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800 > Week 11 (CR Treatments) > Flashcards

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
Benefits or secretion clearance
- Reduce infection - Improve ventilation/gas movement - Avoid deterioration of breathing mechanics e.g. decrease WOB
26
Techniques to facilitate the movement and removal of secretions
Huff and cough
27
Techniques to facilitate the movement of excessive secretions
Postural drainage, percussions, vibration, shaking
28
What does a cough do
Clears secretions from upper central airways
29
What are the 4 components of an effective cough
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
Varying the size of a huff can
Affect where the secretions are moved from within the lungs (i.e. central vs peripheral airways)
31
What are the 4 components of an effective huff
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
How to maximise clearance of secretions with huff
Alter the force and length of expiration - High to mid lung volume - Mid to low lung volume
33
2 phase gas-liquid flow explains
Interaction of liquid and gas with a conduit and it is responsible for how secretions move towards the mouth
34
Definition: annular flow
Surface of the liquid layer moves in waves
35
Definition: mist flow
Liquid is carried as small droplets in the gas
36
For gas-liquid flow to occur, expiratory flow rate must be (answer) than inspiratory flow rate
At least 10% greater
37
Cough uses which flow
High expiratory flow rate so mist flow
38
Huff uses which flow
Lower flow rates so annular flow
39
Dynamic compression is...
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
Dynamic compression occurs
Towards the mouth at EPP
41
Equal pressure point is...
The point where intra pleural pressure is equal to the alveolar pressure i.e. EPP is Ppl = Pal
42
EPP: When Ppl = Pal
> dynamic compression > faster flow rate > movement of secretions
43
EPP: Small breath in =
Less alveolar recoil so less alveolar pressure to start with
44
EPP: Big breath in =
More alveolar recoil so greater alveolar pressure to start with
45
Postural drainage is...
Positioning the bronchus to a particular lung segment uppermost and perpendicular to horizontal to allow secretions to drain centrally by gravity
46
Physiology of postural drainage
- 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
How to do percussions (5 steps)
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
Percussions: physiology
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
Contraindications to percussions
Severe bronchospasm, rib fractures, unstable spine, coughing up blood
50
Definition: Vibrations and shaking
Application of vibratory action (compression and oscillation) to the chest wall
51
3 steps to vibrations and shaking
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
Physiology: vibrations
- Transmission of vibrations to the airways: increase peak expiratory flow (aids annular flow) and decrease mucus viscosity - Elicits spontaneous cough
53
How to evaluate our treatment for gas movements
- Ausc: increased BS - Increase spo2 - CXR: increased translucency - ABG: increase pao2, decreased paco2
54
How to evaluate our treatment for secretion movements
- Cough: stronger/increase effectiveness - Patients report decrease difficulty clearing secretions - Sputum: decrease amount, decrease viscosity, colour improved
55
Is cough most appropriate or huff?
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
Precautions to cough
Raised ICP, recent eye surgery, bronchospasm
57
Low volume huff moves secretions from
Peripheral airways
58
Mid volume huff moves secretions from
Middle airways
59
High volume huff moves secretions from
Central airways
60
Postural drainage for upper lobe, apical segment
Upright sitting
61
Postural drainage for upper lobe, anterior segment
Supine lying
62
Postural drainage for upper lobe, posterior seg RUL
L side lying, 1/4 off prone
63
Postural drainage for upper lobe, posterior segment LUL
R side lying, 1/4 off prone
64
Postural drainage for middle lobe, L lingula
R side lying, 1/4 off supine, head down 15 degrees
65
Postural drainage for middle lobe, RML
L side lying, 1/4 off supine, head down 15 degrees
66
Postural drainage for lower lobe, apical segments
Prone lying
67
Postural drainage for lower lobe, anterior basal segments
Supine lying, head down 20 degrees
68
Postural drainage for lower lobe, posterior basal segment
Prone lying, head down 20 degrees
69
Postural drainage for lower lobe, lateral basal segment RLL (ant basal segment)
L side lying, head down 20 degrees
70
Postural drainage for lower lobe, lateral basal segment LLL (and medial basal segment RLL)
R side lying, head down 20 degrees

800 (12 decks)

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