sinus resp Flashcards
The four major pairs of sinuses are the:
Frontal sinuses (in the forehead)
Maxillary sinuses (behind the cheek bones)
Ethmoid sinuses (between the eyes)
Sphenoid sinuses (behind the eyes)
sinusitis, is
an inflammation of the sinuses and nasal passages.
A sinus infection can cause a headache or pressure in the eyes, nose, cheek area, or on one side of the head.
A person with a sinus infection may also have a cough, a fever, bad breath, and nasal congestion with thick nasal secretions.
Sinusitis is categorized as acute (sudden onset) or chronic (long term, the most common type).
Anatomy of the sinuses (also called paranasal sinuses):
skull contains four major
pairs of hollow air-filled-cavities called sinuses. Sinuses help insulate the skull, reduce its
weight, and allow the voice to resonate within it.
Ethmoid sinusitis (between/behind the eyes)
Acute sinusitis:
o Nasal congestion with discharge or postnasal drip (mucous drips down the
throat behind the nose)
o Pain or pressure around the inner corner of the eye or down one side of
the nose
o Headache in the temple or surrounding the eye
o Pain or pressure symptoms are worse when coughing, straining, or lying
on the back and better when the head is upright
o Fever is common
Chronic sinusitis:
o Chronic nasal discharge, obstruction, and low-grade discomfort across the
bridge of the nose
o Pain is worse in the late morning or when wearing glasses
o Chronic sore throat and bad breath
Maxillary sinusitis
(behind the cheek bones)
Acute sinusitis:
o Pain across the cheekbone, under or around the eye, or around the upper
teeth
o Pain or pressure on one side or both
o Tender, red, or swollen cheekbone
Chronic sinusitis
o Discomfort or pressure below the eye
o Chronic toothache
o Pain possibly worse with colds, flu, or allergies
o Increased discomfort throughout the day with increased cough at night
Frontal sinusitis
(behind forehead, one or both sides)
Acute sinusitis:
o Severe headaches in the forehead
o Fever is common
o Pain is worse when reclining and better with the head upright
o Nasal discharge or postnasal drip
Chronic sinusitis:
o Persistent, low-grade headache in the forehead
o History of trauma or damage to the sinus area
Sphenoid sinusitis
(behind the eyes)
Acute sinusitis:
o Deep headache with pain behind and on top of the head, across the
forehead, and behind the eye
o Fever is common
o Pain is worse when lying on the back or bending forward
o Double vision or vision disturbances if pressure extends into the brain
o Nasal discharge or postnasal drip
Chronic sinusitis:
o Low-grade general headache is common
Sinusitis Assessment
HISTORY:
Do you have any allergies? Are you on medications? Have you been dx by your doctor? Do you have a history of sinusitis? Where do you feel the pain? Do you have a fever? Cold? Flu? Have you had any dental work recently? Abscesses? Do you have any nasal discharge?
Sinusitis Assessment
OBSERVATION:
Swelling over sinuses/eyes/runny nose
Squinting eyes
Breathing through mouth
Postural abnormalities in c/s or t/s possible
Sinusitis Assessment
PALPATION:
Gentle palpation over the frontal in the orbit of eye (superiorly) and maxillary sinuses
under the zygomatic arch can be used to detect sinusits. There may be possible
tenderness, heat and swelling.
Sinusitis Assessment
MOVEMENT:
c/spine arom/prom etc may be used to detect OA dysfunction. Sympathetic innervation
to sinuses in the upper t/spine pass through the c/spine ganglion.
Sinusitis Assessment
NEUROLOGICAL:
DDX between other headaches, trigger points and facet or nerve impingement.
Decompression, compression and sperlings tests.
Sinusitis Assessment
REFERED PAIN:
There may be refered pain in the eyes, ears, neck, temples, teeth, cheeks back of head.
Sinusitis Assessment
SPECIAL TESTS:
Transillumination test
Palpation
SINUSITIS TREATMENT GOALS:
Relieve obstruction and pain Increase venous and lymphatic flow Effect reflex change Improve mucociliary clearance Treatment to all sinuses to assist drainage of all sinuses (although only one sinus may be infected.)
Chronic Hyperventilation
Habitual breathing rate in excess of 18 breaths per minute
Chronic Hyperventilation
Signs and symptoms
Erratic heartbeats and/or chest pain
Breathless “attacks” at rest for no reason
Frequent sighing and/or yawning (average is once every 5-10 minutes)
Irritable coughing and chest tightness
Dizziness and “spaced out” feelings
“pins and needles” or numbness in lips, fingertips and toes
Gut disturbances – indigestion, nausea, wind or irritable bowel
Muscles aches, pains, or tremors
Tiredness, weakness, disturbed sleep, and nightmares
Phobias
Clammy hands, flushed face, feelings of high anxiety
Sexual problems
Normal, easy breathing
12 regular breaths/minute (10-14 acceptable)
70-80% of the work of respiration is done by the diaphragm
Accessory muscles of respiration are used during or shortly after extreme effort
or stress
Inspiration: 2-3 seconds
Expiration: 3-4 seconds
Little or no upper chest movement
Nose breathing
This is reversed in chronic hyperventilators
Physiological changes related to Hyperventilation;
Immediate
Adrenalin pours into the bloodstream
Heart and breathing rates speed up Muscles become tense
Eyesight and hearing sharpen
The pain threshold drops and pain is less intense
Physiological changes related to Hyperventilation;
Chronic
More carbon dioxide is breathed out; carbon dioxide levels in the blood start to
drop
Normal pH becomes more alkaline = respiratory alkalosis
Smooth muscle cells are galvanized into action by lowered carbon dioxide levels,
which leads to tightening or constriction of the blood vessels
The heart and pulses start pounding; the hyperventilator may feel panic stricken,
with palpitations and chest pain
The brain may have its oxygen supply cut by as much as 50%
Habitual mouth breathers develop irritable upper airways, with the risk of repeated
throat infections
A very common sign of hyperventilation is repeated throat clearing – the
AAHHRRRRMMMMM bug
- Triggers increased histamine levels in the blood – sweaty palms and armpits,
clammy skin, flushed face are all signs of this
- response to pain is amplified- stiffness in mm and joints feels rheumatoid pain
-heart disease-type symptoms, like tight chest pain and pounding pulses.
People with allergies such as hayfever, skin rashes, food intolerances, or asthma
find their symptoms much worse
Mental fuzziness, headaches, or loss of concentration can erode self-confidence,
especially if work suffers
Making love can be a nightmare – for both partners – if the “heavy breathing” that
precedes orgasm leads to a panic attack
Vivid dreams, nightmares, and disturbed sleep patterns commonly accompany
hyperventilation – creates distress 24/7
Treating Hyperventilation
“BETTER”
Breath retraining
Esteem
Total body relaxation
Talk
Exercise
Rest and sleep
1) Becoming aware of faulty breathing problems
2) Learning to nose-diaphragm breathe
3) Suppressing upper-chest movement during normal breathing
4) Reducing breathing to a slow, even, rhythmic rate
Treating Hyperventilation
LUNG HO Salute
Place your dominant hand on your abdomen, between the lower ribs and
umbilicus
Other hand on the sternum; just below the clavicles
Take a deep breath
Notice which part of your chest moved first? Which part moved the most? Did
you breathe through your nose or your mouth?
If you breathed in through your nose, your abdomen expanded first, and you felt almost
no upper-chest movement, you are a good breather.
If you breathed in fast through your mouth, your upper chest heaved first, and you felt
little or no movement, or your abdomen drew IN, you are a weak breather
Bronchitis is
an inflammation of the bronchi
- Swollen and filled with extra sticky mucus
- partially blocks airflow in and out of lungs
Acute bronchitis usually caused by
viruses.(same as usually give you common cold)
How many breaths per minute do you take?
12 regular breaths/minute (10-14 acceptable)
What is the average respiratory rate for an adult at rest?
The typical respiratory rate for a healthy adult at rest is 12–20 breaths per minute. Average resting respiratory rates by age are: birth to 6 weeks: 30–60 breaths per minute. 6 months: 25–40 breaths per minute.
Breathing Sequence
- diaphragm contracts
- lateral costal expansion as the ribs move up and out
- upper chest rises (accessory respiratory muscles should be at rest)
The primary inspiratory muscles are
the external intercostals and the diaphragm
The muscles of inspiration elevate the ribs and sternum
The primary expiratory muscles are
The internal intercostals, intercostalis intimi and subcostals.
muscles of expiration depress the ribs and sternum
The accessory inspiratory muscles are
the sternomastoid, the scalenus anterior, medius and posterior, the pectoralis major and minor, the inferior fibres of serratus anterior and latissimus dorsi, the serratus posterior anterior may help in inspiration also the iliocostalis cervicis
The accessory expiratory muscles are
the abdominal muscles: rectus, abdominis, external oblique, internal oblique and transversus abdominis. And in the thoracolumbar region the lowest fibres of iliocostalis and longissimus, the serratus posterior inferior and quadratus lumborum.
Indications for
Respiratory Assessment and Treatment
- COPD
- post-operation
- client who has been confined to bedrest
- abnormalities / decreased mobility of thorax
- postural disorders (extreme kyphosis, scoliosis)
- voice training, breath control (singers, actors)
- client who’s trying to quit smoking
- allergies
- chronic pain
- improved breathing awareness
- post traumatic stress disorder
- athletes
CAUTION: with advanced COPD, the therapist must have MD’s referral to proceed
with treatment
CI’s for
Respiratory Assessment and Treatment
: fever, sudden changes in guest’s condition
Considerations for treatment for a client
with advanced Respiratory Illness
History questions
CIs and precautions (Rattray & Ludwig P 881, 893 and 904)
Pre-treatment hydrotherapy
During treatment hydrotherapy
Negotiate long term and short term goals
Positioning for treatment, is there any modifications required? Bolsters? Slanted
table? Other?
Is postural drainage appropriate? If so, perform the assessment to identify areas
that need to be addressed.
Treatment techniques and modifications to treatment
-Durations: if client is fragile, shorter tx may be appropriate
-Tapotement/shaking/vibrations/rib springing etc appropriate?
-Breathing exercises/training
-Productive cough? As appropriate
Post-treatment hydrotherapy
Remedial exercise recommendations (consider cardiac health)
Respiratory System – Assessment protocol
HISTORY
Diagnosis, when did they last see physician, have they been cleared for tx Are they seeing other health practitioners (respiratory therapist, physiotherapist etc) Medications Episodes of dyspnea Cardiac health history Current physical exercise ADLs Cough, is it productive? Triggers? How long have they had the condition? Xrays? Areas of pain, soreness or discomfort? Which lobe is affected? Fever? Other symptoms?
Respiratory System – Assessment protocol
OBSERVATION
Rate, rhythm, and effort of breathing
Colour – nail beds, lips (periphery, central)
Mouth or nose breathing
Jugular vein engorgement – associated with increased venous pressure and a
sign of potential right ventricular heart failure
Shape of chest and the way it moves – location of breath
Musculature – tone
Posture – head forward? t/s kyphosis, rounded shoulders?
Shape and movement of nostrils
Shape of lips (smaller upper lip may indicate chronic hyperventilator)
Pursed lip breathing – may be COPD
Shape of face – longer lower third may indicate chronic hyperventilator
Compare one side to the other, work proximal to distal
Respiratory System – Assessment protocol
PALPATION
Identify areas of tenderness, hypertonicity, atrophy – note them down
Palpate spine (feel for hyperlordosis/hyperkyphosis)
Assess abnormalities in ribs, spine etc
Elicit vocal or tactile fremitus
Respiratory System – Assessment protocol
MOVEMENT
Assess rib excursion (if using measuring tape, note down measurements)
C/Spine and T/Spine
Respiratory System – Assessment protocol
NEUROLOGICAL
Nerve entrapment TOS from overuse of accessory respiratory muscles
Respiratory System – Assessment protocol
REFERRED PAIN
Trigger points from overuse of accessory respiratory muscles
Respiratory System – Assessment protocol
SPECIAL TESTS
Rib excursion Lobe expansion test Percussion Auscultation Vocal/tactile fremitis
RIB EXCURSION
Measure at the axilla, xiphoid process at the top of the inhale and at the end of the
exhale with a tape measurement. Note that the measurements should be 3-7 cm apart
for the inhale to exhale at each location.
LOBE EXPANSION TEST
notes adapted from Therapeutic Exercise text – please refer to this text for a complete
discussion of respiratory assessment
The purpose of this test is to assess the symmetry of the moving chest to consider the
mobility of the thorax. It may indicate indirectly what areas of the lung may be or may
not be responding.
Check upper lobe expansion
Stand facing your guest
Tips of thumbs at midsternal line, at sternal notch
Fingers above clavicles
Guest fully exhales, then inhales deeply
Check middle lobe expansion
Face your guest
Place tips of thumbs at xyphoid, extend fingers laterally around the ribs
Guest exhales fully, deep inhalation
Check lower lobe expansion
Go to the back of your guest
Place tips of your thumbs along their back, at the spinous processes (lower T/S);
extend your fingers around their ribs
Guest exhales fully, deep inhalation
PERCUSSION TEST
Assesses lung density – i.e., air to solid ration in the lungs. Determines whether
underlying tissues are air-filled, fluid-filled or solid. Only penetrates 5-7 cm –
can’t detect deep-seated lesions
Place middle finger of non-dominant hand flat against chest wall along an
intercostals space
Use tip of the middle finger of the dominant hand to tap firmly on the finger
positioned along the intercostals space
Repeat at several points on right and left, anterior and posterior
Percussion produces resonance – pitch varies with density of underlying tissue
AUSCULTATION
Listening to breath sounds -> indicate movement of air in the airways of the lungs during
inspiration/expiration
Use a stethoscope
Allows therapist to identify where congestion exists, so that postural drainage can
be performed properly
Allows therapist to evaluate whether postural drainage has been
properly/effectively performed
Guest sits in comfortable, relaxed position
Stethoscope is placed directly on guest’s skin, anterior and posterior chest wall
Follow a PATTERN along the right and left sides of the chest wall,
anterior/posterior, so that you can accurately re-evaluate
Ask your guest to breathe in deeply and out quickly through the mouth as you
move the stethoscope from point to point
Record your findings: note quality, intensity, and pitch
See text for detailed explanation of breath sounds
Deep breath through mouth – follow percussion path
Location, pitch and intensity ** note them down!
Normal vs abnormal and adventitious (extra): e.g. crackles, wheezes
VOCAL/TACTILE FREMITIS
Place palms of your hands lightly on the chest wall
Ask the guest to speak a few words or repeat “99” or blue balloons
Normal: fremitus (vibration) is felt uniformly on the chest wall
Abnormal: fremitus increases in the presence of secretions in the airways;
decreases/absent when air is trapped (obstructed airways
Goals of Breathing Exercises
Improve or redistribute ventilation
Increase the effectiveness of the cough mechanism and promote airway
clearance
Prevent post-operative pulmonary complications
Improve the strength, endurance, and coordination of the muscles of ventilation
Maintain or improve chest and thoracic spine mobility
Correct inefficient or abnormal breathing patterns and decrease the work of
breathing
Promote relaxation and relieve stress
Teach the client how to deal with episodes of dyspnea
Improve a client’s overall functional capacity for ADLs
Breathing Exercises
Clients should be in comfortable, relaxed positions with loose clothing on. (no tight bras,
belts etc).
Advise the client to never force or prolong expiration – the breath should be
relaxed and passive.
Work in cycles of 3-4 breaths at one time.
Try to bring awareness to natural breathing pattern:
1)abdominal
2)lateral costal
3)chest
Bring awareness to habit of initiating breathing with accessory muscles and upper chest
(if they do so). I.e. during inspiration, upper chest should be “quiet”.
May be most effective to do breath training after a relaxing massage treatment.
Diaphragmatic Breathing
First the therapist uses their hand on the rectus abdominus, below the anterior
costal margin, then the client does this.
Breath in through the nose, out through the mouth
Practice in different positions of their ADLs
Segmental Breathing
This is most effective when used to emphasize expansion of the problem areas of the
lung and chest wall. E.g. because of pain and muscle guarding after surgery, collapsed
lung, pneumonia, prolonged bed rest, etc.
Lateral Costal Expansion:
As the client breaths out, place a firm downward pressure into the ribs with the
palms of your hands.
Just prior to inspiration, apply a quick downward and inward stretch to the chest.
This places a quick stretch on the external intercostals to facilitate their
contraction.
These muscles move the ribs outward and upward during inspiration.
Posterior Basal Expansion
Repeat with hands over the posterior aspects of the lower ribs (especially important for
bedridden post-surgical clients, who has to be in a semi-upright position for an extended
period of time).
Right Middle Lobe or Lingula Expansion
Repeat with your hands just below the axilla (right or left)
Apical Expansion
Apply pressure, usually unilaterally, below the clavicle with the fingertips.
Pursed Lip Breathing
Creates a back pressure in the airways
Taught to clients with COPD to help deal with shortness of breath
Must not force the expiration
The client is taught not to contract abdomen – place your hands here to detect
contraction
Instruct the client to breathe in slowly and deeply
Then have them loosely purse lips and exhale. (use the bending the flame analogy)
Shortness of Breath Attack During a Treatment
Have your client lean forward in a supported sitting position.
This stimulates diaphragmatic breathing – the viscera drops forward so the diaphragm
can descend easier
Teaching an Effective Cough
The client sits or leans forward with their neck slightly flexed
Therapist demonstrates: take a deep diaphragmatic breath and demonstrate 2
short coughs, contracting the abdomen
The client puts their hands on their abdomen and takes 3 “huffs” on
expiration/exhalation, feeling his/her abdomen contract
The client practices making the “k” sound to experience tightening of the vocal
cords and closing of the glottis
Ask the client to take a deep but relaxed inspiration/inhalation, followed by a
double cough – the 2nd cough is more productive
NOTE: no gasping should occur
Manual Assisted Cough
Self-Assisted
Sitting position: the client crosses arms over abdomen
After a deep breath in, push up and in on the abdomen, lean forward and try to cough
Therapist Assisted
Therapist stands behind the seated client, with heel of one hand on the epigastric area
of the client’s abdomen; the other hand is on top of the first
After a deep inhale, abdomen is compressed upward and inward
Respiratory Treatment Goals
- Reduce workload of breathing
- Ease removal of accumulated bronchial secretions and phlegm
- Improve lymphatic and venous flow
- Improve arterial circulation to carry immune system products to lungs
- Restore and maintain thoracic mobility
- Decrease hypertonicity of accessory muscles of respiration
- Reduce pain and discomfort by decreasing muscle spasm, TP’s and adhesions
- Identify and treat chronic hyperventilation
- Increase client’s awareness of “good breather”
Postural Drainage Technique
Prior to performing postural drainage technique you need to:
1. Rule out any CI’s to performing postural drainage (see below)
2. identify which lobe(s) are/is affected with patient case history and special tests
(vocal/tactile fremitis, percussion or auscultation)
3. Teach patient to diaphragmatically breath and cough effectively
4. Set up a signal for your patient to tell you to stop if they need a break
5. Set up pillowing/table for the correct position, have garbage and tissues near by
Contraindications to Percussion:
Osteoporosis
Malignancy (and/or potential malignancy)
Inflammation in the area to be treated/percussed
Recent trauma in the area to be percussed
Pain during application of percussion
