S2L4: Pulmonary Rehabilitation Flashcards
Pulmonary Rehabilitation Goals, except:
A. To control and alleviate, as much as possible, the symptoms and pathophysiological complications of respiratory conditions
B. To help patient achieve optimal functional capacity
C. To help in improving patient’s quality of life
D. None
D
Pulmonary Rehabilitation Goals , except:
A. To increase exercise tolerance
B. To decrease psychological symptoms
C. To promote independence and self-reliance
D. None
D
PHYSICAL THERAPY INTERVENTIONS, except:
A. Breathing Techniques
B. Airway Clearance Techniques
C. Mechanical Techniques
D. Manual Techniques
E. Coughing exercise
E
PHYSICAL THERAPY INTERVENTIONS Except:
A. Post-operative Pulmonary PT
B. PT Associated with Respiratory Failure
C. Cardiopulmonary Endurance Exercises
D. Deep breathing
D
Breathing Techniques:
From tidal inspiration to tidal expiration
Used to:
* maximize ventilation
* facilitate relaxation
* decrease the use of accessory muscles
A. Relaxed Diaphragmatic Breathing
B. Deep Diaphragmatic Breathing Exercise
C. Stacking Breaths
D. Pursed-Lip Breathing
A
Breathing Techniques:
Aka Lower Cage Breathing
- From maximum inspiration up to controlled maximum expiration
- Patient position: semi-fowler’s
- Alternative: side-lying
A. Relaxed Diaphragmatic Breathing
B. Deep Diaphragmatic Breathing Exercise
C. Stacking Breaths
D. Pursed-Lip Breathing
B
Breathing Techniques:
Used to optimize diaphragm function and maintain/improve chest wall mobility
- Parameters: 3-4/5 reps prn
A. Relaxed Diaphragmatic Breathing
B. Deep Diaphragmatic Breathing Exercise
C. Stacking Breaths
D. Pursed-Lip Breathing
B
Breathing Techniques:
Used to maximize ventilation when the volume of air that the patient can inhale is limited
- Done by taking a small-to-moderate size breath and adding 2-3 additional breaths to increase inspiratory volume
- Usually done prior to huffs or coughs
A. Relaxed Diaphragmatic Breathing
B. Deep Diaphragmatic Breathing Exercise
C. Stacking Breaths
D. Pursed-Lip Breathing
C
Breathing Techniques:
Inspiring air then expiring air with pursed lips (1:2 ratio, eg 2-sec inhalation and 4-sec exhalation)
- To prolong expiratory phase -> Dec. RR, delay small airway closure, dec. dyspnea, improve controlled airflow, and calm anxiety
A. Relaxed Diaphragmatic Breathing
B. Deep Diaphragmatic Breathing Exercise
C. Stacking Breaths
D. Pursed-Lip Breathing
D
Breathing Techniques:
Aka Frog Breathing
- Used by ventilator-dependent patient
A. Glossopharyngeal Breathing
B. Segmental Breathing
C. Dyspnea Relieving Positions (DRP’s)
D. Paced breathing
A
Breathing Techniques:
Usually done for patients with asymmetrical chest wall mobility (eg pneumonia)
- Teach patient to expand localized area of the lungs
- PT provides tactile feedback
A. Glossopharyngeal Breathing
B. Segmental Breathing
C. Dyspnea Relieving Positions (DRP’s)
D. Paced breathing
B
Breathing Techniques:
Techniques:
- Unilateral Lateral Costal Expansion
- Bilateral Lateral Costal Expansion
- Posterior Basal Expansion
A. Glossopharyngeal Breathing
B. Segmental Breathing
C. Dyspnea Relieving Positions (DRP’s)
D. Paced breathing
B
Breathing Techniques:
Incorporating breathing into functional activities
Performance of functional activities within the limits of patient’s ventilatory capacity
A. Glossopharyngeal Breathing
B. Segmental Breathing
C. Dyspnea Relieving Positions (DRP’s)
D. Paced breathing
D
Breathing Techniques:
Positions to help ease breathlessness
* Semi-fowler’s or side-lying; sitting; standing
- Instruct patient to incorporate relaxed breathing or pursed-lip breathing exercises to control dyspnea
A. Glossopharyngeal Breathing
B. Segmental Breathing
C. Dyspnea Relieving Positions (DRP’s)
D. Paced breathing
C
Airway Clearance Techniques: Coughing
- Effective up to __ generation
- Effective cough: __,__,__
7th generation
sharp, deep, double cough
Phases of an effective cough:
Glottis closes and vocal cords tighten
Abdominal muscles contract; diaphragm elevates -> inc. intra-abdominal and intrathoracic pressures
A. Deep inhalation
B. Breath hold
C. Forceful expiration of air
B
Phases of an effective cough:
Deep inspiration
A. Deep inhalation
B. Breath hold
C. Forceful expiration of air
A
Phases of an effective cough:
Glottis opens
Explosive expiration
A. Deep inhalation
B. Breath hold
C. Forceful expiration of air
C
Strategies for an effective cough except:
A. Patient position: standing are the preferred positions for coughing; modify if needed
B. Demonstrate to the patient proper coughing
C. Feedback: palpate abdominal muscles (introduce muscle contraction during huffing)
D. Practice making “k” sound for closing of glottis
A. Patient position: sitting or leaning forward are the preferred positions for coughing; modify if needed
Identify the Manual-Assisted Coughing
- Placing a pillow or clean towel over an incision to splint the area during coughing in somewhat flexed posture
A. Coughing with Splinting
B. Self-assisted Coughing
C. Therapist-assisted Coughing
D. Tracheal Stimulation
A
Identify the Manual-Assisted Coughing
In sitting, the interlocked hands will assist
A. Coughing with Splinting
B. Self-assisted Coughing
C. Therapist-assisted Coughing
D. Tracheal Stimulation
B
Identify the Manual-Assisted Coughing
Aka Tracheal Tickle
- May be used for infants or disoriented patients who cannot follow instructions
- PT places 2 fingers at sternal notch and applies circular motion with pressure downward into the trachea -> to elicit reflexive cough
A. Coughing with Splinting
B. Self-assisted Coughing
C. Therapist-assisted Coughing
D. Tracheal Stimulation
D
Identify the Manual-Assisted Coughing
Inward & upward manual pressure on abdominal area during cough (semi-fowler’s or sitting)
A. Coughing with Splinting
B. Self-assisted Coughing
C. Therapist-assisted Coughing
D. Tracheal Stimulation
C
Identify the Airway Clearance Techniques:
- Aka Forced Expiratory Technique (FET)
- Based on optimal airflow and avoidance of cough to prevent premature airway collapse
A. Huffing
B. Active Cycle of Breathing Technique (ACBT)
C. Autogenic Drainage (AD)
D. Coughing
E. Manual-Assisted Coughing
A
Identify the Airway Clearance Techniques:
Steps:
- Mid- to Full inhalation – glottis remains open
- Air is “huffed” out – airy/breathy sound on “O”-shaped mouth
A. Huffing
B. Active Cycle of Breathing Technique (ACBT)
C. Autogenic Drainage (AD)
D. Coughing
E. Manual-Assisted Coughing
A
Identify the Airway Clearance Techniques:
An independent breathing exercise to clear secretions from airways
- It combines the forced expiratory technique, bronchial drainage* and manual techniques*
A. Huffing
B. Active Cycle of Breathing Technique (ACBT)
C. Autogenic Drainage (AD)
D. Coughing
E. Manual-Assisted Coughing
B
Identify the Airway Clearance Techniques:
Easy to learn, easy to teach
- Phases:
- Relaxed Diaphragmatic Breathing / Breathing Control Phase
- Thoracic Expansion Exercises
- Forced Exhalation/Expiratory Technique/Huffing (may be followed by coughing)
A. Huffing
B. Active Cycle of Breathing Technique (ACBT)
C. Autogenic Drainage (AD)
D. Coughing
E. Manual-Assisted Coughing
B
Identify the Airway Clearance Techniques:
Aka Ketchup-bottle technique; means “self-drainage
Has Phase 1 (Unsticking), Phase 2 (Collecting), Phase 3 (Evacuating)
A. Huffing
B. Active Cycle of Breathing Technique (ACBT)
C. Autogenic Drainage (AD)
D. Coughing
E. Manual-Assisted Coughing
C
Identify the phase of autogenic drainage
- loosen the mucus in small lower airways
- breathing at low volumes
A. Phase 1 (Unsticking)
B. Phase 2 (Collecting)
C. Phase 3 (Evacuating)
A
Identify the phase of autogenic drainage
- move mucus into the middle airways
- breathing at low to mid lung volumes
A. Phase 1 (Unsticking)
B. Phase 2 (Collecting)
C. Phase 3 (Evacuating)
B
Identify the phase of autogenic drainage
- move mucus out by breathing & huffing
- breathing at mid to high lung volumes
A. Phase 1 (Unsticking)
B. Phase 2 (Collecting)
C. Phase 3 (Evacuating)
C
Airway Clearance Techniques:
Active Cycle of Breathing Technique (ACBT)
Breathing Control = ___sec
Thoracic expansion = __ times
Huffing = max of __ times
Breathing Control = 20-30 sec
Thoracic expansion = 3-4 times
Huffing = max of 5x
Mechanical Techniques
- Ventilatory training emphasizing sustained maximum
inspirations (SMI) - Breathing against resistance during exhalation using a device (Flutter or Acapella)
A. Positive Expiratory Pressure (PEP)
B. Incentive Spirometry
C. Inspiratory Resistance Training
D. Inspiratory Expiratory Resistance Training
- B. Incentive Spirometry
- A. Positive Expiratory Pressure (PEP)
Mechanical Techniques
- Used to prevent premature airway closure during exhalation to promote secretion removal
- Use of pressure- or flow-based devices to provide
resistance to improve strength and endurance of muscles
of inspiration
A. Positive Expiratory Pressure (PEP)
B. Incentive Spirometry
C. Inspiratory Resistance Training
D. Inspiratory Expiratory Resistance Training
- A. Positive Expiratory Pressure (PEP)
- C. Inspiratory Resistance Training
Mechanical Techniques
Used to increase the volume of air inspired to prevent alveolar collapse and atelectasis in post-operative patients
A. Positive Expiratory Pressure (PEP)
B. Incentive Spirometry
C. Inspiratory Resistance Training
D. Inspiratory Expiratory Resistance Training
B. Incentive Spirometry
Postural Drainage / Bronchial Drainage Parameters
Positions are maintained for [] - [] minutes.
5 to 10 minutes
Postural Drainage / Bronchial Drainage Parameters
The total duration is [] - [] minutes, and proper breathing is incorporated all throughout the treatment.
45 - 60 minutes
The ff are Postural Drainage/Bronchial Drainage considerations, except
A. Severe hemoptysis
B. Pregnancy
C. Recent neurosurgery, especially Trendelenburg position
D. Arrhythmia, recent myocardial infarction
E. None
E. None
The ff are Postural Drainage/Bronchial Drainage considerations, except
A. Stable angina
B. Severe Hyper-/Hypo- tension
C. Nausea, vomiting
D. Untreated acute conditions
E. None
A. Stable angina
The ff are Postural Drainage/Bronchial Drainage considerations, except
A. Severe pulmonary edema
B. Large pleural effusion
C. Pulmonary embolism
D. Pneumothorax
E. None
E. None
Positions & Landmarks for Postural Drainage/Bronchial Drainage
Upper Lobes
- Directly over the nipple; supine with pillow under knees
- Under the clavicle; sit & leaning backward (30º)
- Above the scapula; sit & lean forward (30º)
A. Anterior apical
B. Posterior apical
C. Anterior
D. (L) Posterior
E. (R) Posterior
- C
- A
- B
Positions & Landmarks for Postural Drainage/Bronchial Drainage
Upper Lobes
- One quarter-prone from prone on (R), head & shoulders elevated 18 in (45º) 6:00 3:00 position
- Lies flat & one quarter-turn from
prone on (L) - Over (L) scapula
- Over (R) scapula
A. Anterior apical
B. Posterior apical
C. Anterior
D. (L) Posterior
E. (R) Posterior
- D
- E
- D
- E
Positions & Landmarks for Postural Drainage/Bronchial Drainage
- One quarter-turn from supine (R)
- One quarter-turn from supine on (L), 30º head-down
- Just under the breast
A. Lingula
B. Middle lobe
C. Both
D. Neither
- A
- B
- C
Positions & Landmarks for Postural Drainage/Bronchial Drainage
- Foot of bed elevated 16 in.
- One quarter-turn from supine on (R), 30º head-down
- One quarter-turn from supine (L)
A. Lingula
B. Middle lobe
C. Both
D. Neither
- C
- A
- B
Positions & Landmarks for Postural Drainage/Bronchial Drainage
Lower Lobes
- Lower portion of ribs
- Below the scapula; prone with pillow under the abdomen
- Foot of bed elevated 20 in.
A. Anterior basal
B. Posterior basal
C. Lateral basal
D. Superior
E. A and B only
F. A, B, and C only
- E
- D
- F
Positions & Landmarks for Postural Drainage/Bronchial Drainage
Lower Lobes
- Supine, 45º head-down
- Bed flat; prone with pillows under the hip
- Quarter-turn from prone
- Can also be positioned in sidelying
A. Anterior basal
B. Posterior basal
C. Lateral basal
D. Superior
E. A and B only
F. A, B, and C only
- A
- D
- C
- A
Positions & Landmarks for Postural Drainage/Bronchial Drainage
Lower Lobes
- Lies on contralateral side 45º head-down
- Lateral aspect of rib cage
- Prone, 45º head-down; with pillow under hips
A. Anterior basal
B. Posterior basal
C. Lateral basal
D. Superior
E. A and B only
F. A, B, and C only
- C
- C
- B
Manual Techniques used in Postural Drainage/Bronchial Drainage
- Vibratory action being applied by hands; usually applied during expiration
- More vigorous form of vibration during exhalation
- Usually done for 5-10 reps
- Hands are cupped & strikes area in an alternating rhythmic manner for ~3-5 mins
A. Percussion
B. Vibration
C. Shaking
D. B and C only
- B
- C
- D
- A
NOTE: Fracture, embolus, hemorrhage, tumor, open wound, and serious cardiovascular issues are contraindications of percussion.
It is an airway clearance and manual technique where various positions are used so gravity can aid in the drainage.
Postural drainage / Bronchial drainage
TRUE OR FALSE: In physiotherapy management for COVID-19 in the acute hospital setting, patients with significant functional limitations are recommended for PT referral with observance of airborne and droplet precautions.
True
PT referral with observance of airborne precautions (True or False)
- Mild Sx and/or pneumonia with co-existing respiratory or neuromuscular comorbidity and problems on secretion clearance
- Mild Sx and/or pneumonia with ability to clear secretions
- True
- False, mild Sx and/or pneumonia with inability to clear secretions
Clinical Practice Recommendations: Proposed PT Interventions (Yes or No)
From “Physiotherapy management for COVID-19 in the acute hospital setting”
- Airway clearance techniques
- Supine positioning of patients in ICU
- Breathing exercises
- CV endurance exercises
- Mobilization exercises
- Resistance exercises
- Yes
- No, prone positioning of patients in ICU
- Yes
- Yes
- Yes
- No
FITT: Cardiorespiratory Endurance Training (Yes or No)
- F: 2-3 days/wk
- RPE = 14-16 -> 17-18
- 20-60 mins/session
- 65-90% HRR
- No, 3-5 days/wk
- No, RPE = 11-13 -> 14-16
- Yes
- No, 40-85% HRR
FITT: Cardiorespiratory Endurance Training (Yes or No)
- 40-85% MHR
- Type: dynamic exercise of large muscle groups
- Walking
- Cycling
- Stair climbing
- No, 65-90% MHR
- Yes
- Yes
- Yes
- Yes
FITT: Strength & Muscle Endurance Training (Yes or No)
- F: 2-3 days/wk
- Volitional exhaustion on each set or stop 1 rep before volitional exhaustion
- Yes
- No, volitional exhaustion on each set or stop 2-3 reps before volitional exhaustion
FITT: Strength & Muscle Endurance Training (Yes or No)
- Low resistance & high repetition initially
- 1 set of 3-20 reps on 8-10 exercises involving major muscle groups
- Yes
- Yes
FITT for Mild COPD/Well-controlled asthma (Yes or No)
- RPE PSOB Scale of 5-6 (mod
intensity) initially, progress to 7-8 (vigorous intensity) - Resistance exercise
- Flexibility exercise
- Yes
- Yes
- Yes
FITT for Mild COPD/Well-controlled asthma (Yes or No)
- At least 3-5 days/wk
- Walking, stationary cycling
- 10-20 mins/day of continuous/ intermittent physical activity
- Yes
- Yes
- No, 20-60 mins/day of continuous/ intermittent physical activity
FITT for Mod to Severe COPD (Yes or No)
- At least 3-5 days/wk
- Resistance exercises
- Walking, stationary cycling
- Only done at specified intensity for few mins (intermittent exercise, ~5 mins)
- Yes
- Yes
- Yes
- Yes
FITT for Mod to Severe COPD (Yes or No)
- Flexibility exercise
- 40-60% peak work rates
- Dyspnea rating of 3 (mod SOB) initially, progress to 5 (strong or hard breathing)
- Yes
- No, 60-80% peak work rates
- Yes
Post-Operative Pulmonary PT management guidelines
- Position pt in semi-fowler’s position
- Object dislodged from the patient -> cover wound
- Incentive spirometry
A. S/P Thoracotomy/Post-Thoracic Surgery
B. Chest Tube Thoracostomy (CTT)
C. Both
D. Neither
- A
- B
- A
Post-Operative Pulmonary PT management guidelines
- Maintain drainage bottles lower than the point of insertion of P-tubes
- Adaptive/Compensatory bed mobility training
- Breathing exercises (DDBE, Segmental)
A. S/P Thoracotomy/Post-Thoracic Surgery
B. Chest Tube Thoracostomy (CTT)
C. Both
D. Neither
- B
- A
- A
Post-Operative Pulmonary PT management guidelines
- Pain-free AAROM of shoulder
- Active exercises of distal UE & LE (including ankle pumping)
- Object dislodged from the bottle -> make a knot on tube
A. S/P Thoracotomy/Post-Thoracic Surgery
B. Chest Tube Thoracostomy (CTT)
C. Both
D. Neither
- A
- A
- B
Post-Operative Pulmonary PT management guidelines
- Can do functional exercises (bed mob, amb) provided it is not painful on wound
- Huffing w/ splinting, progress to Coughing w/ splinting
- Graded ambulation training (bed-side ambulation progress to hallway ambulation)
A. S/P Thoracotomy/Post-Thoracic Surgery
B. Chest Tube Thoracostomy (CTT)
C. Both
D. Neither
- B
- A
- A
Post-Operative Pulmonary PT
- Thoracotomy for 1 lobe of lungs
- Thoracotomy for a segment of the lungs
- Small incision on chest wall usually for drainage purposes (for pneumothorax, hydrothorax, etc.)
- Thoracotomy for 1 side of lungs
A. Lobectomy
B. Pneumonectomy
C. Segmental
D. Thoracostomy
- A
- C
- D
- B
PT Associated with Respiratory Failure: Patients in ICU Considerations
Yes or No:
- Caution with attachments to avoid dislodging them
- Presence of palpable crepitations in the neck, face, chest, axilla or abdomen d/t diffused air in the soft tissues
- Yes
- Yes
PT Associated c Respiratory Failure: Patients on Mechanical Ventilation
Modified TF
A. The general guideline is PT treatments should be performed when the patient is not scheduled for
weaning initially.
B. During weaning, the patient must learn to incorporate proper breathing exercises taught by PT.
TT
NOTE: It is ideal to schedule PT exercises before weaning.
PT Associated c Respiratory Failure: Patients on Mechanical Ventilation
- Tube extends from mouth to trachea
- Liberating patient from mechanical ventilation (gradually)
- Tube extends from nose to trachea
- Tube is directly attached to trachea
A. Intubation: Nasotracheal
B. Intubation: Orotracheal
C. Intubation: Tracheostomy
D. Weaning
- B
- D
- A
- C
PT Associated with Respiratory Failure Evidence
TRUE OR FALSE: PT practice of airway clearance techniques is patient-centered with individualized assessment to determine clinical need.
True, treatment should be tailored to the specific presentation, with a range
of available techniques to use.
Modified TF: Patients in the ICU
A. Subcutaneous emphysema is a precursor to hemothorax.
B. If patient presents with this condition, PT management including PROM exercises will be postponed unless clearance is given by the
doctor.
FT
A: Subcutaneous emphysema is a precursor to pneumothorax.
Modified TF
A. Ventilator dependency is a result of respiratory failure.
B. Neck exercises are delayed for patients on mechanical ventilation.
TT
