Respiratory pathophys 2 Flashcards
Restrictive Patterns of pulmonary disease examples
Pulmonary fibrosis
lung cancer
Extra pulmonary causes –> neurological and musculoskeletal
Restrictive pulmonary diseases
any condition that limits lung expansion
generally characterized by stiffening of lung parenchyma which prevents lung from fully expanding (low compliance)
PFTs will show decreased vital capacity, FEV1 will be the same
often associated w/occupations and inhalation
Clinical Presentation of restrictive lung diseases
varies according to cause
shallow, rapid breathing pattern = chronic hyperventilation
disease progression leads to hypoxemia and CO2 retention
Treatment goals/prognosis of restrictive lung disease
maintenance of adequate oxygenation
most conditions are not reversible and lead to ventilatory failure
Treatment guidelines for restrictive lung diseases
pts will desaturate quickly
pace activities, monitor dyspnea, SPO2, HR
ineffective cough–facilitation techniques
routine positioning
Synonyms of pulmonary fibrosis
diffuse interstitial pulmonary fibrosis, interstitial lung disease
Pulmonary Fibrosis
chronic irritation of lung tissue that leads to progressive scarring of lungs. Causes issues with the alveoli, progressively grow bigger
Etiology of pulmonary fibrosis
Idiopathic–> no identifiable cause
others are inhalation of harmful particles, autoimmune disorders, certain drugs
Treatment of Pulmonary Fibrosis
No cure, limited treatment
glucocorticoids, O2, pulmonary rehab
generally poor prognosis
Indications for O2 therapy
hypoxemia
oxygen desaturation w/exercise
increased work of breathing
increased myocardial work
Low flow O2
Not intended to meet total inspiratory needs of pt. when pt inspires, supplemental O2 is diluted w/RA. inspiratory flow, cannot accurately calculate the FiO2
High flow O2
everything the patient breathes come from the device. FiO2 is stable and unaffected by pts type of breathing
Definition of Minute ventilation
volume of air per unit time that moves into and out of the lungs
MV = RRxTV
MV is about 8L/min for normal adult
Low-flow O2 delivery systems
flow rates are low enough that patient can easily overcome with MV
nasal cannula, simple face mask, non-rebreather mask
Nasal cannula
flow rates 1-6L/min
most common method
at higher flow rates, dries nasal mucosa and can be uncomfortable
actual FiO2 depends pts MV and breathing pattern
24-40% FiO2
Face mask
flow rates 5-10 L/min
mouth and nose covered, mask has exhalation ports for CO2
35-55% FiO2
Non-rebreather mask
flow rates 10-15 L/min
1-way valve between mask and reservoir bag prevents inhalation of expired air
80-95% FiO2
High Flow O2 delivery systems
flow rates high enough that patient cannot overcome with MV, so FiO2 is stable
rebreather, venturi, high-flow nasal cannula
Venturi mask
flow rates >40 L/min
allows precise measurements of FiO2 delivered, which is
useful in persons with COPD where precise O2 delivery may be crucial
different sized ports change the FiO2 delivered
24-50% FiO2
High-flow nasal cannula
flow rates >60L/min, up to 100% FiO2
heated, and 100% humidified O2 through wide-bore nasal prong
decreases inflammation, maintains mucociliary function, improves clearance, reduces caloric expenditure
O2 delivery devices
O2 concentrators
Compressed gas cylinders
O2 concentrators
draw RA through series of filters to leave concentrated O2
most units deliver O2 flows .5-5L/min
can be transported
Compressed gas cylinders
metal container filled with compressed gas held under high pressure
O2 cylinders available in range of sizes that determine the capacity for O2
Why would someone be on high-flow O2
high flow O2 delivery can provide the patient a consistent and known amount of O2 which might be important for pts with long-standing COPD
PCO2 levels rise (called ______) with progressive COPD, especially pronounced in pts with predominant _____
hypercemia
bronchitis
How do the central chemoreceptors respond to hypercapnia? (short term)
increase firing rate, stimulates neurons in rhythmicity center in the medulla, increased firing of descending motor via the phrenic nerve to the diaphragm, increased ventilation
How do the central chemoreceptors respond to hypercapnia? (long term)
pH is normal due to metabolic compensation, and receptors no longer respond to elevated PCO2
How do the peripheral carotid bodies respond to pH, PCO2, PO2?
pH and PCO2 = no response
PO2 = hypoxic drive to breathe
What could happened during an acute severe exacerbation of chronic bronchitis if FiO2 is increased dramatically?
Carotid bodies now sense increased PaO2, decrease their input to rhythmicity center, essentially removing hypoxic drive to breathe
ventilation decreases, leading to acute respiratory acidosis
Should O2 therapy be withheld from hypoxemic patients with COPD to avoid loss of hypoxic drive to breathe?
NO
administration of high flow O2 is associated with higher mortality
lower the concentration (88% to 92%)
Should PTs increase the O2 flow rate when pts are mobilizing/exercising?
YES
monitor for S/S of hypoxemia (cyanosis, dyspnea, decreased coordination, decreased brain function)
pts desat quickly
When adjusting O2 flow rate, make sure to…
monitor vitals at baseline and exercise
O2 has to be turned down after activity
post exercise vitals to check s/s of hypoxemia
Pathogenesis of Pulmonary fibrosis
abnormal wound healing response
thickened alveolar walls and fibrosis shrinks affected lobes, decreases compliance
Acute respiratory distress syndrome (ARDS)
life-threatening form of acute respiratory failure characterized by inflammatory pulmonary edema, results in severe hypoxemia
can be causes by shock, trauma, infection, lung contusion, pneumonia, near drowning, toxic inhalation
Pathogenesis of ARDS
increased vascular permeability allows fluid to seep into interstitial spaces, leads to edema
damage to alveolar epithelial cells inactivates surfactant, increases surface tension
Clinical presentation of ARDs
labored breathing, tachypnea, intercostal retractions, crackles
hypoxemia
Dx and Treatment of ARDS
Dx: history and PE, CXR
Treatment: intubation, postive pressure ventilation, diuretics, glucocorticoids, PRONING
What does proning do?
improves respiratory mechanics
assists airway clearance
helps prevent ventilator induced lung injury
improves V/Q and increases PaO2
Nutrition and COPD
experience unintended weight loss
tips: rest before meals, limit salt to limit edema, choose foods that are easy to chew
General problems that should be identified in pulmonary pts
Decreased airway clearance
increased work of breathing
decreased ventilation
decreased exercise tolerance
decreased knowledge of disease process and compliance
Decreased airway clearance
consolidation/infiltrates, sputum, crackles/sounds, mediate percussion is dull, ejophany
Increased work of breathing
hypertrophy of accessory muscles, increased RR, dyspnea
Decreased ventilation
hypoxemia, hypercapnia, decreased breath sounds, SPO2
Decreased exercise tolerance
SPO2 drops, increased RPE, decreased H/H, dyspnea on exertion
Pulmonary rehab
part of a comprehensive treatment program for individuals w/pulmonary diseases
includes medical management of disease, pt education, counseling, reconditioning
general goal is to improve QOL through cardiopulmonary functions
Specific cardiopulmonary PT goals
Improve breathing pattern and effectiveness
improve airway clearance
improve exercise tolerance
improve pt awareness of cardiopulmonary problems and resolutions
Improve breathing pattern and effectiveness
decrease RR and increase TV (increasing MV)
decrease work of breathing
improve chest wall mobility
improve coordination of breathing
improve functional activities and SOB/DOE
Improve airway clearnace
improve hydration status
improve cough effectiveness
Improve exercise tolerance
improve ADL tolerance
incorporate active and wellness activities
Improve pt awareness of cardiopulm problems and resolutions
teach pt signs of increasing cardiopulm problems
help pt increase independence in managing self-care and personal wellness
Techniques to alter pts breathing pattern
positioning
ventilatory strategies
manual strategies
Which breathing pattern should you promote?
always promote symmetrical activation
any one that promotes oxygen uptake
When should you help increase activation of diaphragm?
in early COPD
When should you help decrease activation of accessory muscles?
all stages of COPD
When should you help increase activation of accessory muscles?
SCI, decreased musle tone, decrease breath support
To facilitate activation of diaphragm
posterior pelvic tilt
shoulder adduction IR
To facilitate activation of respiratory accessory muscles
anterior pelvic tilt
shoulder abduction, ER
Manual strategies to facilitate breathing
cueing
provide resistance during movement to prolong expiratory phase
interrupted airflow to prolong expiratory phase
What are the impediments to airway clearance?
respiratory conditions that produce lots of secretions
pain and meds
neuro impairments
dysfunctional mucociliary escalator
endotracheal tube
What is done during chest physical therapy?
postural drainage
percussion
vibration
ALL positions are contraindicated for
Intracranial pressure, head injury, active hemorrhage, spinal surgery/injury, aged/confused pts., rib fracture
Trendelenburg position is contraindicated for
high ICP, uncontrolled HTN, distended abdomen, esophageal surgery, radiation therapy, uncontrolled airway at risk for aspiration
Reverse Trendelenburg is contraindicated for
hypotension or vasoactive medication
Airway Clearance Techniques
Chest PT
active cycles of breathing (huff)
autogenic drainage (huff)
positive pressure devices
aerobic exercise
consider motivation, compliance, ability, expense, availability
Active cycles of breathing
get air distal to the secretions
gentle technique that uses changes in lung volume to ventilate different areas of the lung
repeated cycles of 3 ventilatory phases (breathing control, thoracic expansion, forced expiration)
Phases of active cycles of breathing
Control: gentle breathing
Thoracic expansion: loosen secretions by breathing above TV w/deep inspiration
Forced expiration: mobilize secretions by one or two huffs
Autogenic drainage
- unstick secretions
- collect
- evacuate
cycle is repeated 3-4 times. encourage pt not to cough until done with cycles
Positive pressure devices
used during exhalation to keep airways open and mobilize secretions
Manual percussors
penumatic device that provides overall percussion
the vest
good results for pts with CF and neuromuscular weakness
Why should individuals participate in aerobic exercise if they have a hard time breathing?
- increases transpulmonary pressure, opens airways and increases ventilation (ACT)
- increases mucociliary transport (ACT)
- increase mobility of chest wall
- general strength training
- respiratory muscle training
How can we best describe the benefits of exercise for the individual with respiratory disease?
Ex helps prevent this classic downward spiral
helps you to become more efficient, muscles eventually require less oxygen
increases circulation, decreases resting HR and BP
Considerations when walking
walk as often as possible
maintain controlled breathing and proper posture
start small 5-10 min, level ground
Techniques to help relieve dyspnea
control breathing pattern
pursed lip breathing
alter posture
relaxation techniques
PT interventions for outpatient pulmonary
- assess readiness to quit smoking
- position to promote optimal o2 uptake
- teach effective breathing patterns
- prescribe aerobic exercise program
- prescribe resistance ex program
- teach energy conservation
- teach relaxation strategies
- supplemental O2
