Pulmonary Treatment

Question 1

Drainage for Anterior Upper Segments of Upper Lobes

Answer 1

Position: Angled 30-45 degrees backward in reclined seating

Percussion/Auscultation: Over trapezius between the clavicle anteriorly and the scapula posteriorly

Question 2

Drainage for Posterior Apical Segment of the Upper Lobes

Answer 2

Position: Sit upright in bed/chair while learning forward

Percussion/Auscultation: Over trapezius muscle on top of shoulder

Question 3

Drainage for Anterior Segments of Upper Lobes

Answer 3

Position: Supine (flat)

Percussion/Auscultation: Over pectoralis major muscle

Question 4

Drainage for Right Posterior Segment of Upper Lobe

Answer 4

Position: Prone with pillow under Right shoulder creating a 1/4 turn upward

Percussion/Auscultation: Over scapula

Question 5

Drainage for Left Posterior Segment of Upper Lobe

Answer 5

Position: HOB elevated (30-45 deg) & prone with pillow under left shoulder creating a 1/4 turn upward

Percussion/Auscultation: Over scapula

Question 6

How should percussion be given?

Answer 6

Lightly with cupped hand(s)

Question 7

What position is the best for providing vibration?

Answer 7

Extended elbows over patient

Question 8

Auscultation vs Percussion/Vibration layers

Answer 8

Auscultation needs to be directly over the skin
Percussion/Vibration is typically over a shirt/layer

Question 9

What kind of pressure is associated with vibration

Answer 9

Slight weight bearing pressure to assist in movement of secretions

Question 10

How long do you percuss?

Answer 10

3-5 minutes

Question 11

How long should the patient stay in the drainage position?

Answer 11

5-10 minutes MINIMUM - As long as the can to aid in secretion movement (ideally 20-30 mins)

Question 12

Drainage for Right Middle Lobe

Answer 12

Position: Raise feet 12 inches so the head is downward. Left side lying with right shoulder rotated back towards bed. Place pillow under right shoulder. (Armpit for women)

Percussion/Auscultation: On the thoracic wall over the anterior portion from nipple to mid-axillary line (armpit-to-nipple)

Question 13

Drainage for Left Lingula

Answer 13

Position: Raise feet 12 inches so the head is downward. Right side lying with left shoulder rotated back towards bed. Place pillow under left shoulder. (Armpit for women)

Percussion/Auscultation: On the thoracic wall over the anterior portion from nipple to mid-axillary line (armpit-to-nipple)

Question 14

How long do you vibrate?

Answer 14

1-10 breaths - ONLY during exhalation

Question 15

Drainage for Bilateral Anterior Segments of Lower Lobes

Answer 15

Position: Raise feet 18 inches so head is downward. Lie supine

Percussion/Vibration: Over thoracic wall on the anterior surface just above the inferior border of the rib cage

Question 16

Drainage for Right Lateral Segment of Lower Lobes

Answer 16

Position: Left side lying with foot of bed raised 18 inches (Trendelenburg) with head downward

Percussion/Vibration: Over right thoracic wall in the mid-axillary line at the inferior border of the thorax

Question 17

Drainage of Left Lateral Segment of Lower Lobes

Answer 17

Position: Right side lying with foot of bed raised 18 inches (Trendelenberg) with head downward

Percussion/Vibration: Over left thoracic wall in the mid-axillary line at the inferior border of the thorax

Question 18

Drainage for Posterior Segments of Lower Lobes

Answer 18

Position: Prone with foot of bed raised 18 inches (Trendelenburg) with head downward

Percussion/Vibration: Over posterior thoracic wall just above the inferior border of the ribcage

Question 19

Drainage for Superior Segments of Lower Lobes

Answer 19

Position: Prone with foot of bed flat

Percussion/Vibration: Over posterior thoracic wall just at the inferior angle of scapula

Question 20

How many postural drainage positions are there?

Answer 20

Upper = 5
Middle = 2
Lower = 5
Total = 12

Question 21

Order of Pulmonary Treatment

Answer 21

Airway Clearance
Breathing Techniques
Assisted Cough
Flexibility & Postural Reeducation
Strengthening
Energy Conservation
Patient/Family Education

Question 22

Airway Clearance Techniques

Answer 22

Refer to manual or mechanical procedures that facilitate mobilization of secretions from airways. Includes: Percussion, vibration, postural drainage, active cycle of breathing, deep breathing, coughing & positive expiratory pressure

Question 23

Indications for Airway Clearance

Answer 23

Impaired mucociliary transport, excessive pulmonary secretions, ineffective or absent cough

Question 24

Guidelines to remember for Airway Clearance

Answer 24

Perform at least 30 minutes - 1 hour after a meal/tube feeding OR prior to eating
Monitor vitals due to thoracic pressure changes due to coughing
Inhaled bronchodilator meds should be given PRIOR to airway clearance and to enhance outcome
Repeat every 4-6 hours as needed

Question 25

Airway Clearance Precautions

Answer 25

Uncontrolled bronchospasm Osteoporosis Rib fx Metastatic cancer to ribs Tumor obstructions Anxiety Coagulopathy Convulsive/Seizure disorder Recent pacemaker placement

Question 26

Airway Clearance CONTRAINDICATIONS

Answer 26

Hemoptysis Untreated tension pneumothorax Platelet count < 20,000 Unstable hemodynamic status Open wounds/burns in thoracic area PE Subcutaneous emphysema Recent skin graft to thorax

Question 27

Postural Drainage Precautions

Answer 27

Pulmonary edema Hemoptysis Massive obesity Large pleural effusion Massive ascites

Question 28

Postural Drainage CONTRAINDICATIONS

Answer 28

Increased ICP Hemodynamically unstable Recent spinal fusion/injury Recent head trauma Diaphragmatic hernia Recent eye surgery

Question 29

CONTRAINDICATIONS for Trendelenburg position

Answer 29

ICP > 20 mmHg Uncontrolled HTN Patients with ICP that should be avoided (neurosurgery, aneurysm, eye surgery) Esophageal surgery Distended abdomen Recent gross hemoptysis related to lung carcinoma/radiation Uncontrolled airway at risk for aspiration (tube feeding stopped 1 hour prior and started 1 hour after) CHF Cardiomegaly

Question 30

Components of Pulmonary/Chest PT

Answer 30

Postural drainage, percussion, vibration

Question 31

Active Cycle of Breathing

Answer 31

Breathing Control --> Thoracic Expansion --> Forced Expiration

Question 32

Active Breathing Protocol

Answer 32

1. Breathing control 2. 3-4 Thoracic Expansion 3. Breathing control 4. 3-4 Thoracic Expansion 5. Breathing control 6. Forced Expiratory Technique 7. Breathing control

Question 33

What is the purpose of Active Cycle of Breathing?

Answer 33

Assist them with airway clearance!

Question 34

Purpose of Diaphragmatic Breathing

Answer 34

Manage dyspnea and improve oxygenation

Question 35

Purpose of Inspiratory Hold Technique

Answer 35

Gets air to poorly ventilated areas of lungs and aids in airway clearance

Question 36

Purpose of Paced Breathing

Answer 36

Controls dyspnea, especially during activty

Question 37

Purpose of Pursed Lip Breathing

Answer 37

Aids in dyspnea, especially with activity and emphysema

Question 38

What are the 3 normal breath sounds?

Answer 38

Vesicular, Bronchial & Bronchovesicular

Question 39

Vesicular Breath Sound

Answer 39

Soft, low pitched sound heard during inspiration. Only minimal during expiration. Auscultated over peripheral lung fields

Question 40

Bronchial Breath Sound

Answer 40

Tubular sound - Low, high pitched sound heard equally upon inspiration and expiration Auscultated over anterior chest and tracheal area

Question 41

Bronciovesicular Breath Sound

Answer 41

Softer version of bronchial sounds Auscultated over junction of mainstem bronchi - Anterior 1st-2nd intercostal space near sternum & between scapulae posteriorly

Question 42

What are the two classifications for abnormal (adventitious) breath sounds?

Answer 42

Continuous (Wheezes) & Discontinuous (Crackles)

Question 43

What are Wheezes?

Answer 43

Continuous sounds with constant pitch & varying duration. Heard more on EXHALATION & associated with airway obstruction

Question 44

What are Crackles?

Answer 44

Discontinuous adventitious sounds that are brief bursts of popping bubbles or fire crackling. Either fine or course crackles. More common during inspiration & associated with restrictive or obstructive respiratory disorders

Question 45

What kind of effect will emphysema have on lung tissue density and sound transmission?

Answer 45

Both decrease - Lung tissue density decreases in emphysema, which makes it more difficult for sound transmission (resulting in decreased transmission)

Question 46

What kind of breath sounds are heard with Hyperinflation?

Answer 46

Weaker, softer sounds

Question 47

What kind of breath sounds are heard in the presence of consolidative pathologies like pneumonia?

Answer 47

Stronger, louder sounds

Question 48

What is Egophany?

Answer 48

Patient is asked to say "EE" while having their lung tissue auscultated. Normal results will sound soft and muffled - sounding like "EE". If it sounds like "AY" then there is consolidation present

Question 49

Why is the Tripod position used by patients?

Answer 49

Increases intra-abdominal pressure and lengthens the diaphragm, which increases the strength/tension relationship of the diaphragm for contraction during breathing -- Relieving dyspnea

Question 50

Pursed Lip Breathing

Answer 50

Sign of COPD Alleviates trapped air within the lungs & improves gas exchange. Decreases dyspnea & slows RR

Question 51

Paradoxical Breathing

Answer 51

Indicator of advanced COPD Chest moves inward during inhalation rather than outward. Abnormal movement impairs effectiveness of inhale and limits oxygen intake

Question 52

What are the 5 steps of coughing?

Answer 52

1. Deep inspiration (60% VC) 2. Closure of Glottis 3. Contraction of Chest Wall 4. Opening of Glottis 5. Forceful Expulsion of Air

Question 53

Name 4 standardized assessments that are appropriate for pulmonary patients

Answer 53

BORG, VRI, 6MWT, Gait Velocity