W6 Flashcards
What is dysfunctional breathing?
An alteration in the normal biomechanical patterns of breathing that results in intermittent or chronic symptoms which may be respiratory and/or non-respiratory
What are the types of dysfunctional breathing patterns?
- Hyperventilation
- Hypoventilation
- Erratic
- Thoracic dominant
- Asynchrony
What are the aetiologies of dysfunctional breathing (causes)?
- Respiratory disease (e.g. COPD, bronchiectasis, asthma etc.)
- Physiological condition (metabolic conditions with resp compensation)
- Muscle dysfunction
- Psychological factors (anxiety, stress)
What is the typical pattern of dysfunctional breathing in obstructive lung disease? (flow chart)
Airflow limitation –> gas trapping –> hyperinflation of lungs –> increase AP diameter of chest (barrel chest) –> flattened diaphragm –> V/Q mismatch
What is the typical pattern of dysfunctional breathing specifically in restrictive lung disease? (flow chart)
Decreased lung compliance –> reduced FRC, TLC, FVC –> rapid and shallow breathing
Subjective assessment of dysfunctional breathing questions
- Description of symptoms
- Awareness of own breathing pattern
- Triggers
- Easing factors
- Recovery techniques
- Air hunger signs (yawning/sighing/tingling hands and feet)
-Sleep - Voice changes
- Nasal symptoms (bloked/runny)
- PMHx, SHx
Objective assessment of dysfunctional breathing things to LOOK at
- Breathing at rest
- Breathing during exercise/functional task
- Posture
Objective assessment of dysfunctional breathing things to FEEL
- Diaphragmatic excursion (thoracic expansion)
- Basal expansion
Objective assessment of dysfunctional breathing things to LISTEN to
- Sounds during inspiration and expiration
- Auscultation
- Cough
What are the outcome measures of dysfunctional breathing?
- Nijmegen questionnaire
- Breathing Pattern Assessment Tool (BPAT) (>4 indicates dysfunctional)
- Self Evaluation of Breathing Questionnaire (SEBQ)
- Manual assessment of respiratory motion (MARM) (Thoracic and abdominal movements)
- Breath-hold test (after exhale, <20 sec indicates dysfunction)
What is dyspnea?
A subjective experience of breathing discomfort often associated with the sensation of a lack of air
What are the stages in an assessment of dyspnea?
- Sensory perceptual experience (Intensity, quality descriptors)
- Affective distress (anxious, depresses, frustrated etc.)
- Impact (functional, emotional, QOL)
The negative cycle of dyspnea and activity
Cardiorespiratory disease –> Breathlessness –> Inactivity –> Muscle deconditioning –> Excess lactate/CO2 production –> Breathlessness –> ongoing cycle increasing in severity
What are some management techniques for the breathless patient? (list 6)
- Breathing Control
- Pursed lip breathing
- Inspiratory Muscle Training (IMT)
- Positioning
- Hand held fan
- Activity pacing and energy conservation
What are some techniques for activity pacing and energy conservation in the breathless patient?
- Seated hygiene (move mirror down at sink, shower stool)
- Seated dressing
- Kitchen organisation (move frequently used items to low levels on shelves)
What is a hand-held fan used for in the breathless patient?
- Increased airflow decreasing WOB
- Provides sensory stimulation of airflow (reducing anxiety)
- Possibly stimulates trigeminal nerve
- Cooler temperature of air
Steps to teaching Breathing Control (BC)
- Focus on relaxing the arms, shoulders and chest
- Place hand on upper abdomen to feel gentle rise and fall with each breath
- Focus on relaxing throughout
Steps to teaching pursed lips breathing
- Inhale slowly through nose
- Purse your lips as if you are going to whistle
- Exhale slowly whilst keeping your lips pursed
- Do not force lungs to empty completely
What is the purpose of inspiratory muscle training (IMT)?
Reduce the perception of breathlessness by modulating central neural processing
Steps to teaching IMT
- Use a 30-60% maximal inspiratory pressure on the device
- 6-10 breaths x3-4 sets
- 2x per day, every 2nd day
- Complete for 5-8 weeks
What are some positions for reducing dyspnea?
- Forwards lean “tripod” (fixates shoulder girdle)
- Lean back against wall
- Arms on hips
- Prop arms out to side with pillows in bed
What is asthma?
Chronic obstructive respiratory disease due to chronic inflammation of the airways
What are the aetiologies of asthma?
- Atopic (allergen triggered)
- Nonatopic (exercise, viral infection etc.)
What occurs during an asthma attack? (hyperresponsiveness flow chart)
Stimulus –> hyperresponsiveness –> smooth muscle contraction of airways –> bronchoconstriction
What occurs during an asthma attack? (inflammatory flow chart)
Stimulus –> airway inflammation –>
- Mucosal hypertrophy/inflammation
- Airway oedema
- Inflammatory cascade
What are some symptoms of an asthma attack
- Wheezing
- SOB
- Increased WOB
- Increased RR
- Accessory muscle use
- Cough with increased sputum
What are the effects of an asthma attack on the respiratory system
- Decreased expiratory flow
- Premature airway collapse
- Increased airway resistance
- Increased static lung volumes
- Hypoxaemia
- Excessive sputum production
What are some signs and symptoms of severe asthma?
- Increased SOB
- Increased WOB
- Ongoing attack for hours/days despite bronchodilator use
- Weakened respiratory muscles
- Type II respiratory failure (Respiratory acidosis and hypoxaemia)
What are the goals of asthma management?
- Achieve best lung function
- Maintain best lung functions: avoid triggers, medication
- Action plan (for attacks, and for keeping stable)
- Education and frequent reviews
What are the main types of medications for asthma (2 types)
Relievers - Bronchodilators
Preventers - Corticosteroids
What is a bronchodilator?
Reliever medication, acting to relax and therefore dilate the airways, reducing airflow restriction
What is a croticosteroid?
Preventative medication to reduce inflammation of the airways, through reducing the amount of mucous that is produced by cells
What are some examples of bronchodilators?
SABAs: Salbutamol (Ventolin), Terbutaline (Bricanyl)
LABAs: Salmeterol (Servent), anti-cholinergics (ipratropium bromide)
What are some examples of corticosteroids?
Inhaled: Beclomethasone (Ovar), Budesonide (Pulmicort), Flixotide (Fluticasone)
oral: Prednisolone, Prednisone
What are some examples of combined asthma medications (bronchodilator and corticosteroid)
- Seretide
- Symbicort
What are some medical management strategies for acute asthma
- Oxygen therapy (if hypoxic)
- SABA (via inhaler with spacer)
- Nebulised SABA
- Nebulised ipratropium bromide (anti-cholinergic)
- Oral steroids
- IV steroids
- Adrenaline (if anaphylactic reaction)
Why should a spacer be used with an inhaler?
The use of an inhaler increased the dose of drug that is deposited in the lungs, as opposed to the mouth when used only with the inhaler
What are the goals of physiotherapy for patients with asthma?
- Management of dyspnoea
- Inhaler technique
- Position and breathing techniques
- Airway clearance
- Exercise
- Pulmonary rehabilitation
What is aerosol therapy
Delivery of a therapeutic dose of desired drug in the form of inspired particles. The particle size may be small enough to enter even alveoli. This may involve use of an inhaler, or nebuliser.
What are the advantages of aerosol therapy?
- Smaller dose of drug needed
- Fewer side effects
- Rapid onset of action
- Can include antibiotics/antifungals/saline which are otherwise not possible with inhalers
What is nebulised saline used for?
Either normal or hypertonic saline, used to rehydrate the sol layer, and reduce sputum viscosity
What are mucolytics used for?
Aid in sputum expectoration by reducing viscosity. May be used in nebulised form or dry powder inhaled form.
How does a nebuliser work?
- Compressed gas exits into a chamber through a narrow constriction, creating negative pressure around the exit
- This negative pressure draws fluid up a capillary which opens next to the exit
- The gas source then shatters the fluid as it exits the capillary, creating an aerosol
- The aerosol is then inhaled through a mouth piece
What are the oxygen/air flow settings for nebulisers
Can use on O2 –> 6-8L/min
OR
Can use on Air –> 6-8L/min
OR
Can use with portable compressor air –> >6L/min
- If supplementary O2 required, use on O2 in hospital, or use on compressed air with portable O2 via NP at home
What is the procedure for prescribing a nebuliser?
- Pt sitting upright and well supported
- 3-5ml of drug placed into nebuliser acorn (possibly mixed with saline to reach volume)
- Pt breaths normally through mouth
- 5-8 minutes until all drug is used (machine will become noisier when finished)
What is bronchiectasis?
Chronic obstructive respiratory condition whereby there is abnormal and irreversible dilation of the bronchi. This is due to elastic and muscular tissue being destroyed through chronic inflammation.W
What are the 3 mechanism of bronchiectasis?
- Congenital disorders
- Chronic infections
- Airway obstruction (excessive mucus, foreign body, tumour)
What are some symptoms of bronchiectasis?
- Chronic moist/productive cough
- Recurrent/persistent bacterial chest infections
- Added chest sounds (crackles)
- GORD history
- Childhood illness history
- Dyspnoea
- Chest wall pain
- Haemoptysis (blood in sputum) (late stage)
- Finger/toe clubbing (late stage)
What investigations should take place for diagnosis of bronchiectasis?
CXR - “tram lines” visible (indicating dilated airway filled with sputum)
High resolution CT (shows dilation of bronchial walls)
Pulmonary function testing
Sputum culture
ABGs
What are some options for medical management of bronchiectasis?
- Antibiotic therapy
- Lobectomy (if localised disease)
- Lung transplant (if widespread)
What are the goals of physiotherapy in patients with bronchiectasis?
Prevention of infections:
- Compensation strategies for decreased muco-ciliary clearance
- Prevent accumulation of secretions
Treat airway obstruction (exacerbations):
- Decrease hyperinflation
- Ensure adequate oxygenation
- Positioning
Rehabilitation:
- Education (behavioural changes)
- Airway clearance techniques
- Pelvic floor retraining
- Increase exercise tolerance
