Volume gain
What is the difference between Reverse Trendelenberg and Semi-fowlers positions?
- Reverse trendelenberg - bed head elevated
- semifowlers - head and trunk raised - breathing difficulties, cardiac and neurological NGT
What two things can predict mortality in Lung disease?
Decline of DLCO (carbon monoxide diffusing capacity) 15% over 6 months
Desaturation to 88%
