Treatment justification (handbook) Flashcards
What is the vicious cycle of inactivity?
Feel breathless → Fear activities that make you breathless → Avoid activities that make you breathless → Do less activity → Muscles weaken → Muscles are insufficient and require more oxygen
How can positions of ease help a patient?
- Most breathless patients will benefit from upright, supported positions
- Encourages relaxation of the upper chest + shoulders and allow movement of the lower chest and abdomen.
- Should be comfortable, relaxed and in cases in severe dyspnoea - fully supported.
Positions of ease justification?
→position the respiratory muscles to work optimally
→ reduce extraneous muscle work (reduce demand on the respiratory system)
→ support the shoulder girdle to allow the accessory muscles to work more efficiently
→ forward leaning can improve the length-tension relationship of the diaphragm and reduces hyperinflation
By leaning fwd. in sititng/standing, abdominal contents raise anterior part of diaphragm, doming it which is thought to facilitate its contraction during inspiration
Justification for breathing control?
→ reduce the work of breathing
→ help relieve breathlessness at rest or on exertion
→ encourage a normal, efficient breathing pattern
→ improve ventilation of lung bases, therefore increasing gaseous exchange
→ encourage relaxation
(can use before or after exertion)
How can anxiety/stress impact breathing
- pt. may have raised shoulder girdles, flexed elbows and flexed torsos.
- postural manifestations and increased metabolic rate adds to overall work of breathing
- leads to a vicious cycle of stress, anxiety and breathlessness
How can relaxation help patients (justification)?
Can break down vicious cycle and aims to reduce muscular tension, improve the feeling of well-being and improve the patient’s ability to cope with certain situations.
Relaxation can:
- reduce sensation of breathlessness
- reduce HR, RR and BP
- reduce anxiety and improve sleep
Advice and education for increased WOB?
- should be carried out regularly
- ongoing practice and level of commitment
- if patient recognises than positioning and breathing control reduce dyspnoea in a safe environment, they are more likely to be confident to try the techniques at home.
- stress that rate of breathing doesn’t matter, as the patient gains control of their breathing, the rate will slow down on it’s own accord
What is a key goal for managing breathlessness?
e.g. through pacing - desensitising the patient to breathlessness during exercise - a key goal - can help prevent the vicious cycle of breathlessness and inactivity
Justification for pursed lip breathing?
Longer duration for exhalation.
Patients with emphysema have “floppy” airways, which have reduced elastic recoil.
Breathing out through pursed lips created a small back-pressure which can help to keep the airways open during exhalation, reducing hyperinflation
What is orthopnoea?
breathless when lying down flat
What am i feeling for on palpation of the thorax?
- symmetry of movement
- the quality of expansion during deep breath
- bronchial fremitus
What is the vicious cycle of retained sputum and repeated respiratory infection?
Infection → inflammation → airway damage → excess sputum
Justification of thoracic expansion exercises?
- assist in loosening and removing excess secretions
- aid re-expansion of lung tissue
- mobilise the thoracic cage
- improve ventilation and therefore gaseous exchange
Thoracic expansion impact on collateral channels?
Expanding the rib cage and hence the underlying lung, increases air flow through the collateral channels of ventilation.
This allows air to enter alveoli lying adjacent to collapsed or poorly ventilated alveoli and inflate them or get behind secretions to move them toward the mouth for expectoration.
How does FET expectorate sputum?
FET involves active expiration which increases the expiratory flow rate, producing shearing forced which loosen sputum from the airways.
Depends on depth of inspiration and speed of exhalation.
How is active exhalation different from passive exhalation?
Pleural pressure is positive which combines with the elastic recoil pressure to exert a large force on the alveoli.
The greatest alveolar pressure occurs from a maximal breath in.
How can EPP be used to mobilise secretions?
The point at which the pressure inside the airway is equal to the pressure outside it.
In active exhalation - pleural pressure is equal to pressure within airway - squeezes airway, and mobilises secretions away from the airway walls and towards the mouth.
How to clear secretions from smaller, peripheral airways?
Shallow inspiration
Long forced exhalation
How to clear secretions from larger, more proximal airways?
A large inhalation followed by rapid forced exhalation recommended.
Advantages of FET?
- uses less energy than a cough
- less painful than coughing post-op
- causes less bronchospasm than coughing
- does not generate high intra-thoracic pressures
Disadvantages of FET?
- some patients have difficulty learning
- if performed wrongly, technique is ineffective
How can the active cycle of breathing be adapted?
Can be adapted to individual patient’s needs.
E.g. particularly breathless patients may need to spend longer on breathing control, pt. with reduced lung volume may revisit thoracic expansion exercises multiple times before moving on to the FET
Supported cough justification?
- gives the patient confidence
- can limit tension on the wound from the increased intra-thoracic pressure and/or muscle work associated with coughing
Justification for oscillatory/vibratory effect?
(percussion + vibrations)
Loosens sputum away from airway walls, mobilising it mouth-wards.
→ thought to affect the viscoelastic properties of sputum, making it less thick and tenacious by stimulating secretion of airway surface liquid.
→ may stimulate cilial beating if freq is 3-17 Hz
Justification for rapid increase in expiratory flow?
(vibrations, shakes, compression)
→ particularly effective if well-times with the onset of expiration from peak inspiration
Justification for passive recoil of the chest wall improving inspiratory depth?
(vibrations, shakes, compresison)
→ timing of the technique is key to achieving this effect as pressure should be maintained throughout expiration and released immediately prior to inspiration
PEP justification?
- breathing out against resistance creates positive pressure within the airways
- this pressure acts as a “splint” to airways, keeping them open during exhalation
useful for COPD, CF, bronchiectasis as airways can become “floppy” and prone to collapse during exhalation (loss of elasticity) which can trap sputum in the small airways.
Oscillatory element (of OPEP) justification?
- may affect viscoelastic properties of sputum
- making it less think and tenacious by stimulating secretion of airway surface liquid
- the oscillations also produce variable levels of PEP which may help to shear mucous away from different parts of the airway
How does a mechanical in-exsufflator work?
Uses positive pressure to deliver a maximal lung inhalation followed by an abrupt switch to negative pressure.
Stimulates airflow changes that occur during a normal cough.
Advice and education for sputum clearance?
- cough out sputum
- regular airway clearance should be emphasised with goal of minimising risk of chest infections (vicious cycle)
- advise to use ACT on regular basis to loosen + remove secretions (half hourly when acutely unwell or once daily for chronic disease maintenance)
- regular fluid intake recommended
- check colour of sputum - report to GP
- gradually return to physical activity
- mobilisation on a regular basis
Exercise justification?
- induces spontaneous deep breathing
- associated with increased expiratory flow rates
- mobilisation of respiratory secretions
- can trigger coughing and improve expiratory muscle strength
Positions that should be encouraged in patient positioning?
- sitting upright
- standing
- side lying inclined towards prone
How can thoracic expansion be adapted for a patient who’s primary problem is reduced lung volume?
- end inspiratory hold (3s)
- sniff (after 3 seconds of holding)
- resistance (from therapist)
- over pressure
- incentive spirometer
Justification for end inspiratory holds?
Utilises collateral ventilation channels to open adjacent alveoli
Justification for sniff?
Further increases expansion which augments collateral ventilation.
“breathe in, hold hold hold, now sniff!”
Justification for incentive spirometer?
- encourages regular and effective thoracic expansion exercises
- offers visual feedback on the volume of their breath and/or the flow rate they have achieved
- can also be used to strengthen the diaphragm and intercostal muscles
How often should thoracic expansion exercises be completed?
At least 10 times every waking hour to be effective
Advice and education for lung volume?
- continue with appropriate positioning and thoracic expansion exercises independently
- TE 10 times and hour
- avoid lying down - try to sit up straight - support form pillows (in hosp. sit out for meals)
- promote exercise
How does mobilisation aid lung volume?
- combines upright posture (which encourages distribution of air to dependent regions) with natural deep breathing.
- exercise response should be elicited
- should be gradual, progressive and appropriate for individual’s functional capability
