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Week 11 (CR Treatments) Flashcards

1
Q

Gas movement impairments are due to LOW LUNG VOLUMES such as

A
  • Low ventilation
  • Low FRC
  • Reduced volume in a particular part of the lung
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2
Q

DBE: Depth of inspiration

A

Encourage deep inspiration to TLC

Deep breaths increase ventilation throughout the lungs

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3
Q

Pathophysiology of depth of inspiration

A

Increased tidal volume > alveolar stretch > stimulate surfactant production > decrease surface tension > increase lung compliance > increased VA/VE

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4
Q

DBE: Inspiratory flow rate

A

Encourage slow inspiration so there is better distribution to the dependent regions of the lung due to more compliance

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5
Q

Fast inspiration for inspiratory flow rate

A

Airflow depends on airway resistance

- Resistance is less in non-dependent regions (uppermost) so airflow is better distributed here

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6
Q

Slow inspiration for inspiratory flow rate

A

Airflow depends on lung compliance
- Compliance is greater in dependent (lowermost) regions so airflow is better distributed here
“SLOW GOES LOW”

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7
Q

DBE: Pattern of breathing

A

Encourage LBE and try to decrease AP/upper chest breathing. LBE increases distribution of VE to the dependent lung regions.

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8
Q

DBE: +/- inspiratory hold

A

Encourage 3 second hold at the end of full inspiration at TLC

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9
Q

Mechanism: +/- inspiratory hold

A
  • Recruits collapsed alveoli via collateral ventilation and alveolar interdependence
  • Limited to 4-5 breaths to limit hyperventilation and fatigue
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10
Q

Who are inspiratory holds appropriate for

A

Atelectasis, low lung volumes but not for hyper-inflated or breathless patients

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11
Q

Who would benefit most from LBE breathing

A

Post-abdominal surgery patients who have low lung volumes with areas of atelectasis rather than those with respiratory diseases e.g. emphysema

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12
Q

General positioning aims to…

A

Increase lung volumes generally (most important FRC >CC)

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13
Q

Specific positioning aims to…

A

Re-expand areas of localised atelectasis then return to general positioning
- Uses effects of gravity to stretch open the alveoli

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14
Q

Definition: Closing capacity

A

Lung volume at which the dependent airways begin to close or cease to ventilate. Normally FRC > CC so alveoli is open during tidal breathing.

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15
Q

What does it mean if CC > FRC

A

Small airway closure during tidal breathing resulting in

  • Reduced gas exchange and decreased PaO2/SaO2
  • CC increases with age, smoking, post-op
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16
Q

If FRC > CC then there is

A

Increased lung compliance
Reduced respiratory load
Increased VQ matching and gas exchange

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17
Q

General positioning: what postures have the highest FRC?

A

Upright postures: sitting and standing
Standing > sitting
If unable to SOOB then side-lying

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18
Q

Specific positioning: how to position patient

A

Position patient so that the problematic area is uppermost/non-dependent

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19
Q

Specific positioning: how does placing the patient upright help with localised gas movement

A

Gravity stretches the area open stimulating surfactant release and increased lung compliance. Once collapsed region has passively opened then you can use generalised positioning + DBE to maintain FRC.

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20
Q

Modified specific positioning is…

A

Specific positions for some lung segments (e.g. ML/LL) involving a head down tilt

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21
Q

Contraindications to head down tilt

A

High blood pressure
Bad reflux
Acid reflux

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22
Q

Most common specific positions are

A

L and R side-lying

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23
Q

Mobilisation includes

A
  • Bed to chair i.e. SOOB
  • Standing up/marching on the spot
  • Walking
  • Progressive exercise
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24
Q

Benefits of mobilisation

A

Better gas movement and gas exchange

  • Increases FRC leading to better distribution of ventilation to dependent regions
  • Increases O2 demand leading to increased RR and VT
  • Increases V/Q matching
  • Increases CO and lung perfusion
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25
Q

Benefits or secretion clearance

A
  • Reduce infection
  • Improve ventilation/gas movement
  • Avoid deterioration of breathing mechanics e.g. decrease WOB
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26
Q

Techniques to facilitate the movement and removal of secretions

A

Huff and cough

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27
Q

Techniques to facilitate the movement of excessive secretions

A

Postural drainage, percussions, vibration, shaking

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28
Q

What does a cough do

A

Clears secretions from upper central airways

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29
Q

What are the 4 components of an effective cough

A
  1. Deep inspiration to TLC
  2. Closure of the glottis
  3. Contraction of abdominal muscles
  4. Opening of glottis and an explosive breath out
30
Q

Varying the size of a huff can

A

Affect where the secretions are moved from within the lungs (i.e. central vs peripheral airways)

31
Q

What are the 4 components of an effective huff

A
  1. Breath into a specified volume (i.e. small Vt vs large inspiration VC)
  2. Keep glottis open
  3. Contract abdominal muscles
  4. Controlled force expiration to specified volume
32
Q

How to maximise clearance of secretions with huff

A

Alter the force and length of expiration

  • High to mid lung volume
  • Mid to low lung volume
33
Q

2 phase gas-liquid flow explains

A

Interaction of liquid and gas with a conduit and it is responsible for how secretions move towards the mouth

34
Q

Definition: annular flow

A

Surface of the liquid layer moves in waves

35
Q

Definition: mist flow

A

Liquid is carried as small droplets in the gas

36
Q

For gas-liquid flow to occur, expiratory flow rate must be (answer) than inspiratory flow rate

A

At least 10% greater

37
Q

Cough uses which flow

A

High expiratory flow rate so mist flow

38
Q

Huff uses which flow

A

Lower flow rates so annular flow

39
Q

Dynamic compression is…

A

During a forced expiration, some parts of airway narrows (dynamic compression) > high airflow and turbulence > shearing of the mucus layer and gas-liquid interaction (either mist or annular flow)

40
Q

Dynamic compression occurs

A

Towards the mouth at EPP

41
Q

Equal pressure point is…

A

The point where intra pleural pressure is equal to the alveolar pressure i.e. EPP is Ppl = Pal

42
Q

EPP: When Ppl = Pal

A

> dynamic compression > faster flow rate > movement of secretions

43
Q

EPP: Small breath in =

A

Less alveolar recoil so less alveolar pressure to start with

44
Q

EPP: Big breath in =

A

More alveolar recoil so greater alveolar pressure to start with

45
Q

Postural drainage is…

A

Positioning the bronchus to a particular lung segment uppermost and perpendicular to horizontal to allow secretions to drain centrally by gravity

46
Q

Physiology of postural drainage

A
  • Gravity assists movements of secretions from peripheral
  • Secretions are then removed by forced expiratory manoeuvres
  • Often combined with other manual techniques
  • Used for patients with excessive secretions
47
Q

How to do percussions (5 steps)

A
  1. Use of cupped hand to rhythmically clap chest wall
  2. Apply 2 layers of towel over patient’s chest wall
  3. Relax wrists (floppy wrists)
  4. Percuss rhythmically throughout inspiration and expiration with a firm but comfortable force
  5. Duration of technique varies e.g. 1-10 mins per area
48
Q

Percussions: physiology

A

Imparts mechanical energy to airways to loosen secretions and increase expiratory flow rate

  • Enhances rate of sputum production more than cough alone
  • Useful for patients with excessive secretions <30ml/day
49
Q

Contraindications to percussions

A

Severe bronchospasm, rib fractures, unstable spine, coughing up blood

50
Q

Definition: Vibrations and shaking

A

Application of vibratory action (compression and oscillation) to the chest wall

51
Q

3 steps to vibrations and shaking

A
  1. Ask patient to take a maximal inspiration to TLC
  2. Apply vibratory action in direction of normal movement of ribs during EXPIRATION only
  3. Continue to end of expiration with slight overpressure
52
Q

Physiology: vibrations

A
  • Transmission of vibrations to the airways: increase peak expiratory flow (aids annular flow) and decrease mucus viscosity
  • Elicits spontaneous cough
53
Q

How to evaluate our treatment for gas movements

A
  • Ausc: increased BS
  • Increase spo2
  • CXR: increased translucency
  • ABG: increase pao2, decreased paco2
54
Q

How to evaluate our treatment for secretion movements

A
  • Cough: stronger/increase effectiveness
  • Patients report decrease difficulty clearing secretions
  • Sputum: decrease amount, decrease viscosity, colour improved
55
Q

Is cough most appropriate or huff?

A

Depends on what we are trying to achieve
Low volume huff - peripheral airways and annular flow
High volume huff - target more central airways towards mist flow
Cough - central airways and mist flow

56
Q

Precautions to cough

A

Raised ICP, recent eye surgery, bronchospasm

57
Q

Low volume huff moves secretions from

A

Peripheral airways

58
Q

Mid volume huff moves secretions from

A

Middle airways

59
Q

High volume huff moves secretions from

A

Central airways

60
Q

Postural drainage for upper lobe, apical segment

A

Upright sitting

61
Q

Postural drainage for upper lobe, anterior segment

A

Supine lying

62
Q

Postural drainage for upper lobe, posterior seg RUL

A

L side lying, 1/4 off prone

63
Q

Postural drainage for upper lobe, posterior segment LUL

A

R side lying, 1/4 off prone

64
Q

Postural drainage for middle lobe, L lingula

A

R side lying, 1/4 off supine, head down 15 degrees

65
Q

Postural drainage for middle lobe, RML

A

L side lying, 1/4 off supine, head down 15 degrees

66
Q

Postural drainage for lower lobe, apical segments

A

Prone lying

67
Q

Postural drainage for lower lobe, anterior basal segments

A

Supine lying, head down 20 degrees

68
Q

Postural drainage for lower lobe, posterior basal segment

A

Prone lying, head down 20 degrees

69
Q

Postural drainage for lower lobe, lateral basal segment RLL (ant basal segment)

A

L side lying, head down 20 degrees

70
Q

Postural drainage for lower lobe, lateral basal segment LLL (and medial basal segment RLL)

A

R side lying, head down 20 degrees

800 (12 decks)

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