Rehab Lectures Flashcards
Define spirometry and what it measures
Measurement of the individual’s ability to move air in and out of the lungs. It measures volume and flow rate
What does a diagnosis of a lung disease require?
Positive spirometry findings, a history of respiratory risk factors and/or respiratory symptoms
What is FEV1?
The volume of air expired forcefully during the first second - forced expiratory volume in one second
What is FVC?
The total volume of air exhaled forcefully after a full inspiration - forced vital capacity
How to calculate the forced expiratory volume and forced vital capacity ratio?
FEV1/FVC
Describe the volume flow loop for different diseases
- Obstructive = slow down really quickly = a concave appearance on expiratory part
- Restrictive = shape looks the same but just smaller
See lecture notes for diagrams :)
How much air should come out in the first second of forced expiration?
75%-80%
What are the predictive values of spirometry?
Sex, height, age (sometimes ethnicity)
Obstructive lung disease summary
Obstruction to airflow on expiration = air gets trapped in lungs = hyperinflation of lungs = flattening of diaphragm = SOB develops due to inability to increase tidal volume
Restrictive lung disease summary
Increased stiffness of lungs = restricted inspiratory volumes = total lung capacity is reduced = SOB develops due to an inability to increase tidal volume
What would you expect in spirometry if someone had an obstructive lung disease?
- FEV1 is reduced (brakes come on a bit soon) due to air being stuck in expiration
- FVC remains relatively unchanged
- FEV1/FVC ratio decreases (>70% = obstructive lung disease)
What does the new COPD scale display?
Severity of symptoms, hospital admissions, frequency of exacerbations
What would you expect in spirometry if someone had a restrictive lung disease?
- Total lung capacity and FVC are reduced as they aren’t able to inspire enough - so no problem with obstruction/airflow, they just can’t get a lot of air in
- FEV1/FVC ratio is the same or increased
What is peak expiratory flow rate and what are the normative/predictive values?
PEFR = the maximum speed of expiration. This is used to monitor pulmonary function over time for someone with a known lung pathology e.g. asthma
Values = age, sex, height and ethnicity
What determines the black and white on an X-ray?
X-ray absorption - if the X-ray pass through the body easily = black
What are the cobweb-like structures on a normal X-ray?
The pulmonary blood vessels which you can see right to the edge of the lungs - blood is fluid, hence, why it looks whiter on the X-ray
What is the common view for a chest X-ray and how should it be done?
Postero-anterior view
It should be completed with a breath in and hold, patient is standing, arms abducted to rotate scapulae away and X-ray is about 1.8 metres away from the patient
What are some things that should be seen on a normal chest X-ray (posteroanterior view)?
Air in trachea (shown by trachea being slightly darker), heart should take up ~50% of diameter of the chest, cobweb-like pulmonary vessels, dome shapes of diaphragm, right diaphragm is higher (due to liver), clavicles are the same distance away from the spine, can see 8-9 ANTERIOR ribs, trachea is in midline (in line with spinous processes)
Anterior view X-rays
- Used when patient is unable to stand i.e. unconscious or too unwell
- X-ray is ~40 inches away from patient = hazy/blurry X-ray
- Heart will appear bigger as X-ray machine is closer
How to tell if the X-ray is overexposed?
You can see the intervertebral discs clearly and the image appears really dark
How to tell if the X-ray is underexposed?
You cant see individual spinous processes and the X-ray looks ‘bright’
What would you expect in an X-ray for a patient with COPD?
Flattened diaphragm, wide spacing between ribs , blunted costophrenic angles, may appear blacker due to increased air in the lungs
What would you expect in an X-ray for a patient with consolidation (infection)?
White patchy appearance due to inflammation and secretions, no clear outline of the heart (known as the Silhouette sign)
What would you expect in an X-ray for a patient with heart failure?
Enlarged heart (cardiomegaly) i.e. above 50% of the chest diameter
What would you expect in an X-ray for a patient with a pneumothorax (collapsed lung)?
White blob where collapsed lung is, no pulmonary vessel markings, air leaking into chest cavity = blacker X-ray on side of pneumothorax, more air = more pressure = compression of heart, great vessels, diaphragm (downwards), ribs (wide apart), and trachea
What are some risk factors for respiratory conditions?
Environmental, smoking, ageing, genetics, infection, trauma, post-surgery, neuromuscular weakness and idiopathic (no known cause)
What are the four main symptoms of respiratory conditions?
Cough, dysponea, sputum and reduced exercise capacity
Define dysponea
Shortness of breath that is perceived as unpleasant and uncomfortable. This is a complex symptom which is the result of sensory feedback and cognitive and contextual factors
Dysponea can affect people with cardiac or respiratory conditions and can induce anxiety for people
How does obstructive lung disease lead to dyspnoea?
Incomplete exhalation due to obstruction -> gas trapping in lungs -> diaphragm flattens -> lungs become more hyperinflated (especially after exercise) -> less able to get tidal volume -> short of breath/dyspnoea
How does restrictive lung disease lead to dyspnoea?
Reduced compliance (increased stiffness) -> reduced total lung capacity (hard to inflate the lungs) -> thus, can’t increase tidal volume so msut increase respiratory rate to increase ventilation -> SOB/dyspnoea
How to assess dyspnoea either at rest or during activity
- Observed signs of dyspnoea/increased work of breathing - the upper chest will be moving as not only is the diaphragm working but the accessory muscles are working as well
- Patient report (ask them) i.e. are you feeling breathless right now?
- Rate of perceived exertion on either Borg scale (6-20) or Modified Borg scale (0-10)
How to assess impact of dyspnoea on daily life
Modified Medical Research Council (mMRC) scale. This gives grades of dyspnoea on a scale from 0-4 (0 being not troubled by breathlessness except when doing strenuous exercise and 4 being too breathless to leave the house or becoming breathless when dressing/undressing)
What is a cough?
Normally a protective reflex stimulated by receptors in pharynx, larynx, trachea or bronchi
What are some examples of abnormal cough?
- Chronic productive cough e.g. COPD and bronchiestasis
- Persistent dry cough e.g. interstitial lung disease, medication side effect
- Nocturnal cough e.g. poorly controlled asthma or cardiac problems in older adults
What are some questions to ask for someone with cough?
- How frequent?
- Is it productive or dry?
- How does it compare now to normal?
What is sputum?
Excess secretions which may contain mucus, cellular debris, microorganisms, blood and foreign particles
What is considered to be abnormal secretions i.e. sputum?
Anything that isn’t clear, watery fluid
What are some questions to ask for sputum?
- Colour and consistency?
- Amount?
- Frequency?
- Is it different to normal?
- Easy to clear, or having difficulty?
What comes under an objective assessment for the respiratory system?
- Look = observe chest shape and breathing pattern
- Feel = chest movement at rest and/or with deep inspiration
- Listen = speech; strength and nature of cough (moist or dry); auscultation
- Measure = respiratory rate, oxygen saturation, lung function tests/spirometry and chest X-ray
Look: chest shape
Chest shape should be symmetrical, ribs descending at a ~45 degree angle (in adults), transverse diameter should be greater than anterior-posterior diameter, thoracic spine should have a slight kyphosis
What are some chest shape abnormalities?
- Barrel shape = hyperinflated lungs = obstructive disease
- Thoracic kyphosis
- Pectus excavatum (funnel chest) = sternum goes in
- Pectus carinatum = sternum sticks out a bit
Look and feel: breathing pattern (normal at rest)
- Nose, low and slow
- Rhythmical, symmetrical, relaxed i.e. effortless
- 80% of movement coming from lower chest while 20% comes from upper chest
Look and feel: breathing pattern (abnormal at rest)
- Decreased lower chest or increased upper chest movement
- Increased work of breathing: visible accessory muscle contraction, shoulder elevation, active expiratory phase or pursed lip breathing, mouth breathing
- Asymmetrical chest expansion
Feel: thoracic expansion
- Place hands with thumbs together like a butterfly = thumbs should move apart as chest wall moves apart
- Test at sternal notch, lateral side (under armpits ish) and under scapula
- First feel chest wall expanding at rest/tidal volume and then ask patient to take a slow, deep breath
- DISCOURAGE SHOULDER ELEVATION (if possible)
- You are assessing the amount of expansion (more at lower ribs) and the symmetry of chest movements
Listen: speech
Are they able to speak in full sentences? - can be a sign of dyspnoea if they are struggling to finish a sentence without taking a breath
Listen: cough
- Nature: moist or dry
- Quality: strong or weak
Auscultation
Breath sounds are generated by turbulent airflow within the larger airways and subsequently filtered through lung tissue and the chest wall
Why do we perform auscultation on the larger airways rather than the smaller ones?
Flow in larger airways = turbulent = makes noise
Flow in smaller airways = laminar = silent
Normal breath sounds: Tracheal/bronchial
- What we hear near the trachea
- Harsh and loud
- Inspiration and expiration
Normal breath sounds: Vesicular
- Listening away from large airways i.e. lung periphery
- Softer and lower pitched
- Inspiration and at the start of expiration i.e. inspiration = longer than expiration
What can alter normal breath sounds?
Obese patients may have diminished breath sounds (quieter/lower intensity) due to thickness of chest wall
Abnormal breath sounds: Bronchial
- Bronchial sounds (i.e. loud and harsh) heard at periphery
- Heard throughout inspiration and expiration (we want to hear only inspiration and expiration briefly)
- Indicates open airway surrounded by dense/inflamed lung tissue e.g. pneumonia (open airway -> increases sound transmission -> louder)
Abnormal breath sounds: Reduced or absent airflow
Caused by reduced airflow e.g. blockage in airway, pneumothrax (collapsed lung)
Abnormal breath sounds: Wheeze
- High pitched, musical/whistling quality
- Produced by narrowing of airways (air has to be squeezed through - wheeze)
Abnormal breath sounds: Crackles
- Popping or clicking quality
- More commonly heard during inspiration
- Caused by the opening of previously closed small airways
How to auscultate
- Position patient appropriately (supported/comfortable)
- Stethoscope should be touching the patient’s bare skin
- Patient should breathe deeply through mouth
Where to place stethoscope
Anteriorly (both medially and laterally):
- Apex of lung (near clavicle and sternal notch)
- Superior lobe of lung (above nipple around the armpit area)
- Middle lobe of lung (next to nipple medially)
- Inferior lobe of lung (just below the nipple laterally)
Posteriorly (both medially and laterally):
- Apex of lung (above scapula)
- Superior lobe of the lung (next to medial border of scapulae)
- Inferior lobe of the lung (under inferior angle of scapulae)
MAKE SURE TO LISTEN TO BOTH SIDES!
Vital signs
Respiratory rate: Normal = 12-18 breaths/min
- Tachypnoea = >18 breaths/min
- Bradypnoea < 12 breaths/min
Oxygen saturation: Normal = 96%-100%
What is oxygen saturation and how do we measure it?
Oxygen saturation is the percentage of haemoglobin bound to oxygen in arterial blood
It is measured by a pulse oximeter which calculates arterial oxygen saturation by comparing how much red light (absorbed by deoxy Hb) and infra red light (absorbed by oxy Hb) is absorbed by the blood i.e. depending on how much is absorbed = how much you oxygen saturation is
Oxygen saturation and respiratory failure
Normal PaO2 = 80-100 mmHg and respiratory failure = <60 mmHg
If someone had 90% saturation (~60 mmHg), they can desaturate quickly if 02 demand increases and may indicate hypoxia
What are signs of hypoxia?
SOB, rapid RR and/or HR, confusion, decreased consciousness and people may complain of ‘jelly legs’
