Week 5 Flashcards
What are the indications for pulmonary pharmacological interventions?
• Reduce bronchospasm • Reduce inflammation/allergic reaction • Reduce mucous production • Treat bacterial infection • Improve Oxygenation • Special Considerations: - Cough suppressant - Smoking cessation
What role does the sympathetic nervous system play in pulmonary?
Causes bronchodilation by increase cAMP, resulting in:
• Facilitates smooth muscle relaxation
• Inhibition of Mast Cells (inflammatory response and mucous production)
What role does the parasympathetic nervous system play in pulmonary?
Causes bronchocontrstriction by increasing cGMP resulting in:
• Facilitates smooth muscle constriction
• Facilitation of Mast Cells (inflammatory response and mucous production)
What is the primary method of drug administration to the lungs?
Primarily through inhalation (aerosol)
• May also be delivered orally or IV
What are the benefits of a Metered Dose Inhaler (MDI) or Dry Powder Inhaler (DPI)?
- Rapid delivery and absorption of medication
- Large Surface area
- Delivered Directly to tissue
- Less systemic effects
What are the limitations of a Metered Dose Inhaler (MDI) or Dry Powder Inhaler (DPI)?
- Unable to predict exact dosage
- Delivery is dependent on inspiratory flow
- Can be irritating to tissues
How is an inhaler used properly?
• Shake for 2-5 seconds, remove cap, inspect inhaler
• If the inhaler hasn’t been used in a while, may need to prime it.
• Breathe out all the way.
• Start breathing in slowly through your mouth, then press down on the inhaler 1
time.
• Keep breathing in slowly, as deeply as you can.
• Hold breath and slowly count to 10.
• Wait about 1 minute before you take your next puff (Beta agonists only)
What is a spacer?
Also known as aerosol-holding
chambers, add-on devices and
spacing devices, long tubes that slow the delivery of medication from pressurized MDIs.
What are the characteristics of a spacer?
• Helps improve delivery of
medication.
• Often used for inhaled
corticosteroids and with younger patients
What is a nebulizer?
A device that mix drugs with air to form a fine mist that is inhaled through a mask
What are the characteristics of a nebulizer?
• Prolongs the delivery of the medication (10minutes)
• Originally thought to improve delivery of medication to distal bronchioles (Inconclusive)
• Useful for patients who cannot perform MDI technique correctly
- Young children
- Patients in acute distress
What are the general classifications of bronchodilators for pulmonary pharmacology?
- (SNS) Adernergic Agonists (Sympathomimmetics)
- (PNS) Cholinergic antagonists (Anti-cholinergic)
- Methylxanthines
What are the characteristics of bronchodilator: Epinephrine (Epi-Pen)?
- Non specific beta agonist
- Used most often in emergent cases (anaphylaxis and sepsis/resp failure)
- Can be delivered (IV, IM, SubCut or Inhalation)
- Short time to effect 3-15minutes
- Short peak effect time ~20minutes
- Will affect other tissues with beta and alpha receptors
What are the characteristics of Bronchodilator Adernergic Agonist: SABA-Short acting (rescue)?
- Albuterol (Ventolin) (most common)
- Time to effect 5-15min
- Duration: 3-6hrs
What are the characteristics of Bronchodilator Adernergic Agonist: LABA-Long acting (maintenance)?
Salmeterol (Serevent)
• Time to effect: 10-20minutes
• Duration: 12hrs
What are the side effects for Bronchodilator Adernergic Agonist?
- Tachycardia,
- Tremors
- Nervousness,
- Restlessness
- Weight Loss
What does Bronchodilators: Cholinergic antagonists do?
Block the muscarine receptors in the bronchioles (LAMA)
What are the characteristics of Bronchodilators: Cholinergic antagonists?
• Drug of choice for COPD • Not used as often for asthma • Not absorbed well into bloodvstream • Less side effects than Beta Agnonists • Most Common: - Ipratropium (Atrovent) 3 4/day - Tiotropium (Spiriva) 1/day
What medicine provides a mix between SABA and LAMA?
Combivent
• Ipratropium bromide and
albuterol sulfate.
What are the characteristics of Bronchodilators: Methylxanthines?
Aka Xanthine deriviatives
• Common examples:
- Theophylline, Theobromine and caffeine
• Inhibit phosodiesterase enzyme
(PDE).
- Increases cAMP
- May also act as an adenosine antagonist
• Most common delivery route is oral, may also be injected (IV)
What are the side effects of Bronchodilators: Methylxanthines?
- Tachycardia, HA, irritability, restlessness
* Theophylline Toxicity: can cause arrthymias and seizures
What is the mechanisms of action of anti-inflammatory: glucocorticoids?
- Control inflammatory mediated bronchospasm
- Inhibit production of pro-inflammatory products (cytokines, prostaglandins, leukotrienes etc)
- Decreases vascular permeability
- Immunosuppression: Inhibits migration of neutrophils and monocytes
- Increases the effect of Beta Agonsits
What are the characteristics of inhaled anti-inflammatory: glucocorticoids?
Used often for long term maintenance of Asthma
• Budenoside (Pulmicort), Beclemethasone (Belcovent), Fluticasone (Flovent)
What are the characteristics of oral anti-inflammatory: glucocorticoids?
Used often with acute infections, or exacerbations, 1-3weeks max
• Prednisone
What are the characteristics of IV anti-inflammatory: glucocorticoids?
Use in severe asthma attacks (status asthmaticus) or respiratory distress
• Methylprendisolone (Medrol)
What are the side effects of anti-inflammatory: glucocorticoids?
Hyperglycemia, HTN, Osteoporosis, Myopathy, Mood Swings.
• Less side effects with Inhaled Delivery
What is the suffix for anti-inflammatory: glucocorticoids?
- Sone
What do leukotrienes cause?
- Airway hyperresponsiveness
- Inflammation
- Smooth muscle hypertrophy
- Mucous secretion
- Heavily involved in asthma
What are the characteristics of leukotriene inhibitors?
• Montelukast (Singulair) • Inhibits the effects of leukotrienes - Airway hyperresponsiveness - Inflammation - Smooth muscle hypertrophy - Mucous Secretion • Great for Asthma, “OK” for COPD • Delivered in pill form • Enhance effects of glucocorticoids and allows for smaller dosages. - Often prescribed together
What are the characteristics of pulmonary fibrosis medications?
• Pirfenidone (Esbriet) and nintedanib (Ofev)
• Anti-Fibrotic medication
• Inhibit pathways that lead to fibrosis and scaring of lungs
- Suppress fibroblast proliferation, reduces fibrogenic mediator production,
• Prior to these medications there were no true IPF meds
- Oxygen and Steroids (not ideal)
What is histamine?
A endogenous chemical involved in regulating modulating several physiological functions:
• CNS neural modulation, gastric secretions and hypersensitivity reactions
• 4 receptor subtypes (H1-H4)
• H1 are involved with the respiratory system and
hypersensitivity
- Nasal Congestion, sinusisitis, rhinitis, mucousal
irritation,
What are effects of antihistamines?
Block these receptors, most are non specific
What are the side effects of antihistamines?
Sedation, fatigue, dizziness,
incoordination
What is the most common form antihistamine?
Diphenhydramine (Benadryl)
What is the function of nasal decongestants?
Relieve nasal congestion in the upper respiratory tract
What is the most common nasal decongestants?
Alpha-1 agonist
What are the characteristics of nasal decongestants?
Pseudoephedrine (Sudafed) • Causes vasoconstriction in nasal passages • Essentially “dries up” muscousal vasculature and reduces nasal congestion • Oral or Nasal Spray
What are the functions of mucolytics?
- Decrease viscosity (thickness) of respiratory secretions
* Allows for easier mobilization of secretions up the “muco-cilliary elevator”
How are mucolytics delivered?
Often delivered orally • Guanefisine (Mucinex) • Guanefisine and antitussive (Robitussin) - dextromethorphan (DM) - Codeine (DAC)
What are the functions of antitussive?
Suppress coughing response/ reflex
• Due to irritation in airways and sinuses
What are the characteristics of antitussive not always being indicated?
• Makes it difficult to get rid of the mucus that
collects in the lungs and airways.
• May increase secretions
• Asthma and young children
What are the general types of antitussive?
• Central mediated inhibition: codeine and dextromethorphan (DM)
- Opiates, Act on brainstem
• Local mediated inhibitors: Antihistamines and local anesthetics
- Act on respiratory tissue
What are the functions of antibiotics?
• Treatment of acute exacerbation or infection
- Increased dyspnea, Increased chest congestion AND FEV1 < 50%.
• Treatment of acute bronchitis or pneumonia
• Prevention of acute exacerbation (prophylactic antibiotics)
What are the most common forms of antibiotics?
• Bactericidal
- Penicillins: Penicillin and Amoxicillin,
- Cephalosporins: Ciprofloxacin (Cipro)
• Bacterostatic:
- Macrolides: Azithromycin (Zpack)
What are the characteristics of influenza vaccines?
• Reduce serious illness and mortality in patients with COPD
• GOLD and CDC recommends annual vaccine for:
- Patients with COPD
- Patients with pulmonary fibrosis
- Patients with asthma >6months of age
- The elderly, ages >50years of age
- Young Children, ages 6months-4years of age
- Health-care personnel
- Morbidly Obese patients BMI>40
- Immunosuppressed patients
What are the indications for oxygen therapy?
- Hypoxemia
- Reduce work of breathing
- Reduce work of the heart (especially RV)
What type of patients is oxygen therapy typically for?
For patients with Pulse Oximetry <88% or SpO2 <55mmHg
• May also be prescribed for patients with PAH and RV HF
• Patients with chronic COPD may have different guidelines
What is the general pulse oximetry goal for patients on oxygen therapy during exercise?
Above 90%
____ is the main risk factor in the development of COPD
Smoking is the main risk factor in the development of COPD
What are the benefits of smoking cessation?
- Improves Respiratory symptoms
- Reduces Bronchial hyperresponsiveness
- Prevents accelerated decline in lung function and may improve FEV1.
- In all smokers
How fast does lung function improve when someone stopped smoking?
Within a week
What predicts the difficulty of smoking cessation?
- How much one smokes on a daily basis
* Within 30 minutes of waking up each day.
What are medications usually prescribed to help with during smoking cessation?
- Help reduce the craving for tobacco; Bupropion (Zyban)
- Help reduce withdrawal symptoms; Varenicline (Chantix).
- Nicotine replacement therapy: most helpful for people who smoke >.75PPD
How do we assess respiratory muscle strength?
By measuring Maximum Inspiratory (MIP & Expiratory Pressure (MEP)
How do we assess Chest Wall Mobility?
Posture, Chest wall excursion, Rib and Thoracic Spine
Mobility
How do we assess Respiration?
Arterial Blood Gases (ABG), Pulse Oximetry (SpO2)
How do we assess Ventilation?
Spirometry (FVC and FEV1), Respiratory Rate (RR),
How do we assess Lung Segment Examination?
Fremitus, Voice Sounds, Breath Sounds
How do we assess Cough function?
Independence, Sputum Assessment
How do we assess Quality of Life and Subjective Report?
VAS, RPE, MMRC Dyspnea Scale, St George’s Respiratory Scale, Dyspnea Index
How do we assess Exercise Capacity?
6MWT, Max Test, Submax
How do we assess Balance?
BERG, POMA, DGI, BEST
How do we assess Mobility?
5 or 10m Gait Speed, TUG,
How do we assess Strength?
5Ttime Sit to Stand, 30 Sec Sit to stand
What are we taking note of in the visual inspection aspect of observation?
- Disposition: Distress, Short of breath, Somnolent etc
* Skin: Edema, JVD, Cyanosis, Sweating
What are we taking note of in the body position/posture aspect of observation?
Normal, Barrel Chest, slouched, guarding, pes escavatum or Pectus carinatum
What are we taking note of in the breathing pattern aspect of observation?
• Rate and Depth
- Neck, Chest, Abdomen
• Accessory muscle usage
• Asymmetrical Paradoxical Chest Wall Movements
• Nasal Flaring
• Pulse Oximetry RA or with supplementation
What are the instructions on how to get into the tracheal position?
• Have the patient flex neck slightly
• Place your index finger in the suprasternal notch
• Place the top of finger in suprasternal notch medial to left SC joint.
• Push inwards toward the cervical spine
• Repeat on right side
• Normal test
- No obstruction to the advancement of the finger.
• Most Common Cause of deviation: Midline shift due to Pneuomothorax (moves away from lesion)
When is thoracic wall palpation indicated?
If there is chest pain, a mass seen on inspection, breast masses, or draining sinuses.
What are you palpating for during thoracic wall palpation?
• Examine for tenderness and masses
- Soft tissues (also assess for crepitus
- Large thoracic muscles
- Costal cartilages, intercostal spaces, costochondral junctions and xiphisternal
• Palpate the ribs for point tenderness, swelling, crepitus, and pain on chest compression.
How is the compression test for rib fracture done?
With one hand supporting the back, compression of the sternum with the other elicits pain at the untouched fracture site.
How do we test for thoracic wall movement symmetry?
• Place a hand on each side of the chest wall
• Extend thumbs so their tips meet in the midline.
• Have the patient inspire deeply permitting your palms to move freely with the chest while your fingers are anchored on the chest wall.
• Normally, the thumbs move laterally from midline in equal distances.
• Asymmetric excursions suggest a lesion on the lagging side in the chest wall,
the pleura, or the upper lobe of the lung.
What is the hand placement when palpating the upper thorax for thoracic wall movement symmetry?
Trapezius
What is the hand placement when palpating the mid thorax for thoracic wall movement symmetry?
Axilla
What is the hand placement when palpating the posterior thorax for thoracic wall movement symmetry?
Latissimus Dorsi
What is the hand placement when palpating the Costal Margins for thoracic wall movement symmetry?
Lateral Ribs
How do we test for thoracic wall movement excursion?
Place measuring tape around chest wall
• Xiphoid process is Most reliable landmark
• May also use Axilla and interval between
xiphoid and umbilicus
• Normal excursion is 2-3inches or 4-6cm
How do we test for tactile fremitus?
• Increased transmission of sound, can be detected as fremitus over the affected area
while the patient repeatedly vocalizes
- “one, two, three” or “99”
• The examiner moves his or her palms systematically over the two hemithoraces.
• Common Causes of increased fremitus (Vibration)
- Consolidation of the lung
• Conversely, impairment of sound transmission, as by a pleural effusion, diminishes
vocal fremitus.
• A good test to start chest exam
- Not very specific however due to size of hands
- If differences are appreciated always follow up with auscultation
What are the characteristics of mediating percussion?
Evaluates regional or side-to-side differences in lung density
• Normal lung density willsound resonant (table)
• Areas of increased density (e.g. consolidation, atelectasis) will sound dull. (quads)
• Areas of decreased density (e.g. emphysema) will sound hyperresonant. (puffed out cheeks or bloated belly)
What are the instructions of mediating percussion?
• Place pad of middle finger of non dominant hand on the subject’s chest in the intercostal space.
• Using the middle finger of your dominant hand, tap the knuckle of the middle finger of
your non dominant hand .
- Keep Percussing finger rigid, tap like woodpecker
• Listen for the pitch of the sound produced and note the vibrations from the chest with your finger
What are the presentations of purulent sputum?
- Inflammatory cells, enter the airways and alveoli in response to lower airway infection.
- May be yellow, green, or dirty gray.
In what conditions is purulent sputum in small amounts produced?
Acute bronchitis, resolving pneumonia, small tuberculous cavities, or lung abscess
In what conditions is purulent sputum in copious amounts produced?
Bacterial Pneumonia, Lung abscess, bronchiectasis, or bronchopleural fistula communicating with an
empyema.
In what conditions is purulent sputum in foul smelling amounts produced?
Anaerobic infection (PNA) and/or lung abscess.
What are the characteristics of stringy mucoid sputum?
Increased mucous production and mucous plugs occur in asthma; during resolution retained mucous and mucous plugs are mobilized.
What are the characteristics of bloody sputum “hemoptysis”?
- Coughing up blood or bloody mucous
* Hallmark sign of Pulmonary Embolism, may also occur with trauma, pneumonia
What are the characteristics of Blood-Streaked Sputum?
- inflammation in the nose, nasopharynx, gums, larynx, or bronchi.
- Sometimes it occurs after severe paroxysms of coughing and minor airway trauma
What are the characteristics of Frothy Pink Sputum?
- Alveoli and respiratory bronchioles are flooded with fluid from the capillaries
- Producing thin secretions containing air bubbles, frequently colored with hemoglobin.
- Hallmark sign of pulmonary edema
What are the characteristics of the evaluation of diaphragmatic action?
- Patient lays supine with anterior chest exposed
- Palpate anterior chest well with thumbs over costal margins so tips meet at xiphoid
- Instruct patient to sniff of take deep breath, allow thumbs to move with chest wall
- Normal test is equal upward movement of the costal margins
• ***Can also be done in sitting using percussion and markings pre and post
inspiration,
• Normal should see ascent to T10 expiration, descent to T12 inspiration
How is the maximum inspiratory effort conducted?
My having the subject expire
to a residual volume (RV) (ie, fully expire) and then perform a maximum inspiratory maneuver.
• Opposite for Expiratory Pressures
The maximum inspiratory effort is measured as what?
As the most negative (MIP) or positive (MEP) pressure attained after the first second of effort
What is defined as an acceptable maneuver for the maximum inspiratory effort test?
One that demonstrates a 2-s plateau of inspiratory effort. Take average of 3 trials, values should be within 10% of largest measure
What are the factors that have been considered to influence MIP/MEP?
Effort and understanding of test, age, gender, height, weight, fitness level and smoking status
What are the instrumentation and test performance issues that can affect MIP/MEP?
Type of mouthpiece, presence of a small leak, number of trials and lung volume at the starting point of test performance
What is the maximum inspiratory/expiratory pressure used for?
To assess the strength of the diaphragm
What does Pulse Oximetry (SpO2) do?
Indirectly measures the oxygen saturation of hemoglobin in
arterial blood (SpO2)
• SaO2 is a direct measurement of oxygensaturation, taken from ABG
What is the arterial oxygen saturation of a healthy individual with normal lungs, breathing air at sea level?
95% – 100%
• Percent error of 90%
What are the factors that impair accuracy of a Pulse Oximetry (SpO2)?
- Bright ambient light on probe
- Nail thickness (including nail polish)
- Skin pigmentation
- Low peripheral perfusion states
- Hypoxemia (<80% SaO2)
- Motion artifact
- Carbon monoxide poisoning
What is the normal respiratory rate for an adult?
12-20 breaths/min
What is tachypnea?
Respiratory rate above 20 breaths/min
What is Bradychypnea?
Respiratory rate above 12 breaths/min
What is the normal respiratory rate for an infant (birth–1 year)?
30–60
What is the normal respiratory rate for a toddler (1–3 years)?
24–40
What is the normal respiratory rate for a Preschooler (3–6 years)?
22–34
What is the normal respiratory rate for a School-age (6–12 years)?
18–30
What is the normal respiratory rate for an Adolescent (12–18 years)?
12–16
What is Total Lung Capacity (TLC)?
Max volume air contained in lung at end of max inspiration, 5-7L
What is Vital Capacity (VC)?
- Maximum volume of air that can be expired in single breath after max inspiration,
- Men: 5.0L; Women 3.8L,
- FVC = maximally forced VC
What is Forced Expired Volume in 1 sec (FEV1)?
Amount of air expired in first second of FVC; normal 80%
What is Tidal Volume (TV or VT)?
Normal breath; volume gas expired during unforced respiratory cycle (one breath), 0.4-0.7L
What is Minute Ventilation (MVV)?
Amount of air expired per min (TV x RR), 4L/min; The Cardiac Output of Ventilation
What is Residual Volume (RV)?
Amount of air remaining in lungs after max expiration: 1L
What is DLCO?
Diffusion Capacity,: Normal >80%
What is IRV?
Volume of additional air that can be inhaled after a normal tidal breath in
What is ERV?
Volume of additional air that can be pushed out after the end expiratory level of normal breathing
What is FRC?
Volume of gas that remains in lungs at end of normal tidal breath outequilibrium point (ERV + RV)
What are the contraindications to Spirometry Testing?
• Haemoptysis (of unknown origin)
• Pneumothorax
• Unstable cardiovascular status, recent myocardial infarction or pulmonary
embolism
• Thoracic, abdominal or cerebral aneurysms
• Recent eye surgery
• Acute disorders affecting test performance, such as nausea or vomiting
• Recent thoracic or abdominal surgical procedures
What affects the predicted normal values during Spirometry?
- Age
- Height
- Gender
- Ethnicity
What are the guidelines for Spirometry?
• Patient must inhale maximally to total lung capacity, then blast the air out
• There should be no cough or hesitation during the first second of the maximal exhalation
• The patient must continue to exhale forcefully for at least 6 seconds and until a plateau is reached (3 seconds for children under age 10)
• The largest and second largest FVC and FEV1 values should be repeatable within 150 ml (100 ml if the FVC is less than 1.00 L)
• A minimum of 3 acceptable trials is required
• The largest FVC and FEV1
from acceptable efforts are reported; the FEV1/FVC is calculated from these values
What is the patient positioning for Spirometry?
- Sit upright: there should be no difference in the amount of air the patient can exhale from a sitting position compared to a standing position as long as they are sitting up straight and there are no restrictions.
- Feet flat on floor with legs uncrossed: no use of abdominal muscles for leg position.
- Loosen tight-fitting clothing: if clothing is too tight, this can give restrictive pictures on spirometry (give lower volumes than are true).
- Dentures normally left in: it is best to have some structure to the mouth area unless dentures are very loose.
- Use a chair with arms: when exhaling maximally, patients can become light-headed and possibly sway or faint
What are the instructions for Spirometry?
• Different techniques for performing spirometry.
• Before performing the forced expiration, tidal (normal) breaths can be taken first,
then a deep breath taken in while still using the mouthpiece, followed by a further quick, full inspiration.
• Or; Alternatively, a deep breath can be taken in then the mouth placed tightly
around the mouthpiece before a full expiration is performed.
• Or; The patient can be asked to completely empty their lungs then take in a quick
full inspiration, followed by a full expiration.
• The patient takes a deep breath in, as large as possible (using whichever technique most effective), and blows out as hard and as fast as possible and keeps going until there is no air left.
• Nose clips are essential for as air can leak out
What are the characteristics of dyspnea scales: Baseline (BDI) & Transition (TDI) Dyspnea Index?
• 24 item, Interviewer-administered rating of severity of dyspnea at a single state across 3 domains
• TDI measures changes in dyspnea severity from the baseline as established by
the BDI.
• Provides a multidimensional measurement of dyspnea based on 3 components
that evoke dyspnea in activities of daily living, in symptomatic individuals.
What is the Modified Medical Research Council (MMRC) Dyspnea Scale?
A concise measure of health related quality of life
What is the health related quality of life (HRQoL) of patients with COPD in
daily clinical practice?
MMRC dyspnea scale. May detect changes in QoL faster
than GOLD classifications
What is the grade and accompanying descriptions for the MMRC?
- Grade of dyspnea 0: Not troubled by breathlessness except on strenuous exercise
- Grade of dyspnea 1: Shortness of breath when hurrying on the level or walking up a slight hill
- Grade of dyspnea 2: Walks slower than people of the same age on the level because of breathlessness or has to stop for breath when walking at own pace on the level
- Grade of dyspnea 3: Stops for breath after walking about 100, or after a few minutes on the level
- Grade of dyspnea 4: Too breathless to leave the house when dressing or undressing
What are the characteristics of the St. George’s Respiratory Questionnaire (SGRQ)?
• 50 question, Disease-specific instrument designed to measure impact on overall health, daily life, and perceived well-being in patients with obstructive
airways disease.
• Scores range from 0 to 100, with higher scores indicating more limitations.
• MCID: a mean change score of 4 units is associated with slightly efficacious treatment, 8 units for moderately efficacious change and 12 units for very efficacious treatment
How do we locate the anterior apical segment of the lungs?
Find the clavicle and go right above it. In the middle of the belly of the upper trap
How do we locate the anterior right/left upper lobe segment of the lungs?
Find the clavicle and move straight down, right below the angle of louie
How do we locate the anterior right middle lobe segment of the lungs?
Find the xiphoid, and move superior lateral to it. AN inch over and up
How do we locate the anterior right basal lobe segment of the lungs?
Start at the xiphoid, and go all the way after the clavicular line almost to the mid axillary line
How do we locate the posterior apical segment of the lungs?
Right above the spine of the scapula, over the posterior belly of the trap
How do we locate the posterior segment of the left upper lobe of the lungs?
Find the spine of the scapula, come lateral to almost mid spine of the scapula. Have the patient give themselves a hug to move the bone out of the area. Right around T3
How do we locate the posterior superior segment of the right lobe of the lungs?
Find the border of the scapula, then come up. Right between the spine of the scapula and the inferior angle. More para-sternally. Between T4 and 7
How do we locate the posterior basal segments of the lungs?
Go to the inferior angle of the scapula, and go straight down. In rib spaces 7, 8, 9, and 10, before the mid line of the scapula
What are the guide lines when assessing general breath sounds?
- Have patient take deep breaths through the mouth while you listen through one complete respiratory cycle (inspiration and expiration) in each locations, segment by segment.
- Listen from side to side, comparing the sounds and noting any differences.
- Breath sounds in the same area of the lung should sound the same of the right and left side.
Where do we hear normal tracheal breath sounds and what do they sound like?
Over the trachea
- They are a bit higher pitched, and we hear more expiration than inspiration, because the bore of the airway is wider, so more air flow because it is more turbulent
Where do we hear normal bronchovesicular breath sounds and what do they sound like?
Where we appreciate the 1st divisions of the bronchiole tree, which is around the angle of louie. At the manubrium and upper interscapular region.
- Where they are a bit more harsher. moderately loud, medium pitch, rustling
1: 1 ratio exp:insp
Where do we hear normal vesicular breath sounds and what do they sound like?
Primarily over the lungs fields, at the Peripheral lung fields
- Hear air going through the small airways of the alveoli in the respiratory bronchioles. Only hear inspiratory sound, may not hear expiratory sound, because there is not a lot of air flow there due to the smaller airway, there is not as much flow here compared to the proximal segments
What is the description of bronchial/tracheal sounds?
- Loud, high pitch, tubular
- 1:2 ratio exp:insp
What is the description of vesicular sounds?
- Soft, low pitched, and with a gentle rustling quality
- May not appreciate expiration phase
What can an absent or decreased breath sound mean?
- Air or fluid in or around the lungs (pneumonia, heart failure, and pleural effusion)
- Over-inflation (emphysema)
- Reduced airflow to part of the lungs (rib fracture, pneumorthorax)
- Increased chest wall thickness
What are the characteristics of increased breath sounds?
• Normally breath sounds in peripheral fields are vesicular
• Bronchiovesicular in peripheral fields indicate
- Partial pulmonary consolidation or compression transmitting airway sounds with increased efficiency.
- Usually heard on periphery of consolidation or compression
• If Compression or consolidation increases breath sounds become bronchial in nature.
What do whispered words sound like in normal lungs?
Faint and the syllables indistinct, except over the main bronchi.
What do louder and more distinct sounds in lungs sound indicate?
Consolidation, atelectasis, or fibrosis, which improve sound transmission
Voice sounds are more useful than breath sounds in detecting what?
Detecting pulmonary consolidation, and atelectasis. Whispered tend to be better than spoken for detecting subtle differences
What is Egophony?
A form of bronchophony in which the spoken “Eee” is changed to “Ay,”
What is Bronchophony “99”?
When spoken syllables are normally heard indistinctly, with lung consolidation syllables are distinct and sound close to the ear.
What is whispered pectoriloquy?
When consolidations transmit whispered syllables distinctly, even when too small to produce bronchial breathing
What do crackles (rales) result from?
The “popping”; opening and closing of alveoli compressed by fluid (atelectasis)
When are crackles (rales) best appreciated and what does it sound like?
During (inspiration). Sounds like Velcro
What are the non cardiogenic causes of crackles (rales), what does it present like and how does it resolve?
- Atelectasis and Pneumonia
- Typically present in one lung field
- Resolves with coughing or deep breaths
What are the cardiogenic causes of crackles (rales), what does it present like and how does it resolve?
- Pulmonary Edema from HF
- Present in bilateral lungs fields (especially bases)
- Does not resolve with coughing or deep breaths
- Resolves with sidelying positioning
What causes rhonchi (wheezes)?
Obstruction to airway flow, Asthma, mucous in airway, airway inflammation, tumor, or obstructing foreign bodies
How does rhonchi (wheezes) present?
Typically considered an expiratory sound due to forcing airflow through abnormally narrow or collapsed airways. May occur during both inspiration and expiration in asthma
- Non-cardiogenic should decrease with cough
What are the common causes of a stridor?
Foreign body in the upper airway or esophagus, an acquired lesion of the airway (e.g., carcinoma in adults)
What are the presentations of a stridor?
- Wheeze-like sound
- Usually due to a blockage/obstruction of airflow in trachea, upper airway or in the back of the throat.
- Predominantly inspiratory and best heard over the neck.
What is the description of a pleural rub?
- Coarse, grating, or leathery sound
- Usually heard late in inspiration and early in expiration
Where is the location of a pleural rub?
Posterior lung bases or lower axilla
What are the causes of a pleural rub?
Increased friction due to Inflammation of the pleural linings, multiple causes
What is the description of the breath sounds in the presence of pneumonia?
Bronchial breath sounds in periphery
What is the description of the adventitious sounds in the presence of pneumonia?
Coarse crackles, expiratory wheezing
What is the description of the breath sounds in the presence of asthma?
Decreased
What is the description of the adventitious sounds in the presence of asthma?
Inspiratory and expiratory wheezes
What is the description of the breath sounds in the presence of bronchitis?
Normal
What is the description of the adventitious sounds in the presence of bronchitis?
Coarse crackles, wheezes that clear with cough
What is the description of the breath sounds in the presence of consolidation?
Decreased sounds over consolidation, Bronchial sounds in periphery.
What is the description of the adventitious sounds in the presence of consolidation?
Inspiratory crackles
What is the description of the breath sounds in the presence of atelectasis?
Decreased to absent
What is the description of the adventitious sounds in the presence of atelectasis?
Crackles
What are the ABCs of chest radiographs?
- A-airway
- B-bone
- C-cardiac
- D-diaphragm
- E&F-equal (lung) fields
- G-gastric bubble
- H-hilum (and mediastinum)
What does the standard chest examination consist of?
A PA (posterioranterior) and lateral chest x-ray.
• The PA exam is viewed as if the patient is standing in front of you with their right side on your left.
• The patient is facing towards the left on the lateral view
What are the characteristics of the A-Airway portion of a chest radiograph?
• Look at the trachea and its branches: check the 4’s
- Site, size, shape, and shadow (4 S’s).
• Is it patent, or narrowed indicating stenosis or Edema?
• Is it central? (in children it should be straight but in adults it can deviate to the
right due the aortic arch)
What are the characteristics of the B-Bone portion of a chest radiograph?
• Look at and compare the bony structures paying attention to site, size, shape,
shadows and borders:
- (clavicles, ribs, scapulae, thoracic vertebrae, and humeri).
• Fractures? Using a pointer follow along the smooth edges of each bone looking for an interruption of the smooth line.
• Lytic lesions? Look for discrete darker areas or a change in bone density.
• Deformity? Extra or missing bones?
What are the characteristics of the C-Cardiac portion of a chest radiograph?
• Site: is it located on the right or left?
• Size: is it less than half the transthoracic diameter? (i.e. is the largest diameter
of the heart less than half the largest diameter of the thorax)
• Shape: is it ovoid with the apex pointing to the left?
• Shadows: any change in density?
• Borders: is it clear or well defined?
- unclear right border suggest middle lobe consolidation.
- unclear left border suggest lingular lobe consolidation.
What are the characteristics of the D-Diaphragm portion of a chest radiograph?
• The outline of the diaphragm should be clear and smooth.
• Right hemidiaphragm should be higher (2-3cm) than the left
• Are the costophrenic angles well defined?
- whiteness immediately above the diaphragm indicates pleural effusion or consolidation.
- the presence of fluid will produce a meniscus (Meniscus Sign) or a concave upper border
• Is there air below each hemidiaphragm indicating bowel perforation?
• Is the diaphragm below the anterior end of the 6th rib on the right?
- Indicates hyperinflation
What are the characteristics of the E&F-Equal (lung) fields portion of a chest radiograph?
• Divide lung fields into zones: upper, middle, and lower zones
- upper: from the apex to 2nd costal cartilage
- middle: between 2nd and 4th costal cartilage
- lower: between 4th and 6th costal cartilage
• Look for equal radiolucency (or blackness due to air filling) between the left and the right
lungs zones.
• Look for any discrete or generalized grey/white shadows (described as opacity/patchy
shadows)
• Look for vascular markings:
- indicating pulmonary hypertension pruning
• Bat’s wing distribution: bilateral opacification spreading from the hilar regions into the lungs
- pulmonary edema in heart failure, fluid overload, hypoproteinemia, blood transfusion reaction, and others
What are the characteristics of the G-Gastric Bubble and H-Hilum portion of a chest radiograph?
• GASTRIC FUNDUS
- Look for an air bubble under the left hemidiaphragm.
• Look for diaphragmatic hernia on the right or left.
• Look at the hilum (which consists of main bronchus and pulmonary arteries) -the left
should be higher than the right.
• Compare the convex shapes and densities on both sides.
• The paratracheal lines are thin lines of the right and left tracheal margins which are
thickened in lymphadenopathy
What is the difference between pleural effusion and pulmonary edema?
They are both fluid in the lungs, however pleural effusion is restricted to one side, while pulmonary edema is bilateral
What is huffing?
An airway clearing technique, where you breathe in slowly through the nose, hold the breath for 3 secs, and then exhale with an open mouth
What does huffing do?
If moves mucus from the small airways up into the larger airways, then a deeper breath followed by a forceful exhale moves the mucus from the larger airways, out of the lungs, then you cough to clear the mucus out of the airways
What is airway clearing technique: active cycle of breathing designed for?
It is designed to get air behind the mucus, making it easier to cough up
What are the phases of airway clearing technique: active cycle of breathing?
- Breathing control: gently breathe in through your nose, to relax the airways.
- Chest expansion exercise: inhale deeply and hold the breath for 3 secs, which will get air behind the mucus, and loosen it, making it move up into the larger airways more easily
- Forced expiratory technique: huff-cough to move the mucus from the larger airways and out of the body
What is airway clearing technique: autogenic drainage?
A technique that uses controlled breathing in 3 phases
What are the phases of airway clearing technique: autogenic drainage?
- Phase 1: take in shallow breaths, to unstick mucus from the sides of the small airways
- Phase 2: collect mucus by holding breath for 3 secs
- Phase 3: move mucus out of the airway with a hard huff- cough
What is airway clearing technique: chest physical therapy(postural drainage and percussion)?
When another person uses cupped hands and percussion to loosen mucus from airways, this happens while the patient lies in position that uses gravity to drain the mucus from smaller airways, the patient then huffs or coughs the mucus out of their lungs
What is airway clearing technique: high frequency chest wall oscillating vest?
Works by compressing the chest in and out to create airflow, which loosens mucus from the airway walls
What is airway clearing technique: positive expiratory pressure (PEP)?
Uses resistance to open the airways and get air behind the mucus, loosening it and moving it from smaller airways to larger ones, where it is huffed or coughed out
What is airway clearing technique: airway oscillating device (AOD)?
Resistance forces airways to open, the vibrations from the device, called oscillations also shake mucus, loosening it from the airway walls, once the mucus has moved up into the larger airways, patient huff-cough it out of the airway
What are the contraindications of airway clearing techniques?
- Hemoptysis
- Untreated tension pneumothorax
- Platelet count < 20,000 per mm^3
- Unstable hemodynamic status
- Open wounds or burns in the thoracic area
- Pulmonary embolism
- Subcutaneous emphysema
- Recent skin grafts or flaps on thorax
What are the precautions of airway clearing techniques?
- Uncontrolled bronchospasm
- Osteoporosis
- Rib fractures
- Metastatic cancer to ribs
- Rumor obstruction of airway
- Anxiety
- Coagulopathy
- Convulsive or seizure disorder
- Recent pacemaker
What are the characteristics of vibration as an airway clearance technique?
- Place one hand over the other, and move upper hand side to side for 2-3 mins, with gentle to high frequency force, at 12-20 Hz
- Applied throughout expiration, if performed during ventilation, coordinate with the ventilator
What are the characteristics of shaking as an airway clearance technique?
Similar to vibration, but it is more aggressive, but with bouncing movement rathe r than side to side movements. Apply for 2-3 mins during expiration at a frequency of 2 Hz
When does airway collapse occur and why?
Primarily during expiration, and its due to the fact that the inspiratory pressures and inter-pleural pressures are much higher than inter- pulmonary pressures, which results in collapse
What is ventillatory strategy: Pursed Lip Breathing (PLB)?
Consists of exhaling through tightly pressed (pursed lips) and inhaling through nose with mouth closed.
How is Pursed Lip Breathing (PLB) done?
• The patient inhales through their nose, keeping
their mouth closed.
- Trying to inhale for 2 seconds.
• Exhale slowly through pursed lips,
- Trying to exhale for 4 to 6 seconds.
- “Make the birthday candles flicker but don’t blow them out”
- “Blowing on hot soup
What are the effects of Pursed Lip Breathing (PLB)?
• Improves Ventilation
• Reduces respiratory rate
• Prevents premature airway collapse by increasing back pressure (positive pressure) in
airways
• Prolonging the breathing cycle, may allow for greater opportunity for diffusion at the alveolar capillary interface.
• Slowing respiration may be relaxing and thus reduce anxiety
• Great for patients with COPD!!!
What are the characteristics of Deep Slow Breathing (DSB)?
- DSB, 6-8breaths/min, has been shown to improve symptoms of pain, both chronic and acute.
- Autonomic responses such as increased heart rate variability and reduced skin conductance (markers of increased parasympathetic tone) have been observed following DSB,
- More recent evidence suggests that the effects of DSB are likely more due to achieving a relaxed state or distraction from the noxious stimuli.
- Therefore these changes in autonomic activity in following DSB are more likely a reflection of supraspinal activity due to achieving a relaxed or non-threatened state than the cause.
- In short, breathing slowly and controlled may relax a patient and improve pain rating and the changes in autonomic function are reflection of that change not the mechanism.
What are the characteristics of Lateral Costal and Segmental Breathing?
• Manual contacts to the thoracic wall
- Quick stretch or sustained facilitatory proprioceptive stimulus.
- “Breathe Into my Hands”
• Often used to facilitate breathing in the lower lateral segments in patients with
impaired chest wall expansion.
- Commonly referred to interchangeably as “Diaphragmatic breathing”
- Not too effective for patients with COPD
• Often done in semi-fowlers position to allow for better diaphragm movement
• Can also be done on individual segments elsewhere on the chest well
- “Segmental Breathing”
• Can be done by provider or patient
What are the characteristic of Paced Breathing?
• Volitional coordination of breathing during activity.
• Expiration is primarily a passive activity.
- Having a patient expire during exertion may prevent dyspnea during an activity
• Example
- Inhale while walking 2 steps then, Exhale while walking 4 steps, and repeat
- Take a deep breath to start and exhale while climbing 2 stairs, and repeat
• Often used incorporating PLB, DSB or “Diaphragmatic Breathing” into functional
activities.
What are the characteristic of Braced/Splinted Breathing?
• Used often over areas of chest wall that are painful
- Post-operative site, rib fracture etc
• The sustained supportive pressure can stabilize or brace the segment of the
chest wall
- Allows for better ventilation
- Reduces atelectasis
• Can be done by provider or patient
- Can use hands or pillows
What are the positions to relieve dyspnea?
• With the arms supported the
accessory muscles can act on the chest wall and allow for greater ventilation.
• Supporting the spine may “unload” the diaphragm from it’s postural control role
What are the conditions that are prone to developing secretions?
- Cystic Fibrosis
- Asthma
- COPD; especially Chronic Bronchitis
- Bronchiectasis
- Acute Pulmonary Diseases
- Mechanical Ventilator Dependency
- Status Post Surgery
What does the initial assessment of patients with airway secretions and prior to doing airway clearance techniques include?
- Improved SaO2 or SpO2
- Decreased Respiratory rate
- Decreased Dyspnea
- Resolution of pathological breath sounds
- Improved chest radiograph
- Improved Spirometry
What is manual percussion?
Rhythmically percussing the chest wall with cupped hands.
What is the technique for performing manual percussion?
• Hand should be firm with thumb adducted, wrists and elbows loose
- Motion comes from shoulder
- Wrist acts like a whip almost
- Should hear hollow thumping or cupping noise
- Slapping sounds indicate poor technique
• Percussion 3-5 minutes each segment
• Effective treatment to all segments can take up to 30-45minutes
What is the technique for performing manual vibration?
• The palmar aspect of the clinicians hand is placed in full contact with the chest wall.
- May use hand over hand technique
• At the end of a deep inspiration the clinician exerts
a downward pressure while performing an isometric contraction the arm through expiration.
- This isometric contraction creates the vibration and
helps mobilize secretions
• Often done in conjunction with postural drainage.
• 3-5 minutes per segment
What are the characteristics of High Frequency Oscillating Vest?
• Time/duration: usually 5-10minutes 2-5times/day
• Can be expensive
• Foundations often offer grants or donated units
• As effective as manual percussion for mobilization of secretions/mucous
- Especially for patients with CF
- Often applied with nebulizer treatment of bronchodilators and mucolytics
What are the characteristics of Oscillating Positive Expiratory Pressure?
• Exhaling slowly through these devices creates back pressure (positive pressure)
and transmits vibrations in large and small airways.
• This back pressure opens airways and vibration dislodges and mobilizes mucus.
• After blowing through the device 10-12 times, the person huff coughs.
• Acapella™, Aerobika™, Flutter™
• Aerobika can be connected to nebulizer too
What are the characteristics of Active Cycle Breathing (ACB)?
• ACB uses a series of maneuvers to help mobilize secretions
• Cycle of normal tidal breaths to deep breaths, followed by coughing
- 3 normal breaths
- 3 Deep breaths
- Repeat 3 times
• Finish with coughing technique (usually a Huff Cough)
• Easy to educate patients
What are the characteristics of an inspiratory hold?
• Holding a breath after a maximum inspiration
• Patient is instructed to hold his breath without Valsalva for 2-3sec
• This increases back pressure and stretch on Type 2 Alveolar Cells
• Can be used in conjunction with other airway clearance techniques
- Active Cycle Breathing, Oscillating Expiratory Pressure, Vibration
What are the mechanisms of coughing?
- Irritation
- Inspiration
- Compression
- Expulsion
What are the characteristics of a huff cough?
• Deep inspiration followed by a forced expiration without glottal closure.
- Mouth and throat should be open
• Often done after ACB or other secretion mobilization techniques
• An inspiratory hold if often used
• Patients can often use body movements to help generate expiratory pressure
• Great for elderly patients and those who have pain with coughing
What are the characteristics of an assisted/quad cough?
• Place one hand, below xiphoid, and the heel
of the other hand
- Upper abdomen
• Patient will take a breath and cough as they exhale
• The clinician pushes inward and upwards as the patient cough.
• A pillow or towel can often be used for comfort
• Used for patients with a high lesion or low abdominal tone
What are the characteristics of an incentive spirometer?
- Breathe out (exhale) normally.
- Breathe in (inhale) SLOWLY.
- Goal is to get this marker to rise as high as possible.
- make sure this ball stays in the middle of the chamber while you breathe in.
- Hold your breath for a 3 to 5 seconds. Then slowly exhale.
- 10 to 15 breaths spirometer every 1 to 2 hours.
- Good for preventing atelectasis (alveolar collapse) and mobilizing secretions
- Used to maintain airways, especially in patients who are sitting around a lot
What are the characteristics of exercise for airway blockage?
- Full body exercise and mobility!
- Exercise facilitates increases in ventilation, airflow, chest wall movement and the mobilization of secretions.
- One of the best chest physical therapy techniques is getting patients moving!
Which segments are most likely to develop atelectasis following bedrest?
Posterior Basal
Which areas of the lung would you appreciate through auscultation vesicular lung sounds?
Peripheral
A patient presents to your clinic with an abrupt fever, tachypnea and productive foul smelling purulent colored sputum. On exam you notice increased fremitus in the R Posterior Basal Segments. Decreased breath sounds are noted over the R Posterior Basal Segment. Chest radiograph demonstrates lobular opacities in the R Posterior Basal segment. What is the most likely diagnosis?
Pneumonia
You examine a patient in the ICU following CABGx3 with decreased breath sounds and crackles in bilateral bases that resolve with coughing. Respiratory rate is slightly elevated, Blood pressure and HR are within normal limits and the patient is afebrile. What is the most likely cause of these findings?
Atelectasis
You are providing field coverage for a college rugby match and witness a player collapse to the ground grasping his left side after taking a hard blind-sided tackle. You rush onto the field to examine him. The patient is in distress however conscious and reports sharp 9/10 left sided chest pain, worsening with inspiration. He is dyspneic, tachycardic with a dropping blood pressure and trachea deviated to the right. His chest wall is extremely painful to palpation. On auscultation you appreciate absent breath sounds in all of the left lung segments. What is the most likely diagnosis?
Pneumothorax
Which airway clearance technique would be the most appropriate for a patient with increased pulmonary secretions following abdominal surgery?
Active Cycle of Breathing with Huff
Which ventilatory/breathing technique is effective at improving tolerance to activity in patients with COPD?
Pursed Lip Breathing
The apex of the lung has ___ in regards to perfusion and ventilation
Low Perfusion, High Ventilation
Which of the cough techniques are best for a post operative patient?
Splinted Cough
Which condition is defined as chronic inflammation of lungs characterized by variable airflow and airway hyper-responsiveness?
Asthma
