Respiratory Flashcards
What are the normative values for an ABG?
pH= 7.35 - 7.45
PaCO2= 4.7 - 6.0 kPa
PaO2= 11 - 13 kPa
HCO3= 22 - 26
BE= -2 - +2
What are the 4 Type of Respiratory problems we can influence?
- Sputum Retention
- Loss of Lung Volume
- Increased Work if Breathing
- Respiratory Failure
What are the key categories in a systematic Respiratory Assessment?
A - Airway
B - Breathing
C - Circulation
D - Disability
E - Exposure
In A-E Respiratory Assessment what things is A assessing?
- Is the airway patent? Is it their own? Are they able to talk? Are they self ventilating?
- Occluded/ Obstructed? (Added breath sounds: stridor, hoarse voice, orthopnoea, drooling, dysphasia)
- End of bed: paradoxical breathing, cynosis, added sounds, can feel the sounds
In A-E Respiratory assessment what is included in B section?
- Respiratory Rate (regular? over 25bpm=concern)
- Work if breathing? Using accessory muscles?
- Chest expansion? Even? Deviation of trachea?
- Saturation levels (95-98%, at least above 88%)? Are they on O2? How is it delivered?
- Have they had ABGs? Results?
- Chest X-ray findings?
- Auscultation- breath sounds throughout? Added sounds?
- Palpation- Secretions? Tactile fremitus? Hot/cold? Centrally/peripherally? Oedema?
- Cough- Strong/Weak, Dry/Wet, Productive/ Unproductive?
- Able to clear secretions?
In A-E Respiratory assessment what is included in C section?
- Heart Rate (60-100bpm)
- Blood Pressure (90-60mmHg to 120/80mmHg
-Capillary refill - Skin Colour
- Sweating
- Urine output (800 to 2000ml per day or 1.5 to 2 ml/kg per hour)
- Blood sugar levels(4-7mmol/l before eating and 8.5-9mmol/l 2 hours after eating)
In A-E respiratory assessment what is included in section D?
- Level of consciousness (Alert, Voice, Pain, Unresponsive)
-Glasgow Coma Scale - Are they sedated?
In A-E respiratory assessment what does section E include?
- Injuries/pressure wounds
-Are there any serious surgical wounds? Are these contraindications for any interventions?
-Do they have any drains? Are they swinging and bubbling? - Attachments: Catheter, Arterial line, NG tubes
What does SBAR stand for?
Useful format to deliver handovers/gather on call info:
Situation
-pts name?where they are? whos calling? help/advice needed?
Background
-pts arrival? current status/whats happened?PMH? normal status? previous physio? current obs (A-E)?
Assessment
-vital signs? clinical impressions? concerns? clinical reasoning?
Recommendation
-explain what you need? give advice/suggestions?
Normal urinary output?
0.5-1.0ml per kg of body weight per hour
Is a sensitive marker with poor output related to shock and risk of cardiovascular insufficiency
What are you assessing when using palpation for respiratory assessment?
Temperature- hot/cold, central compared to peripheral
Oedema- central/peripheral? impact on treatment?
Trachea- central? deviated due to collapse/mass?
Expansion- equal and consistent? insp and exp?
Tactile fremitus- crackles under hands? ausc and precussion
Chest X-Ray interpretation. What are we looking for
Patients name/date/orientation
A- Alignment (Film rotated? AP/PA? Airways- trachea)
B- Bones (all there and intact? #’s?)
C- Cardiac (correct position/size/clear borders?)
D- Diaphragm (correct position/clear contours/ angles)
E- Expansion (well expanded-5-7 ribs to pierce diaphragm in anterior midclavicular line? extra structures)
F- Lung Fields (fields clear? extend to edge of thorax?)
G- Gadgets (any lines, drains, tubes, sutures, clips?)
What can percussion indicate for chest physiotherapy?
Hyper-resonant (pneumothorax-air between pleura, or empysema-over expanded lung)
Dull (pleural effusion or consolidation)
What are normal breath sounds?
-Soft, muffled
-Louder on INSPIRATION and fade on expiration
-1:2 ratio for inspiration:expiration
What does bronchial breathing over the lung fields indicate?
Bronchial breathing= EXPIRATION louder and longer with pause between inspiration and expiration
-Consolidation
-Collapse without sputum plug
-Beginning of pleural effusion
What may be causing quiet or absent breath sounds?
-Poor expansion, low lung volumes, atelectasis
Also caused by:
-Shallow breathing
-Poor positioning
-Collapse with complete obstruction of airway
-Sounds reduced by hyperinflation
-Sounds reduced by pleura, chest wall (obese/muscular pts, pleural effusion/pneumothorax/haemothorax)
-Pneumothorax
What is a wheeze? and What does it indicate?
Wheeze= musical sound from narrowed airway, usually heard on EXPIRATION. Usually due to bronchcospasm or secretions in small airways.
- High pitched- bronchospasm-potential increased WOB
-Low pitched- Sputum- disrupted turbulant flow, change with coughing
-Localised- tumour/foreign body- one area on ausc
What does fine crackles indicate? and When does it occur?
Usually late INSPIRATON
Short, sharp at lung peripheries, lessens with deep breath
- Atelectasis
-Intraalveolar/pulmonary oedema
-Secretions small airways
What does coarse crackles indicate? and When does it occur?
May be during inspiration and expiration
Early EXPIRATORY- central airways
Late EXPIRATORY- peripheral airways
changes/clears with coughing
-Obstruction more proximal and larger airways with sputum.
What is a pleural rub? and its causes?
Creaking/rubbing (boots in snow) can be localised/genralised, soft/loud, EQUAL INSPIRATION AND EXPIRATION
- Inflammation of pleura
-Infection
-Tumour
What is stridor? and its causes?
Sound of constant pitch during BOTH INSPIRATION AND EXPIRATION in upper airways.
- Croup
- Laryngeal tumour
- Upper airway obstruction
*Alert medical staff!
What categories does NEWS measure?
What is a significant change?
A significant change in score of 3 in one or more categories, or 5+ in total can trigger critical care support
Measures:
-Resp rate
-SPO2
-Air/oxygen
-Systolic BP
-Pulse per min
-Consciousness
-Temperature
What is atelectasis and where can it occur?
Appearance on CXR?
-Atelectasis is a collapse! And is area of airless lung
- May involve small areas, an entire lobe or an entire lung (RUL-horizontal fissure/above whitness, RML (middle lobe)-indistinct heart boarder, RLL- whitness compared to L with visible heart boarder, LUL-all hazy, LLL-heart border)
-CXR= loss of lung volume, whiteness over area, shift of trachea/heart TOWARDS to fill space, elevation of hemidiaphragm compared to opposite site, less clear borders
What is consolidation?
Where can it occur/
Causes?
CXR appearance?
Consolidation is when air is replaced by fluid in the lung. May present patchy, or entire lobe/segment
CXR= whitness, poor/fluffy boarders, no loss of lung volume
- Pneumonia- infected fluid (most common)
- Aspiration- gastric contents/saliva (particularly RLL)
- Traumatic lung contusion- blood
-Alveolar pulmonary oedema- serus transudate (usually mid zones by hila)
What is a Pleural Effusion?
How does it present on CXR?
Fluid in pleural space= plural effusion
CXR= uniform density throughout which changes dependent on pts position (erect-lower zone/supine-posterior surface).
Blunting of costophrenic angle, large effusion= shift AWAY, white out
What is pulmonary oedema? Causes?
How does it present on CXR?
Pulmonary oedema usually caused by left ventricular failure
CXR:
- heart enlarged
- consolidation around the hila
-Shift AWAY
-Kerley B lines ( tiny, thin, horizontal lines seen in lower zones caused by oedema)
- Large distended veins in upper zones
-May be pleural effusions
What is a pnumothorax?
How does it present on CXR?
Can be normal or tension.
Tension pnumothorax= air in pleural space increases, increasing pressure inlungs, push mediastinum AWAY, can cause cardiac arrest
CXR: Blackness
- Lung edge seen as white line parallel to chest wall
- NO Lung markings
-Outside lung edge blacker than area inside line
*** DON’T USE POSITIVE PRESSURE VENTILATION!
How does emphysema (COPD) present on CXR?
-Lungs appear hyperinflated and blacker in emphysema because of damaged lung tissue
-Thin walled sacs/ bullae may be present as particularly black areas often at top of lung
-No visible edge and lung markings present throughout
What is sputum retention?
If not treated can lead to…?
Sputum retention is where pts cannot clear sputum adequately, either independently or with physio support
May contribute to:
- airway obstruction, respiratory infections, increased WOB, ventilation/perfusion mismatch and respiratory failure
Signs and Symptoms of sputum retention?
- Audible noise= crackles/bubbling/coarse wheeze during coughing, deep breathing, or forced expiration
- Palpation= crackles felt
- Auscultation= crackles/wheeze (may clear with cough)
- History= Pt says difficulty clearing secretions, PMH of sputum condition e.g. bronchiectasis/COPD
- Sputum= infected? colour? sticky/thick?
- CXR= Sputum plugging lead to atelectasis/patchy consolidation also seen
- Ventilator display= increased airway pressure and/ restrictive tidal volumes. Jagged edge waveforms indicating airway obstruction
Causes of sputum retention?
Impaired mucociliary clearance, excessive mucus secretion, impaired cough, or aspiration
What causes mucociliary clearance?
- Increased volume of secretions produced by the goblet cells
- Increased viscosity of secretions because of dehydration, infection, or abnormal secretion (e.g. cystic fibrosis)
- Paralysis of cilia because of smoking, general anesthetic, reduced fluid intake or dry oxygen therapy
- Damaged airways (e.g. brochiectasis)
- Intubation (presence of artificial airway)
Impaired cough and/or reduced expiatory flow rates may be caused by:
- Fatigue
- Breathlessness
- Immobility
- Muscle weakness or paralysis
- Low lung volumes
- Pain
- Reduced level of consciousness related to anaesthesia, analgesia or pathology
What medical interventions are available for sputum retention?
-Hydration= as dehydration causes inefficient cillia, intravenous fluids
-Humidification= deliver oxygen via humidification, cold water humidification systems with wide-bore tubing, heated systems for intubated and noninvasive ventilation patients, heated high flow systems
- Nebulised saline= (0.9%) may be used regularly through the day/immediately before active clearance techniques, hypertonic saline
- Brochodilators= to manage bronchospasm
- Pain control= ensure pain is adequately controlled before tretament, pt should take deep breaths/huff, and move comfortably
- Mucolytic drugs= carbocisteine may be useful for pts with thick sputum (e.g. cystic fibrosis, COPD)
Physiotherapy interventions for spontaneously breathing/ nonintubated patients?
- Good positioning (sitting upright, avoid slumped position)
- Supported cough (support any incisions/trauma to chest or abdomen to make cough effective)
- ACBT (adapt to pt with breathing control to include suitable rests)
- Mobilise (move pts when possible- side lying, sitting, standing and walking can help to mobilise sputum if safe to do so)
- Manual techniques (percussion, shaking, and vibrations can be for useful for patients with thick secretions when unable to clear secretions using ACBT and mobiliy alone, with postural drainage
- Positioning/postural drainage (side lying is useful when pts have generalised secretions, specific positions can be used if sputum is localised to a lobe or series of lobes)
- Positive expiatory pressure (PEP) or oscillatory PEP (Pts with chronic lung disease characterised by sputum retention e.g. cystic fibrosis, COPD, bronchiectasis)
- Autogenic drainage (only use in acute position if the pt knows the technique and both you and they are skilled in its use)
- Mechanical insufflation/exsufflation (used with pts who have ineffective cough caused by primary muscle weakness)
- Intermittent positive pressure breathing-IPPB (useful to improve tidal volumes on inspiration to facilitate expectoration
- Manual assisted cough-MIE (for pts with neurologic compromise e.g. SPI, MND, GBS)
-Suction-nasopharyngeal/oral (only use if secretions in central airways, pts is unable to cough effectively, other methods ineffective)
Lung volume loss usually occurs when one or both of the following is reduced…?
- Inspiratory reserve volume (IRV)
- Functional residual capacity (FRC)
What is inspiratory reserve volume?
IRV is the total volume of air that can be inspired beyond a normal tidal inspiration.
- Determined by amount thoracic cage and diaphragm can expand during inspiration
- Sufficient inspiratory muscle strength is required
- Leads to reduced total lung capacity (TLC), and vital capacity (VC). And reduced ability to increase inspiratory volume in response to increased demand for ventilation= increased risk of resp failure
Causes of reduced inspiratory capacity/ inspiratory reserve volume?
- reduced thoracic mobility
- reduced lung compliance
- inspiratory muscle paralysis
- significant weakness
What is functional residual capacity?
FRC= the volume of air that remains in the lung after a normal tidal expiration. Reaches close to residual volume.
- Can cause air to be trapped and rapidly absorbed leading to atelectasis, and reduced V/Q ratios
- Determined by balanced inward recoil of lungs and outwards recoil of chest wall, when both inspiratory/expiatory mm’s relaxed
-e.g. kyphoscoliosis, abdominal surgery
How is IRV and FRC measured?
Laboratory Spirometry
But can use FVC and FEV1 in clinic- as both will be reduced in pts with low lung volumes.
- Normal FEV1/FVC ratio is usually 70% (0.7)
- A pt with low lung volumes will have low FVC and a normal FEV1/FVC ratio= restrictive pattern
What problems can arise from low lung volumes?
- Reduced compliance
- Reduced diffusion
- Reduced V/Q ratios
Causing increased WOB, breathlessness and reduced exercise tolerance.
8 Type 2 respiratory failure may develop because fatigue leads to an inability to maintain adequate minute volume
Signs and symptoms of loss of lung volume?
- Difficulty taking deep breath
- Reduced thoracic mobility (bilaterally/unilaterally, may be associated with chest wall deformity or #)
- Reduced breath sounds
- Fine crackles possible during inspiration
- Bronchial breathing may be heard over areas of consolidation
- CXR may demonstrate increased opacity and reduced volume, resulting in shifted stuctures. These may be identified as consolidation, atelectasis, scar tissue, pleural effusion, pneumothorax
- Pain on inspiration
- Reduced exercise tolerance
- Restrictive pattern from spirometry
- Use of accessory mm’s, reduced oxygen sats –> resp failure can occur depending on severity and cause of volume loss
What is normal human body temperature?
36.5 - 37.5 degrees
Fever (pyrexia) is anything above 37.5 and is associated with an increased metabolic rate. As temp increases oxygen consumption and CO2 production increases. Results in increased HR and RR.
What is normal heart rate range?
What other heart rate ranges are of note?
- HR= 60-100bpm
- Tachycardia= HR greater than 100bpm at rest
(e.g. anxiety, exercise, fever, anaemia, hypoxia) - Bradycardia= HR below 60bpm
(e.g. athletes, cardiac drugs like beta-blockers)
What is normal blood pressure range?
What other BP ranges are of note?
95/60 to 140/90
- Hypertension= above 145/95 (due to changes in vascular tone/aortic valve disease)
- Hypotension= below 90/60 (normal during sleep, sign of heart failure whilst awake, blood loss, vascular tone)
What is postural hypotension?
Postural hypotension is a drop in BP of more than 5mmHg between lying and sitting, or standing.
- May be due to decreased circulating blood volume/loss of vascular tone
- If 10mmHg or more sudden drop with inspiration suspect pulsus paradoxus and severe airway obstruction
What is normal respiratory rate range?
What other RR ranges are of note?
-Adult normal RR= 12-16 breaths/min
- Tachypnoea= 20bpm RR or above (e.g. any form of lung disease, metabolic acidosis, anxiety)
- Bradypnoea= 10bpm RR or less (*uncommon finding, e.g. central nervous system depression by narcotics or trauma)
What are some causes of finger clubbing?
- Lung disease (infective- bronchiectasis, lung abcess, empyema), fibrotic, malignant- bronchogenic cancer, mesothelioma)
- Cardiac disease (congenital cyanotic heart disease, bacterial endocarditis)
-Other (familial, cirrhosis, gastrointestional disease- Crohn’s, ulcerattive collitis, coeliac disease)
What should a basic subjective assessment include for respiratory patient?
- Check medical records
- Breathlessness, cough, sputum, wheeze, chest pain
- Duration, Severity, Pattern, Associations
- Functional ability, Disease awareness
- Alongside PMH, FH, SH, DH, HPC, Sleep pattern, Aggs/Eases
What physiotherapy strategies are there to manage reduced lung volumes?
Strategies to increase lung volume:
- Pain management
- Controlled mobilisation
- Breathing exercises= focus on thoracic expansion, inspiratory holds and sniffs
- ACBT (if sputum retention reduce forced expiration and emphasise thoracic expansion exercises)
- Positioning= for optimal expansion and length tension relationship of diaphragm, postural drainage (sitting forward lean, side lying, prone-ICU?
- Continuous airway positive pressure (CPAP) to increase FRC
- Intermittent positive pressure breathing/ noninvasive ventilation to increase TV
- Neurofacilitation techniques = ventilated ensure positive end expiratory pressure is maintained throughout
What factors can result in reduced chest wall/ diaphragm mobility?
- Chest wall deformity= (kyphosis, scoliosis), ankylosing spondylitis, degenerative arthritis, trauma- # ribs, abdominal/thoracic surgery
- Lung compression= enlarged abdomen (ascites, pregnancy, obesity, constipation)
- Intrusion of abdominal contents into chest= e.g. diaphragmatic hernia/ hiatus hernia
- Pleural effusion, mass (e.g. tumour)
- Pneumothorax
- Obesity
What factors can result in reduced lung compliance?
- Interstitial lung disease
- Cystic fibrosis
- Atelectasis (secondary to sputum plugging, causing lobar collapse)
- Pulmonary oedema
- Pneumonia, consolidation
- Adult respiratory distress syndrome (ARDS)
What factors can result in inspiratory muscle weakness or paralysis?
- Neuromuscular disease (e.g. GBS, high spinal cord lesions, muscular dystrophy)
- Reduced respiratory drive (e.g. head injury, drugs)
What different respiratory problems can lead to low lung volumes?
- Consolidation
- Atelectasis
- Chest trauma
- Postabdominal/ thoracic surgery
- Pleural Effusion
- Pneumothorax
- ARDS
What are the components of “work of breathing”?
Other terms surrounding/describing this?
Increased WOB= Load (applied to resp mm’s), Capacity (efficiency of resp mm’s), Demand (drive to breathe)
- Dyspnoea, breathlessness, shortness of breath= pts perceived increased WOB
*Beware resp mm fatigue can lead to resp failure!!
Signs of increased work of breathing
- Increased RR (increased demand for gas exchange)
- Increased HR (improve circulation for O2 delivery)
- Altered respiratory pattern (Increased TV, Pursed lip breathing-prevents airway collapse during expiration)
- Mouth breathing (reduces airflow resistance)
- Accessory mm’s use (to improve ventilation)
- Decreased O2 sats (Pt no longer maintaining sufficient gas exchange causing hypoxemia)
- Dereanged ABG’s (no longer able to maintain adequate ventilation/gas exchange/ CO2 removal)
Signs of hypoxia
Hypoxia= low O2 in blood/tissues
- Increased RR
- Cough
- Cyanosis
- Shortness of breath
- Cerebral- confusion/anxiety
- Cardiac- increased/decreased pulse, cardiac arrest
- Sweating
- Reduced SPO2 and partial pressure of O2
Signs of hypercapnia
Hypercapnia= C02 retention/build up (common in COPD)
- Peripheral vasodilation
- Bounding pulse
- Tremor of hands
- Cerebral- restlessness/irritability, confusion, seizure, coma
- Cardiac- increased/decreased pulse & BP, cardiac arrest
- Fatigue
- Increased PaCO2
What treatment options are available to reduce the load of increased work of breathing?
Increased Load= extra thoracic load, airway load, lung tissue load (compliance)
- Positioning (for lung compliance and diaphragm unloading)
- Weight loss
- Address bronchospasm
- Clear sputum
- Reduce inflammation
What treatment options are available to reduce the demand of increased work of breathing?
Increased Demand= Hypoxic drive, metabolic demands, anxiety, hypercapnic drive
- Improve breathing pattern
- Rest
- Reassurance
- Support oxygenation
- Support ventilation
- Reduce metabolic demand
What treatment options are available to reduce the capacity of increased work of breathing?
Increased Capacity= muscle bulk, muscle innervation, muscle nutrition, level of muscle fatigue
- Optimise V/Q matching
- Optimise respiratory mechanisms
- Support oxygenation
- Support ventilation
- Strengthen respiratory mm’s
- Rest
What is respiratory failure?
Respiratory failure= results from inadequate gas exchange by the respiratory system, meaning arterial oxygen, carbon dioxide or both cannot be kept at normal levels
What are the signs of Type 1 Respiratory Failure?
- Oxygen arterial partial pressure below 8KPa (hypoxic)
- RR above 24 bpm (tachyponoeic)
- Partial pressure of CO2 (PaCO2) is normal/low
- Difficulty speaking in full sentences, using accessory mm’s
- Perform full ax: notes, ausc, CXR, ABGs, RR etc. before treatment
** If pt resp mm’s fatigue risk type 2 respiratory failure
What are the causes of Type 1 Respiratory Failure?
- V/Q mismatch (COPD, pneumonia, asthma, interstitial pulmonary fibrosis, bronchiectasis, pulmonary oedema, pneumothorax, pulmonary embolus, ARDS, lobar collapse)
- True pulmonary shunt (no response to O2 therapy- although CPAP/PEEP may help) = large pnumonias/consolidation, large atelectasis, ARDS/acute lung injury, small cell lung cancer
- Diffusion defects= thickened membrane (pulmonary fibrosis/sarcoidosis), reduced lung surface (emphysema)
- Hypoventilation of alveoli (will progress to T2)= dysfunction to ventilatory drive, weakness from neuromuscular dysfunction (SCI), mm fatigue- fixed thorax, worsening V/Q mismatch (severe kyphoscoliosis)
