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Physio Led Assessment & Treatment > Respiratory > Flashcards

Respiratory Flashcards

1
Q

What pathophysiological mechanisms underpin pneumonia and the associated pain response?

With Clinical Physio Flashcard

A

Air sacs (alveoli) in the lungs become filled with microorganisms, fluid and inflammatory cells, impairing gaseous exchange.

PAIN
Predominantly nociceptive: Pleuritic chest pain due to inflammation of the pleura seen most in lobar pneumonia.

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2
Q

What are the predominant patient-reported dysfunctions for pneumonia?

With Clinical Physio Flashcard

A
  • Chest pain, tightness of the chest
  • Shortness of breath walking
  • Increase in fatigue
  • cough
  • diarrhoea
  • loss of taste
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3
Q

What dysfunctions may be found during an objective assessment for pnuemonia?

A
  • Vitals: Decreased sats (<96%), elevated HR (to norm), increased respiratory rate
  • On Obvs: Cyanosis (if severe and not treated), shortness of breath, increased WOB
  • On Auscultation: Reduced breath sounds (particularly in the localised areas identified on imaging), Rales - corse crackles.
  • On palpation: tactile fremitus, reduced thoracic expansion (biasing the unaffected side)
  • On imaging: Cloudiness and consolidation
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4
Q

What modifiable and non-modifiable risk factors influence pneumonia?

A

Modifiable
* Smoking
* Drug and alcohol abuse
* Malnutrition
* Exposure to toxic chemicals and pollutants

Non-modifiable
* Hx of lung disease
* Infection (bacterial or viral)

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5
Q

What are the normal parameters for ABGs

With Clinical Physio Flashcard

A

PH 7.35-7.45
PaO2 10-14
PaCO2 4.5-6.1
HCO3- 22-26
BE -2 to + 2

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6
Q

What is the prognosis of pneumonia? (NICE 2022 guidelines) 1 week to 6 months.

A

1 week- fever should have resolved

4 week- chest pain and sputum production should have substantially reduced

6 week- breathless and cough should have substantially reduced

3 months- most symptoms should have resolved

6 months- most symptoms should have completely resolved

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7
Q

What are the different types of pneumonia? (HAP, CAP, VAP, AAP). Which one did David have?

A

HAP- hospital acquired pnemounia
CAP - community acquired pneumonia
VAP- ventilation acquired pneumonia
AAP- Aspiration acquired pneumonia

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8
Q

What are the presenting clinical features of pneumonia?

A
  • Productive cough
  • Purlent sputum (blood stained/ rust coloured/ greeny/ yellow)
  • SOBAR/ SOBOE
  • fever
  • malaise
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9
Q

What’s is the royal college of physicians (RCP) NEWS2 For?

With Clinical Physio Flashcard

A

The NEWS chart monitors key physiological parameters to monitor the risk of early deterioration and thereby potential death.

Deviation from physiological parameters can escalate in monitoring needs such as more frequent checks, ward doctor review, critical care response team and pt to be moved to ICU/ HDU

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10
Q

What are the normals physiological parameters for the following news2 chart

RR
HR/ pulse
BP
Oxygen sats
02 therapy
Body temperature

What do the aggregate score mean for

What is low risk?
What is medium risk
What is high risk?

With Clinical Physio Flashcard

A

RR- 12 to 20 (per minute)
SpO2 scale 1- > 96 (%)
SpO2 scale 2- 88-92%
Oxygen therapy- RA or oxygen?
Systolic blood pressure- 111-219 mmHg
AVPU Scale- Alert, Voice, Pain, unresponsive (level of responsiveness)
Body temperature- 36.1 to 38

What do the aggregate score mean for

1-4- low risk?
5-6 or a score of 3 in any parameter- medium risk
7 or more- high risk

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11
Q

What are the normal reference ranges for ABGs? (pH, PaCO2, PaO2, HCO3, and Base Excess)

With Clinical Physio Flashcard

A
  • pH: 7.35-7.45
  • PaCO2: 4.7-6 kPa
  • PaO2: 11-13 kPa
  • BE: -2 to +2
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12
Q

What does the pH in ABGs tell you and what influences it?

A

Whether the pH is normal, acidotic or alkalotic?
* Acidotic: pH <7.35
* Normal: pH 7.35 – 7.45
* Alkalotic: pH >7.45

The changes in pH are caused by an imbalance in the CO2 (respiratory) or HCO3– (metabolic). These work as buffers to keep the pH within a set range and when there is an abnormality in either of these the pH will be outside of the normal range.

As a result, when an ABG demonstrates alkalosis or acidosis you need to then begin considering what is driving this abnormality by moving through the next few steps of this guide.

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13
Q

The ABG mnemonic ROME refers to what?

A
  • Respiratory Opposite: If pH and PCO2 have changed in the opposite direction, the cause is likely to be respiratory.
  • Metabolic Equal: In the pH and HCO3 have changed in the same direction, the culprit is likely metabolic.
  • ROME = Mixed: If all the above is true, there is likely a mixed contribution
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14
Q

What does the acronym RIPE mean in CXR interpretation?

A
  • Rotation: The medial aspect of each clavicle should be equidistant from the spinous processes. The spinous processes should also be vertically orientated against the vertebral bodies.
  • Inspiration: The 5-6 anterior ribs, lung apices, both costophrenic angles and the lateral rib edges should be visible.
  • Projection: Note if the film is AP or PA: if there is no label, then assume it’s a PA film (if the scapulae are not projected within the chest, it’s PA).
  • Exposure: The left hemidiaphragm should be visible to the spine and the vertebrae should be visible behind the heart.
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15
Q

What does the A-I inspection of CXRs entail?

With Clinical Physio Tips

A
  • Airway: Inspect the trachea for evidence of deviation
  • Bones: Inspect for fractures or damage to the thoracic cage
  • Cardiac: Inspect Heart size and boarders
  • Diaphragm: Including assessment of costophrenic angles
  • Extras: Any other points of interest (e.g. aortic valve) or abnormalities (e.g. haematoma).
  • Fields: Any signs of consolidation?
  • Gastric: Inspect for the presence of gastric gasses.
  • Hillar Region: The hilar point is also a very important landmark; anatomically it is where the descending pulmonary artery intersects the superior pulmonary vein. When this is lost, consider the possibility of a lesion here (e.g. lung tumour or enlarged lymph nodes).
  • Impression: Given your above inspections, what is this showing you?
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16
Q

What are the clinical features of Type 1 respiratory failure and what causes it?

A

Clinical Features
Hypoxaemia (PaO2 <8 kPa) with normocapnia (PaCO2 <6.0).

Cause
Ventilation/Perfusion (VQ) mismatch, for example:
* Reduced Ventilation and normal perfusion (e.g. pulmonary oedema)
* Reduced perfusion with normal ventilation (e.g. pulmonary embolism)

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17
Q

What are the clinical features of type 2 respiratory failure and what causes it?

A

Clinical Features
Hypoxaemia (PaO2 <8 kPa) with hypercapnia (PaCO2 >6 kPa).

Causes
Alveolar hypoventilation, which prevents a patient from being able to adequately oxygenate and eliminate CO2 from their blood. This can occur for a number of reasons:
1. Increased resistance as a result of airway obstruction (e.g. COPD)
2. Reduced compliance of the lung tissue/chest wall (e.g. pneumonia, rib fractures)
3. Reduced strength of respiratory muscles (e.g. stroke, MND)
4. Drugs acting on the respiratory centre to reduce overall ventilation (e.g. opiates).

18
Q

What pathophysiological mechanisms underpin COPD and the associated pain response?

With Clinical Physio Flashcard

A

The cardinal pathophysiologic feature of COPD is airflow limitation caused by airway narrowing and/or obstruction, loss of elastic recoil, or both. Inhalational exposures can trigger an inflammatory response in airways and alveoli that leads to disease in genetically susceptible people. The process is thought to be mediated by an increase in protease activity and a decrease in antiprotease activity. Respiratory infection (which COPD patients are prone to) may amplify progression of lung destruction.

PAIN
Predominantly nociceptive been signalled from several structures, the following being the primary culprits:
* Adhesions of the parietal pleura.
* Overstretching of the visceral pleura caused by a chronic overinflation of the lungs.
* Free radicals present in bronchial pathways as a result of chronic inflammation.

19
Q

What are the predominant patient-reported dysfunctions for COPD?

With Clinical Physio Flashcard

A
  • Breathlessness
  • Reduced Capacity
  • Chest Pain & Tightness
  • Persistent Cough
  • Impaired ADLs
20
Q

What dysfunctions may be found during an objective assessment for COPD (consider categories based on spirometry)?

A
  • Dyspnea/breathlessness - Worse on exertion
  • Productive cough
  • Impaired spirometry readings:
    Mild: FEV1 ≥80% predicted
    Moderate: ≤ 50% FEV1 <80% predicted
    Severe: ≤ 30% FEV1 <50% predicted
    Very severe: FEV1 <30% predicted.
21
Q

What modifiable and non-modifiable risk factors influence COPD?

A

Modifiable
* Smoking (substantial evidence)
* Secondhand smoke (substantial evidence)
* Occupational and environmental exposure chemicals (work related). (6) (substanial evidence)
* Air pollution

Non-modifiable
* Hereditary genetic condition called Alpha-1 deficiency
* Racial and ethnic factors. (less clear evidence)
* History of childhood respiratory infections. (Evolving evidence)
* Bronchial hyper-responsiveness (Evolving evidence)
* Gender (Evolving evidence)

22
Q

What is the prognosis of COPD and what prognostic factors may influence this?

A

COPD is a progressive, incurable terminal illness and the third leading cause of global mortality. However, there are a number of factors that influence individual outcomes:

  • Smoking - can lead to faster decline in lung function
  • Age - older patients with COPD have increased mortality, contributed by the fact comorbidity increases with age.
  • Exercise capacity - 6-minute walk test has shown to be a predictor of mortality, 80% of patients with a walk distance of less than 100m had 1-year mortality rate and those with similar airflow who could walk greater than 400m had much greater survival rate.
  • Gender - Women report greater levels of dyspnea, despite smoking less and being younger and report greater levels of anxiety and depression. However, the mortality rate is still greater in men. This could be associated with the fact men smoke more and do not live as long as women.
23
Q

What are the psychometric properties of the mBorg (with reference(s) & critical analysis)?

A
  • Validity: good, the study was looking at COPD patients not patients with pneumonia***
  • Reliability: high test-retest reliability, good inter-rater reliability
  • Feasibility: quick and easy to use but some patients find it confusing if they must complete the test without the supervision of a clinician present

Puente-Maestu et al (2008) - RCT

24
Q

What are the psychometric properties for auscultation (with reference(s) & critical analysis)?

With Clinical Physio Tips

A
  • Sensitivity: 37% (low)
  • Specificity: 89% (acceptable)
  • Positive LR: 3.2
  • Negative LR: 0.72
  • Validity: Not mentioned in the study
  • Reliability: Good Intra-Rater reliability, Moderate Inter-rater reliability, no change in reliability depending on clinical experience
  • Feasibility: Very good

Arts et al (2020) - Meta-Analysis (Nature, IF = 69.5)

25
Q

What were the key findings of cox et al (2022)?

A
  • Lung ultrasound has greater diagnostic sensitivity and inter-observer reliability compared to auscultation
  • Lack of availability/ training and can be costly
  • Not very feasible and accessible - particularly in third world countries
26
Q

What are the 5 key treatments for Pneumonia (with references)

With Clinical Physio Flashcard

A
  1. Positioning for VQ matching and postural drainage (McKoy et al, 2016)
  2. ACBTs (Zisi et al, 2022 & Belli et al, 2021)
  3. Patient Education (NICE Guidelines…, 2014)
  4. Manual Techniques (NICE Guidelines… 2014)
  5. Early, progressive mobilisation (BTS & ACPRC Guidlines…, 2009)
27
Q

What were the findings of the systematic review by Bausewein et al (2007) regarding measures of breathlessness/dyspnoea?

A
  • There was at the point of the review no scale that can accurately measure the far-reaching impacts of dyspnoea in patients with advanced/chronic diseases.
  • The mBorg was the most responsive measure for detecting changes in breathlessness severity, while the MRC scale showed a poor ability to detect changes.
  • The review recommends a mixed methods approach to the assessment of dyspnoea - with the use of a unidimensional measure, disease-specific QoL measure, and qualitative investigation of further reaching psychosocial impacts.
28
Q

What patient information provision is reccomended by the 2014 nice guidelines for the Management of Pneumonia?

A

Information Surrounding Prognosis:
* 1 week: fever should have resolved
* 4 weeks: chest pain and sputum production should have substantially reduced.
* 6 weeks: cough and breathlessness should have substantially reduced.
* 3 months: most symptoms should have resolved but fatigue may still be present
* 6 months: most people will feel back to normal

29
Q

What were the key findings of Zisi et al (2022) regarding ACBTs (With critical analysis)?

A
  • ACBT is effective an effective treatment for the short term improvement in respiratory tract secretion clearance and pulmonary function when compared to other treatment modalities.
  • Effective in increasing the expectorated sputum volume, in reducing viscoelasticity of the secretion and in relieving symptoms such as dyspnea. (20-40% reduction in dyspnoea).
  • However, Most studies revealed that ACBT/FET had at least an equally beneficial short-term effect on sputum wet weight, FEV1 and FVC compared to other treatment methods.

Critical Analysis:
* Journal: Heart & Lung J (IF = 3.1)
* Design: SR (Incl. 11 moderate-good quality RCTs)

30
Q

What were the key findings of Belli et al (2021) regarding ACBTs (With critical analysis)?

A
  • ACBTs are comparable to other techniques in terms of patient preference, lung function, sputum weight, oxygen saturation and number of lung exacerbations, lung function, exercise capacity and quality of life.
  • For a long-term use - patient adherence to treatment is greater if self-administered techniques are used
  • Always consider the patient’s preferences, and base one’s choices about which technique to use not only on the relief of symptoms, but also on the adaptability of the technique to the patient’s lifestyle.

Critical Analysis
* Journal: Frontiers of Medicine (IF = 9.9)
* Design: SR

31
Q

What were the key findings of McKoy et al (2016) regarding ACBTs (with critical analysis)?

A
  • ACBTs are as equally effective as autogenic drainage and manual techniques in short-term symptom relief for patients with cystic fibrosis. No significant difference was seen in quality of life, sputum weight, exercise tolerance, lung function, or oxygen saturation.
  • Patient preferences were true to the following order: Autogenic drainage, ACBTs, and Manual Techniques.

Critical Analysis
* Journal: Cochrane Library (IF =11.9)
* Design: SR

32
Q

What are the recommendations of the BTS & ACPRC Guidelines for the physiotherapy management of the adult, medical, spontaneously breathing patient (2009)?

A
  • Medical condition permitting, patient should be out of bed for at least 20 minutes a day within the first 24h of admittance to hospital with mobility being increased daily.
  • Patients admitted with primary uncomplicated pneumonia should not be treated with traditional airway clearance techniques routinely. (Grade B)
  • In patients with uncomplicated community-acquired pneumonia admitted to hospital, the regular use of positive expiratory pressure should be considered. (Grade B)
33
Q

What are the five key treatments for COPD (with references)?

A
  1. Smoking Cessation (GOLD Standards 2023 & NICE Guidlines … 2018)
  2. Pulmonary Rehabilitation (GOLD Standards 2023 & NICE Guidelines … 2018)
  3. Inhaler Training (GOLD Standards 2023 & NICE Guidelines … 2018)
  4. ACBTs (NICE Guidelines … 2018)
  5. PEP Devices (NICE Guidlines … 2018)
34
Q

According to the 2018 NICE Guidelines for the diagnosis and management of COPD, what treatments are the explicit responsibility of physiotherapists?

A
  1. Teaching the use of PEP devices
  2. Provision of ACBT education
35
Q

What are the key recommendations/findings of the Global Initiative for Chronic Obstructive Lung Diseases (GOLD) Standards 2023?

A
  • Pulmonary Rehabilitation*: “a comprehensive intervention based on thorough patient assessment followed by patient-tailored therapies that include, but are not limited to, exercise training, education, self-management intervention aiming at behavior change, designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence to health-enhancing behaviors.” (Grade A Evidence)
  • Education alone has been shown to be ineffective (Grade C evidence)
  • Self Management with communication with a healthcare professional improves health status and decreases hospitalisations (Grade B Evidence)
  • Smoking Cessation interventions should be actively pursued in all people with COPD (Grade A Evidence)
    Physical activity is a strong predictor of mortality in patients with COPD (Grade A Evidence). People with COPD should be encouraged to increase PA levels.
  • Assessment of Inhaler adherence and technique - provide training if necessary.
36
Q

What are the key recommendations/findings of the 2018 NICE Guidelines for the diagnosis and management of COPD?

A
  • Smoking Cessation: At every opportunity, advise and encourage every person with COPD who is still smoking (regardless of their age) to stop, and offer them help to do so.
  • Inhaler Training (if indicated): People with COPD should have their ability to use an inhaler regularly assessed and corrected if necessary by a healthcare professional competent to do so
  • Pulmonary Rehabilitation: Make pulmonary rehabilitation available to all appropriate people with COPD, including people who have had a recent hospitalisation for an acute exacerbation.
  • Offer pneumococcal vaccination and an annual flu vaccination to all people with COPD, as recommended by the Chief Medical Officer.
  • If people have excessive sputum, they should be taught: how to use positive expiratory pressure devices, and active cycle of breathing techniques.
  • Patient Education: At a minimum, the information should cover: an explanation of COPD and its symptoms, advice on quitting smoking (if relevant) and how this will help with the person’s COPD, advice on avoiding passive smoke exposure, managing breathlessness, physical activity and pulmonary rehabilitation, medicines, including inhaler technique and the importance of adherence, vaccinations, identifying and managing exacerbations, details of local and national organisations and online resources that can provide more information and support, how COPD will affect other long-term conditions that are common in people with COPD (for example hypertension, heart disease, anxiety, depression and musculoskeletal problems).
37
Q

What does a subjective respiratory assessment entail?

Clinical Physio Flashcard

A
  1. Information Gathering (MDT, NEWS, Obvs, Scans, and tests).
  2. Risk Ax
  3. Introduction / Informed Consent
  4. PC: How are you today? (SQs: cough, secretions, breathlessness, pain)
  5. HPC (more so for valarie)
  6. PMH
  7. DH: Now, hospital, prior
  8. SH: Accom / Family / Work / Hobbies …
  9. PV & E: Pt led problem list, expectations (realistic, limiting beliefs)?
38
Q

What does an objective respiratory assessment entail?

Clinical Physio Flashcard

A
  1. Re check vitals (Sats, BP, HR, RR)
  2. Visual Ax (Position, WOB, Breathing mechanics, general condition, lucidity)
  3. Chest Pain?
  4. Breathlessness
  5. Auscultation
  6. Cough & Inhaler demo
  7. Palpation (TE/TF - bucket handle and pump handle)
  8. PROM
  9. AROM / Strength
  10. Function / Mobility

Include inhaler demonstration and TUG for Valarie.

39
Q

What can sputum tell you?

Clinical Physio Flashcard

A
40
Q

What are the psychometric properties for the TUG (with reference)?

A

Validity: Highly predictive of 6MW performance with a time <11.2 been strongly indicative of poor health outcomes.
Reliability: Good-to-Excellent for both intra and inter rata.
Feasability: Good. Requires minimal equipment and space.

Mesquita et al (2016)

41
Q

What are the psychometric properties for percussion note (with reference)?

A

Reported a sensitivity of 95.8% and specificity of 100% were obtained when diagnosing pleural effusions when in combination with auscultation 3 cm under the 12th rib.

42
Q

What are the five key respiratory problems?

A
  1. Difficulty Managing Secretions
  2. Reduced Lung Volume
  3. Ineffective Cough
  4. Pain
  5. Reduced Exercise Tolorance

Physio Led Assessment & Treatment (21 decks)

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