Introduction To Treatment

Question 1

Aiming to treat

Answer 1

Sputum retention
Reduced lung volume
Increased work of breathing
Pain
Fatigue
Reduced exercise tolerance
Hypoxia and respiratory failure - can be caused by several problems, can be life-threatening

Question 2

Oxygen therapy

Answer 2

Is a drug
Should be prescribed with target sats
Except in an emergency situation when someone is critically unwell - when a patient is critically unwell or has SpO2 < 85%, once stable, aim for SpO2 94-98% or patient-specific target range

Question 3

Oxygen therapy: target saturations

Answer 3

94-98% for most (scale 1)
88-92% for patients at risk of CO2 retention (scale 2)
92-96% for Covid positive patients

Question 4

Oxygen therapy: oxygen delivery

Answer 4

Nasal specs/ cannulae - up to 6L but generally 4L
Face mask - high flows, 10L
Resivour mask - 15L
Humidified system - oxygen with moisture in it, can be more comfortable than dry oxygen, good if the patient has mucus retention, 60% oxygen
Venturi system - different coloured valves for different percentage of oxygen, 15L
Trachemasks - accommodate the tracheostomy, normally humidified

Question 5

Oxygen therapy: titrating up and down

Answer 5

Increased FiO2 if SpO2 is lower than target range
Decrease FiO2 if SpO2 is higher than target range
Monitor SpO2 for 5 minutes at every change
If FiO2 is increased, medical assessment is needed
Ensure any changes are documented

Question 6

Oxygen therapy: to much oxygen

Answer 6

Absorption atelectasis - absorption of oxygen from alveoli exceeds replenishment of alveolar gas, so that the alveoli are no longer held open by a cushion of inert nitrogen
High concentrations may impair the respiratory drive of hypercapnia COPD patients
Excess oxygen depletes protective anti-oxidants, causing oxygen toxicity - inflammatory response of lung tissue, predominantly
Effect the CV system - increase systemic vascular resistance

Question 7

Oxygen therapy: nebulisers

Answer 7

Direct delivery of medication to the lungs
Saline (0.9% or 7%) - can aid airway clearance by reducing the viscosity of sputum
Bronchodilators can reduce bronchoconstriction to aid air flow
Device that delivers smaller particles that can be inhaled by the lungs
Flow rate of 6-8L in order for the particles to be small enough to be breathed in

Question 8

Oxygen therapy: other medications

Answer 8

Consider from drug history
Pain management - if in pain they will struggle to participate in what you want them to do
Timing of these can be important

Question 9

Positioning

Answer 9

For postural drainage/ gravity assisted drainage
For V/Q matching
For work of breathing
Basic invention, and can be used with other treatments

Question 10

Positioning: postural drainage

Answer 10

Uses gravity to assist drainage of secretions
Area to be drained position highest
Most affected area drained first
Ideally 10 minuted in each position
Maximum of 3 positions per session
A position for each lobe

Question 11

Positioning: postural drainage precautions/ contraindications

Answer 11

When placing head down
Increased work of breathing
Head and neck pathology/ raised intercranial pressure
Cardiovascular pathology
Abdominal pathology
Pregnancy
Obesity
Care with attachments
Reflex GERD/ GORD or nausea

Question 12

Positioning: V/Q matching

Answer 12

Repositioning patient to facilitate deep breathing and expansion
You can position the patient into side lying so the middle zone is in line with the larger airways so the sputum/ mucus is drained into them so they can be cleared

Question 13

Positioning: to decrease work of breathing

Answer 13

Aims - stabilise shoulder girdle/ optimise thoracic cage movement, dome a flattened diaphragm, decrease energy consumption
Forward lean standing and sitting
Supported forward lean sitting
Supported high side lying

Question 14

Active cycle of breathing technique (ACBT)

Answer 14

3 stages repeated as a cycle
1. Breathing control
2. Thoracic expansion exercises (TEEs)
3. Forced expiratory technique (FET)
Flexible approach and can be adapted without assistance
Patients with long term condition e.g. bronchiectasis, may be taught this as a self-management strategy for regular airway clearance

Question 15

Active cycle of breathing technique (ACBT): breathing control

Answer 15

Tidal breathing
Encourage - relaxation of upper chest, diaphragmatic breathing; can allow the patient to control their breathing
Proprioceptive facilitation
Continue until patient is ready to progress
1. One hand on stomach and one hand on chest, breath in through nose
2. Feel stomach expand against your hand and your chest should barely move
3. Breathe out through your mouth and you’ll feel your stomach sink back down

Question 16

Active cycle of breathing technique (ACBT): thoracic expansion exercises (TEEs)

Answer 16

Deep breathing exercises - 3 to 5 breaths normally
Encouraging lateral chest expansion - hands on ribs for proprioceptive feedback
Can add a 3 second hold and a ‘sniff’
Hold - decrease collapsed lung tissue and may be good for those with lung pathology as air will first fill the unobstructed area and then give time for ventilation of collateral pathways
Increased collateral ventilation
Monitor - patients can become lightheaded

Question 17

Active cycle of breathing technique (ACBT): forced expiratory technique (FET)

Answer 17

Forcefully expelling air through an open throat and mouth
Huff - trying to fog up a mirror
Move sputum form small to larger airways
Medium to high volume
Not to many as it can cause bronchospasm
May initiate a cough
Normal breath in and long huff out - medium, moved from more peripheral airways
Deep breath in and short sharp huff out - high, moved from more central airways

Question 18

Active cycle of breathing technique (ACBT): physiology of FET

Answer 18

Equal pressure point - point at which pressure inside the airway is equal to the pressure outside (intrapleural pressure)
Where in the airway this begins depends on where in the airway the pressure is equal to that outside the airway aka a the EPP
The EPP depends in the volume of inspired air

Question 19

Active cycle of breathing technique (ACBT): adapt the treatment to the patient

Answer 19

Breathing control - can reduce work of breathing
Thoracic expansion exercises - hold and sniff can help improve lung volume
Forced expiratory technique - high and low volumes to aid sputum clearance, can also be taught prophylactically
Add in more or less of each component to meet the needs of the patient

Question 20

Active cycle of breathing technique (ACBT): precautions

Answer 20

Consider whether the patient can follow instructions
Bronchospasm - care with FET, may have or need bronchodilators prior to maximise effects
Consider the numbers of TEE and effect on blood pressure

Question 21

Manual techniques: percussion

Answer 21

Rhythmical patting of the chest with a cupped hand; creates a cushion of air
Perform during normal tidal breathing
Loosens the sputum from the walls of the airways
Use a towel
Side lying

Question 22

Manual techniques: shakes

Answer 22

Application of large oscillatory movements to the chest wall
Usually performed on expiration
Mobilise secretions along the airways
Push in and out not up and down

Question 23

Manual techniques: vibrations

Answer 23

Fine oscillatory movements to the chest wall
Usually performed on expiration
Mobilise secretions along the airways

Question 24

Manual techniques: precautions

Answer 24

Bronchospasm
Pain
Osteoporosis
Bone metastases
Near chest drains

Question 25

Manual techniques: contraindications

Answer 25

Fractures (ribs) Surgical wounds Frank haemoptysis Severe osteoporosis Sever hypoxia

Question 26

Mobilisation

Answer 26

Can be to - the edge of the bed, a chair, walking from A to B, achieving functioning level to return home May require aids to assist - for support and safety, to reduce the load and work of breathing Useful for addressing our three main problems

Question 27

Exercise

Answer 27

Maintain range of motion and muscle strength Improve exercise tolerance Increase lung volume Aid sputum clearance Prescription - what type and to what level, reps and sets Patients can be independent with exercises

Question 28

Reduce exercise tolerance

Answer 28

Incorporate pacing and breathlessness management techniques Some patients need supplemental oxygen to be able to mobilise Walking aids might help Monitoring - BORG scale; self assessment perceived exertion, often used in pulmonary rehab, used to measure rate of perceived exertion/ breathlessness, various scales

Question 29

Pulmonary rehabilitation

Answer 29

6-12 week programme Education and exercise - cardio and strengthening Usually run in groups Should involve multi disciplinary teams Aims to improve patients physical fitness and ability to manage their own condition

Question 30

Mobilisation and exercise: education and advice

Answer 30

Long term secretion management Hydration and diet Medication Pacing and activities Exercise/ pulmonary rehabilitation Smoking cessation Signs of infection

Question 31

Evaluate and re-evaluate before, during and after every treatment

Answer 31

Evaluate the patient - assess; include appropriate outcome measures, consider safety and multi disciplinary teams goals, negotiate a plan with the patient Provide treatment - implement treatment, continuously monitor effect Review - reassess with outcome measures, re-consider safety and multi disciplinary teams goals, re-negotiate the plan with the patient (as necessary)