2.4 Pneumonia

Question 1

Restrictive Lung Disease

Answer 1

Lungs restricted from fully expanding w/ air

*Problems INSPIRING!

Question 2

Reasons for RLD?

Answer 2

Primary lung disease w/ stiff non-compliant lung parenchyma, IPF
Pleural abnormalities, effusions
Thoracic abnormalities that restrict chest wall mobility, kyphoscoliosis
Morbid obesity, pregnancy

Question 3

PNA

Answer 3

inflammatory response of bronchioles and alveolar spaces to an infective agent
*bacterial, fungal, or viral

Question 4

Chart review: Indirect

Answer 4

Amount of supplemental oxygen support required?
Trending up or down?
Lab values: WBC specifically.
Vital signs: temp, HR, RR, SpO2

Question 5

Subjective: Direct

Answer 5

Cough? color/consistency
SOB? activities/supplemental O2
Chest pain? SINS, aggs/eases, hx

Question 6

Hypothesis of Key Impairments

Answer 6

Respiratory System:
- decreased aerobic capacity due to hypoventilation and reduced gas exchange at alveolar level
- difficulty w/ airway clearance
MS System:
- decreased LE strength/power due to reconditioning
- impaired dynamic balanced due to reconditioning and loss of strength

Question 7

LOOK

Answer 7

Visual of breathing
Laborious?
Signs of chronic hypoxemia
- cyanosis
- digital clubbing
- hypertrophied accessory musculature

Clues in room

• tissues/suction tubing
• sputum
• VC w/ IS
• pre/post

Question 8

What is normal VC?

Answer 8

3.0-5.0L

Question 9

Volume vs. Capacity

Answer 9

Capacity - 2 or more volumes added (ERV+IRV)

Question 10

PFT’s involve

Answer 10

gender
height
age

mechanical function of the lungs
*compared to predicted value expected

Question 11

RLD: reduced lung volumes

Answer 11

VC
IC
TLC
decreased or normal RV

Question 12

PNA pt can become hypoxic. T/F

Answer 12

True

Question 13

LISTEN

Answer 13

Pulmonary auscultation
- inspiratory crackles & bronchial sounds

Dynamic Airway Assessment: Cough & Huff

• excessive coughing
• huffing

Bronchophony
- increased sounds in consolidated area

Mediate percussion
- dull in areas of consolidated

Question 14

FEEL

Answer 14

Chest Wall Mobility
- decreased pump handle

Tactile Fremitus
- increased remits in consolidated area

Question 15

Hypothesis: decreased aerobic capacity

What treatment?

Answer 15

• functional capacity in comity-dwelling adult
• measures response to therapeutic interventions

*Assess baseline, stop if the pt desat to 85%!! (sharp decline)

Question 16

When doing a test to check when a patient desats at what point do you stop even if they are asymptomatic?

Answer 16

85%!!

• Have face mask nearby!
• Do this only when closer to d/c or feels better!
• If everything checks out, balance/strength/power.

Question 17

For training what do you want the SpO2?

Answer 17

92%

Question 18

Respiratory Treatments

Answer 18

1st hypothesis - use interval training

2nd hypothesis - use IS, ACBT, effective cough mechanics

Question 19

GOALS of airway clearance

Answer 19

• Reduce airway obstruction caused by secretions
• Improve ventilation
• Optimize gas exchange

Question 20

Who’s appropriate for airway clearance?

Answer 20

Atelectasis
Difficulty mobilizing secretions
- impaired ciliary motion
- reduced lung inflation
- impaired lung elasticity
- impaired chest wall mobility and biomechanics
- weak or fatigued respiratory muscles
*Post-op pts!!
*Intubated
*General anesthesia

Question 21

ACBT: PT moving towards this!!

Answer 21

• Patient actively participates
• Promotes patient I/autonomy

Previous treatments used:
*Postural drainage
*Percussion
*Vibration & shaking
PEP devices
High frequency chest wall oscillation

Question 22

How long after a meal should ACBT performed?

Answer 22

30m - 1hr

Question 23

Inhaled bronchodilator meds should be used how long before secretion removal treatment?

Answer 23

20-30 mins at least

Question 24

Inhaled antibiotics should be scheduled AFTER ACBT. T/F

Answer 24

True!

Question 25

ACBT: 3 ventilatory phases

Answer 25

1) Breathing control 2) Thoracic expansion 3) Forced expiratory technique

Question 26

ACBT: Breathing control | Relaxed TV breathing

Answer 26

- Gentle TV breathing w/ relaxed upper chest/shoulder - Prevent bronchospasm - Needs to last long enough for patient to relax - 10-30s *Chair for good posture, can be minutes

Question 27

ACBT: Thoracic expansion Deep breathing TEE

Answer 27

- Deep inspiration helps loosen secretions - Allows air to get behind the secretions an assist w/ mobilization *IS, they already know how to use this

Question 28

ACBT: FET | Huffing

Answer 28

- Huffing to move secretions form smaller/peripheral distal airways to larger/proximal/upper airways that can be expectorated with a cough * Cough only reaches the lung generations within the conducting zone from the respiratory zone! * Technique saves energy for functional activity! * Always follow with breathing control * If wheezing present then increase breathing control time

Question 29

How do we direct FET to specific areas of the lungs?

Answer 29

- To mobilize secretions from peripheral airways, a LONG and QUIET huff after a MEDIUM-sized inspiration will be effective - To clear secretions that have reached the larger proximal airways (were in the distal and it's otw out), a SHORT and LOUDER huff after a deep inspiration will be effective.

Question 30

When would you spend more time in the breathing control phase?

Answer 30

Reactive airways or appear anxious Wheezes or become wheezy Difficult diaphragmatic breathing, excessive accessory muscles

Question 31

When would you spend more time in the thoracic expansion phase?

Answer 31

Atelectasis Post-op Cardiac sx

Question 32

When would you spend more time in the FET phase?

Answer 32

Requires increased sputum expectoration They have a productive cough *PNA may not spend a lot of time here! UNLESS they have productive cough!

Question 33

Treatment Efficacy

Answer 33

``` Pulmonary auscultation Vital signs IS vs. formal PFT Modified BORG Dyspnea (resting vs. activity) 6MWT & supplemental O2 ```

Question 34

Incentive Spirometer (IS), Sustained Maximum Inspiration (SMI)

Answer 34

visual/audio feedback that encourages slow, deep inspiration - treat & prevent atelectasis and PNA, post-op pts for high risk post-op complications - promotes alveolar expansion, gas exchange, thoracic expansion, promote improvement in overall oxygen transport and pulmonary function

Question 35

Position for IS?

Answer 35

Upright in bed, EOB, or chair | Shoulders neutral or slightly snap retracted, shin slightly up

Question 36

Thoracic expansion exercises (TEE)

Answer 36

Slowly breathe in as deep as possible Keep indicator between arrows Hold breath for 3-4s or as long as possible Gently exhale and release the inspired air

Question 37

ACBT

Answer 37

Utilized to clear secretions and maximize ventilation of atelectatic lung segments

Question 38

Two TEE phase may e necessary to loosen secretions before FET can follow. T/F

Answer 38

True

Question 39

In pts w/ bronchospasm or unstable airways, breathing control phase may be long as 10-20s

Answer 39

True

Question 40

When can the ACBT treatment be concluded?

Answer 40

When huff from medium-sized inspiration through complete expiration is nonproductive and dry sounding for TWO cycles in a row.