W7 Flashcards

Question

How to teach AD

Answer 1

1. Clear nose and throat 2. Assist patient to bring chest shape as back to normal as possible if they have barrel chest etc. 3. Position them for ventilation and good to get enough expiratory flow 4. Place your hands on patient 5. 3 x deep breaths to start 6. Breathe in through nose slowly, pause for 2-4 seconds at level of sputum 7. Breath out through nose  fast enough to hear crackles and slow enough to prevent airways compression 8. Follow diagram  when you start to hear crackles at peak inspiration then you know you are ready to move up a level of inspiration 9. Guide patient physically and verbally

Answer 2

ACT that provides constant back pressure to airways during expiration via mask or mouthpiece to splint them open

Answer 3

Inspiration slightly larger than normal tidal volume, usually with end inspiratory pause to allow homogenous filling Slightly active expiration against resistance of Mask or mouthpiece (approx 3 seconds  adjust resistance until this time frame is achieved) - Longer than 3 = resistance too high - Less than 3 = resistance too low FET

Answer 4

Increasing gas behind mucus through collateral ventilation (pushes mucus out of the lungs and opens up regions that would otherwise be closed off) Prevents airway collapse by splinting them open during expiration Increases FRC temporarily

Answer 5

Untreated pneumothorax, Acute Sinusitis, Recent Facial/Oral/Skull surgery or trauma, Epistaxis (nose- bleed), massive haemoptysis, middle ear pathology, extensive and/or large bullae or cysts, recent oesophageal or lung surgery, cognitive impaired/confused, haemodynamic instability, increased intra-cranial pressure, severe bronchospasm

Answer 6

Positioning for ventilating certain lobes may need to change to non-gravity dependent devices

Answer 7

1. Patient sits upright with elbows on table encouraging a forward lean 2. Raise shoulders to protect apices from collapse 3. Mask firmly over nose and mouth 4. Slightly larger volumes than TV w/ pause after for inspiration then expiration against resistance for 3 seconds 5. Complete 12-15 breaths  after 6-8 it looks like a bigger breath but their FRC is just bigger 6. Take mask off and perform FET

Answer 8

Same protocol as normal PEP but MUST have shoulders raised Inhale to TLC Pressures of 40-100cm Can stimulate coughing Use this in patients with highly collapsible airways

Answer 9

Combines air oscillation in airways during expiration with normal PEP

Answer 10

Oscillating positive expiratory pressure which prevents premature airway closure Vibrates the airway wall at a therapeutic range Loosens mucus from airway wall Increases the ASL height Decreases the viscosity of sputum

Answer 11

A GRAVITY DEPENDENT oscillating PEP device 1. Patient must sit upright with flutter just below horizontal but not upside down 2. Put mouthpiece in mouth, between teeth and close lips tightly around 3. Slightly larger volumes than tidal breathing in through nose, with end inspiratory pause 4. Slightly active expiration against resistance last approximately 3 secs (aiming for vibrations to be felt in abdomen) 5. CHEEKS MUST BE STIFF so vibrations occur in lungs and not cheeks 6. 10-15 breaths 7. Turn flutter upside down and perform FET using valve as a huff tube 8. Suppress cough until finished cycle

Answer 12

NON-GRAVITY DEPENDENT oscillating PEP device Same process as flutter but you can perform it lying down 1. Patient sits in position best to increase ventilation in targeted area 2. Put mouthpiece in mouth, between teeth and close lips tightly around 3. Slightly larger volumes than tidal breathing in through nose, with end inspiratory pause 4. Slightly active expiration against resistance last approximately 3 secs (aiming for vibrations to be felt in the abdomen, change the dial on end to adjust) 5. On expiration make sure to keep cheeks stiff so vibrations occur in lungs and not cheeks. 6. 10-15 breaths 7. Take acapella out of mouth and perform FET using a huff tube 8. Suppress cough until finished cycle

Answer 13

Set up: - Length of suction tubing 30 - 50 cm long - A plastic container - A column of 5-10 cm of water - Manometer - attach to tubing with large PEP resistor and connector to ensure correct expiratory pressure Instructions 1. Patient sits leaning forward 2. Elbows supported on table 3. Makes sure to have tubing at the bottom of container and put other end in mouth, between teeth and close lips tightly around to create a seal 4. Slightly larger volumes than tidal breathing in through nose, end inspiratory pause. 5. Slightly active expiration against resistance (aiming for mid expiratory pressure of 10- 20cmH2O) 6. 10-15 breaths Take out of mouth and perform FET

Answer 14

Use currently contentious: ‘Medical device’ not approved by TGA as is home made No infection control standards PEP levels not always measured by therapist Now TGA approved version for sale PLEASE: Check with supervisors for practice at each institution

Answer 15

Increase patients FRC and put some moisture into them before trying ACTs

Answer 16

Can decrease treatment burden, and has dual benefits – increasing aerobic capacity, physical activity potentially training the muscles of respiration. If combined with FET may have same effects to Traditional ACT (evidence is for short-term only) If using for ACT - ↑ RR & recruitment of lung units with ↓ V/Q ratios Exercise if added to traditional ACT can be done prior to ACT or interspersed with it.

Answer 17

Rationale is that exercise of a moderate intensity reduces epithelial sodium conductance and nasal potential difference in people with CF - Possibly then increases the water in the mucus and therefore improving MCC. Through mechanical vibration – oscillation – translation the ground force reactions from walk/run Through hyperventilation – Increase TV and resp flow (seen in treadmill use)- increases PEF 10% > PIF and reduces sputum mechanical impedance. Thus may increase movement of secretions towards the head

Answer 18

Precautions = Breathlessness, desaturation, fatigue. Contraindications = as per all exercise Modifications = can change intensity, frequency, aerobic or strength to suit the patient

Answer 19

Postural Drainage/Gravity Assisted Drainage refers to the use of gravity and accurate body positioning to drain secretions from a specific segment of the lung. The lobe/segment of lung which has retained secretions is positioned appropriately for drainage with bed mechanics and pillows to support patient BAD LUNG UP, GOOD LUNG DOWN

Answer 20

Believed that by positioning body in a certain lying or semi-lying position you can utilise gravity to mobilise secretions from more peripheral airways centrally

Answer 21

Vertigo, Pregnancy, Fracture ribs

Answer 22

Not immediately prior to or following a meal, Increased ICP/cerebral oedema, Preterm infant, Severe hypertension, Severe frank haemoptysis, Aortic or cerebral aneurysm, Cardiac failure, Abdominal distention, (GORD), Hiatus hernia, Recent diaphragmatic, oesophageal, thoracic, head or neck surgery.

Answer 23

Removing head down tilt to reduce risk of GORD.

Answer 24

Hands on chest wall Small/fine vibratory action in direction of normal rib movement (small amplitude, high frequency compared to shaking which involves large amplitude and lower frequency) Direct the force towards the carina Applied during expiration only Done in conjunction with TEEs and possibly Gravity Assisted Drainage Usually 10-20 minutes

Answer 25

Percussion is the relaxed rhythmical tapping of the chest wall by flexion and extension of the wrist on the patient’s chest wall, usually using cupped hands. Must elicit a cupping sound (not flat slap-like sound) Two hands (adults), 2-3 fingers (infants) Not timed with breathing, completed during inspiration and expiration May be done in conjunction with TEEs and Gravity Assisted Drainage Usually 10-20 minutes

Answer 26

Believed positive pressure generated by the vibration/percussion it transmitted through chest wall to the airways, which causes oscillation and increase in expiratory flow therefore mobilising secretions. peripheral airways centrally. NO STRONG EVIDENCE TO SUPPORT/REJECT (Research often on Vibration/Percussion in conjunction with other techniques)

Answer 27

May increase intrathoracic pressure, hypoxaemia, patients with bronchospasm

Answer 28

Osteoporosis (or metastatic bone cancer) associated with brittle or extremely fragile bone, severe/frank haemoptysis, chest trauma #thoracic age/sternum/ribs, bronchial tumour, lung contusion, coagulopathy/thrombocytopaenia e.g. low platelet, chest pain, recent Tx, head and neck surgery, active TB

Answer 29

Inhaled mucoactive agent is a medication that is inhaled and promotes secretion clearance Usually administered prior to ACT Saline is most commonly used

Answer 30

Hypertonic and Normal Saline (High), Mannitol (unclear), Dornase alfa (no benefit)

Answer 31

Normal Saline, Mesna (low), N-acetylcysteine (unclear), Hypertonic Saline (no benefit)

Answer 32

Dornase Alfa (only in severe disease), Hypertonic saline, N- acetylcysteine, Mannitol (unclear) (Tarrant et al 2017)

Answer 33

Hypertonic Saline, Mannitol, Dornase alfa (high)

Answer 34

Mucoactive agents work in different ways ➢Promote cough ➢Reduce sputum adhesion of sputum ➢Thin sputum ➢Increase Airway surface liquid Most evidence in CF, though increasing in other non-CF lung disease

Answer 35

Adverse events wheeze, bronchospasm, cough, chest tightness, shortness of breath (SOB), increased work of breathing (WOB), upper respiratory tract discomfort, cardiovascular dysfunction, gastric discomfort, ‘flu’ like symptoms

Answer 36

Timing of administration, combining with PEP to reduce treatment burden and improve deposition or combining with physical activity