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Respiratory Muscle Wekness (exam 2) Flashcards

1
Q

When is mechanical ventilation indicated?

A

Respiratory failure!
Pt cannot sustain the work of breathing required to meet metabolic needs

Indicated by hypercapnia (buildup of carbon dioxide in your bloodstream) and either
Hypoxemia (oxygen in blood) OR
Academia (hydrogen ion concentration of the blood, pH) OR
fatigue/altered mental state

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2
Q

What causes respiratory failure?

A

Increased airway resistance
- Pneumonia, acute respiratory distress syndrome

Hypermetabolic state
- Burn injuries

Failure of central ventilatory drive
- CVA, TBI

Failure of the ventilatory pump
- Muscle weakness (neuromuscular disease)
- Altered breathing mechanics (severe COPD)
- Reduced compliance (pulmonary fibrosis)
- Chest trauma

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3
Q

What are some examples of negative pressure ventilation?

A

Iron lung or chest cuirass

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4
Q

What are some examples of noninvasive positive pressure ventilation?

A

Ambu bag
BiPAP or CPAP

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5
Q

What are some examples of invasive positive pressure ventilation?

A

ET tube
Nasotracheal tube
Tracheostomy tube

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6
Q

How is oxygenation controlled?

A

Fraction of inspired oxygen (FiO2)
Positive end-expiratory pressure (PEEP)
Also influenced by tidal volume, inspiration/expiration ratio

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7
Q

What would be a severe impairment of fraction of inspired oxygen (FiO2)?

A

> 60% suggest severe impairment in gas exchange

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8
Q

What would be a severe impairment of of PEEP and what does it do?

A

Prevents airway closure and alveolar collapse
Improves ventilation-perfusion matching

Typically 5–10 cm H2O
If greater than 10, avoid disconnecting vent to transfer

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9
Q

How is ventilation controlled?

A

Tidal volume, respiratory rate, inspiratory flow
rate, and inspiration/expiration ratio can all be
manipulated

Minute ventilation (MV) is the key parameter

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10
Q

What is minute ventilation and what does it reflect?

A

MV reflects alveolar plus dead space ventilation
Alveolar ventilation reflected in PaCO2
Higher PaCO2 = lower alveolar ventilation

MV = volume of air ventilated in 1 minute
MV = respiratory rate * tidal volume
MV = 15 breaths/min * 0.5 L/breath = 7.5 L/min

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11
Q

How is the work of breathing controlled?

A

Mode of ventilation determines the degree of effort the patient contributes to ventilation

Mode is defined by two variables:
1. Volume vs. pressure control
2. Degree of patient control over initiating and sustaining the breath

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12
Q

How is volume controlled?

A

Ventilator delivers a set tidal volume at a set respiratory rate

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13
Q

How is pressure controlled?

A

Airway pressure, rather than volume, is main controlled variable
- Respiratory rate set by clinician
- Tidal volume determined by inspiratory time, patient effort, lung compliance, and airway resistance

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14
Q

What are the different types of breath initiation?

A

Control: all breaths are initiated by machine
Assist: some breaths are initiated by machine
Support: patient initiates all breaths

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15
Q

What are the 3 different degrees of patient control within ventilation?

A

Breath initiation

Duration of inspiration
Machine vs. patient control

Amount of assistance provided by machine
- Amount of pressure/volume delivered by machine in

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16
Q

What does it look like when a patient triggered or normal breath occurs?

A

Negative pressure

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17
Q

What does a volume assist mode vs a pressure assisted mode look like?

A

Volume assist mode: “Shark Fin”
Pressure assisted mode “Square shape”

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18
Q

What is Synchronized Intermittent MV (SIMV) mode?

A

The ventilator will deliver a mandatory (set) number of breaths with a set volume while at the same time allowing spontaneous breaths

Variable square heights

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19
Q

What is Continuous Positive Airway Pressure (CPAP) mode?

A

Machine only provides PEEP

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20
Q

List the vent modes from least patient contribution to most

A

Control modes
Assists control
SIMV
Pressure support
CPAP

21
Q

What are some weaning from the ventilator strategies?

A

Decreasing PEEP and FiO2
Use a mode that allows greater patient control
- Assist control to SIMV or pressure support
Spontaneous breathing trial
- “T-piece” or “blow-by”

PT implications
- Coordinate with medical team

22
Q

How does vital capacity change with posture?

A

Reduced in upright position with patients with an SCI

23
Q

Key PT interaction strategies

A

Maintain ROM, prevent contracture
Maximize strength of available muscles
Improve function
Maintain clear airways
Prevent skin breakdown
Increase tolerance to upright sitting

24
Q

Intervention: ROM, stretching, strengthening

A

Active/active assistive for innervated musculature and passive for others

Key considerations/priorities
- Shoulder ER and extension with elbow and wrist extension
- Preserve tenodesis: avoid stretching finger flexors with wrist extension
- Stretch HS while maintaining lumbar extension

25
Intervention: Positioning
Change every two hours - Right and left side lying, supine - Protect bony prominences
26
Intervention: Airways clearance
Suctioning of endotracheal tube to clear upper airway secretions - Endotracheal suctioning - Chest PT if retained secretions are a significant issue
27
Intervention: Increasing upright tolerance
Weak abdominals: abdominal binder to support abs/diaphragm Orthostatic hypotension - Elastic bandages/compression stockings to minimize venous pooling - Gradual exposure to upright posture - Monitor vitals and symptoms
28
What is the triad (muscles of respiration)?
Intercostals Diaphragm Abdominals
29
What is normal ventilation during inspiration? (In regards to the triad)
Diaphragm contracts and descends Intercostals and scalenes stabilize push and elevate rib cage
30
What is normal ventilation during expiration? (In regards to the triad)
Passive: Abdominal “tone” supports viscera, which helps to push diaphragm up to resting position Forced: Contraction of abdominals drives diaphragm upward Speaking requires eccentric control of inspiratory muscles.
31
High tetraplegic respiratory muscle activation (C1-C4)
Absent/weak diaphragm No spontaneous breathing for C1–C2, some possible for C3–C4
32
Low tetraplegic respiratory muscle activation (C5-T1)
Abdominal paralysis (initially flaccid) - Visceral splay: resting position of diaphragm is lower Intercostal paralysis (initially flaccid) - Thorax collapses during strong inspiratory effort Both inspiration and expiration are weak
33
What is paradoxical breathing?
Chest collapses during inspiration due to strong diaphragm, but weak intercostals, abdominals
34
High paraplegic respiratory muscle activation (C8-T11)
Increasing control of intercostals - Greater stabilization/expansion of rib cage: stronger inspiration Weak abdominals: weak cough, forced exhalation
35
Low paraplegic respiratory muscle activation (T6-L3)
Increasing control of abdominals - Improved support of viscera: higher resting position of diaphragm; stronger inspiration - Stronger forced exhalation, cough
36
How is vital capacity impacted by SCI?
The higher up the SCI the lower the vital capacity
37
Expected CVP impact of SCI (level and muscle impact)
C1–C2: Likely full-time vent dependent due to severe diaphragm paralysis C3–C4: Diaphragm weakness; periods of unassisted ventilation possible C5: Independent ventilation possible in long term, but initial ventilatory support common. Diaphragm function intact, but abdominal and intercostal paralysis lead to decreased lung volumes, poor cough C6–C8: Independent breathing; below C7, can augment inspiration with pectoralis major and pectoralis minor T1–T4: Inspiration and forced expiration supported by intercostals, but cough reduced due to abdominal weakness T5–T12: Progressive relative improvement in strength at descending lesion levels. Minimal disruption to autonomic system below T6 T12: Essentially normal respiratory function
38
How can PT’s help patients wean from ventilators?
Generally avoid intense mobility/exercise sessions during weaning trials, but PTs can help maximize chance for success with weaning
39
How can positioning maximize ventilation for SCI patients?
Supine or slight head down - If sitting upright, use abdominal binder Trunk extension Arms elevated/supported on pillow
40
How can inspiratory muscle training maximize ventilation for SCI patients?
Inspiratory muscle training can improve pulmonary function in individuals with cervical SCI Evidence for effect on complication rate, dyspnea, and quality of life inconclusive
41
Describe inspiratory muscle training during weaning?
Mode: threshold training device Intensity: work up to about 60% of maximum inspiratory pressure OR RPE of 5–6/12–13 - Note: avoid significant fatigue, start at lower intensity and work up Dosage: seven sets of two minutes each with one minute rest in between Frequency: five times per week Duration: ongoing (eight weeks minimum)
42
Other issues that could impact an acute SCI patient after ventilation
Pulmonary edema in early stages - Affects 50% of those with tetraplegia - Results from fluid resuscitation, hypotension Venous thromboembolism - Incidence: 4.5% in acute SCI - Risk of death 500 times higher in SCI - Deconditioning of respiratory muscles during mechanical ventilation
43
Exam components (focus on CVP)
Vital signs, especially respiration: rate, depth, rhythm Breathing pattern Posture Chest wall motion Breath control Cough effectiveness
44
What is and how can you correct the “beer belly posture in SCI patients
Posture not optimal for respiration - Protracted scapulae, shoulder internal rotation - Mid-trunk fold Use of towel roll for trunk support - Improved posture for respiration
45
How to assess breath control?
How long can you say “ah?” - Normal is 15 seconds How many syllables per breath while speaking? - Normal is 8–10
46
How to evaluate and grade a cough?
Stages of cough 1. Inspiration 2. Closure of glottis 3. Contraction of abdominals, intercostals 4. Opening glottis, expulsion of air Grading cough - Effective/functional: sharp, crisp, large volume of air, able to clear airway - Weak: decreased volume or diminished air movement - Ineffective: unable to clear airway
47
What are the goals after a patient gets off a ventilator
Maintaining clear airways Maximizing ventilation Prevent skin breakdown Prevent contracture Optimize functional mobility
48
How can you maximize ventilation?
Positioning Incorporating breathing into functional activities - Exhalation with trunk flexion movements - Inhalation with trunk extension movements Breathing exercises - Breath stacking - Incentive spirometry - Inspiratory/expiratory muscle training
49
How can you maintain clear airways?
Manually assisted cough - Deep breath—hold— cough with manual assist - Abdominal thrust, costophrenic assist, or anterior chest compression Self-assisted - Inhale with extension - Cough/exhale with flexion and manual assist

PT755 (11 decks)

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