Lung Sx, Patients Requiring Ventilatory Support, Outpatient Pulmonary Therapy

Question 1

VATs

Answer 1

Referred to as a VATs (Video Assisted Thoracotomy)

Video camera used

if they can avoid it they do not want to open the chest

Question 2

What does CDI stand for

Answer 2

clean, dry, intact

Question 3

Types of lung surgery removal

Answer 3

Lobectomy – a lobe is removed
Segmentectomy – a lung segment is removed
Wedge Resection – a wedge shaped section of the lung is resected
Pneumonectomy – an entire lung is removed

Question 4

What would be INEFFECTIVE for a pleural effusion

Answer 4

postural drainage and percussion, vibration

Question 5

Pleurodesis

Answer 5

an irritant (often talc powder) is introduced in the pleural space to create inflammation and tack the two pleura together to prevent recurrent fluid accumulation

Question 6

What O2 reading is pretty serious

Answer 6

under 86

Question 7

Ventilators

Answer 7

Patients who are ventilator dependent may also be referred for physical therapy/chest PT

Ventilation can be a short or long term intervention

Question 8

Four primary reasons for employing endotracheal intubation:

Answer 8

1) Upper airway obstruction
2) Inability to protect lower airway from aspiration
3) Inability to clear secretions from the lower airways
4) Need for positive pressure mechanical ventilatory assistance

Question 9

Four types of AIRWAY ADJUNCT devices

Answer 9

Oral pharyngeal airway (often used in emergencies)
Nasal pharyngeal airway
Oral endotracheal tube (commonly seen post sx)
Tracheostomy tube

Question 10

When would an Oral pharyngeal airway be used

Answer 10

emergencies

Question 11

Short-term or Long-term? Oral endotracheal tube (ETT)

Answer 11

Short-term

commonly seen post sx

Question 12

Tracheostomy is for and would affect

Answer 12

For patients who require long term intubation

Incision is made in the tracheal rings

Provides greater mobility

Decreases risk of irritation/infection

Tracheostomy tube is inserted below the level of the vocal chords

-speaking

Question 13

Tracheostomy Tube and considerations for PT

Answer 13

if tubing has condensation you want to drain it

Question 14

Decannulation is

Answer 14

If the tube comes out it is referred to as a
DECANNULATION

Patient can still breathe

If accidental: needs to be rectified immediately

Question 15

What is weaning

Answer 15

The process of progressing from mechanical ventilation to breathing on one’s own is referred to as WEANING

Question 16

Intubation vs Tracheostomy and mobilization

Answer 16

PT intervention for pt’s with tracheostomy has long been standard practice

Intubated pts less mobile
require more assistance

Trached pts ↑ Independence

Question 17

What is a passy muir and what are some considerations

Answer 17

Tracheostomy tubes can be accessorized with valves to facilitate speech. Passy-Muir is the most common valve

To let them speak they would need this but keep in mind when it is in it is harder to breath, so dont ask person to do anything that demanding

Question 18

Vents are

Answer 18

Mechanical ventilators deliver gas to patient’s lungs by creating positive pressure to ↑ intrathoracic pressure to expand the chest wall

You can tell how much of the work of breathing is being provided by the ventilator by checking the setting

Question 19

Four Basic Settings for Vents

Answer 19

CMV (Continuous Mandatory Ventilation)

A/C (Assist Control)

IMV (Intermittent Mandatory Ventilation)

CPAP (Continuous Positive Airway Pressure)

Question 20

CMV

Answer 20

Controlled Mandatory Ventilation
(set tidal volume and rate)

Machine is preset

Ignores patient effort

Provides set TV and rate

Uncomfortable if patient is conscious

Question 21

What is an A/C vent setting and what potential harm could be caused

Answer 21

Assist Control - responds to pt effort

Non-weaning mode

Triggered by patient effort

Set rate provides breath in absence of pt effort

Ventilator provides breath at preset tidal volume with every patient effort

Potential for hyperinflation or resp alkalosis

Question 22

Which vent is for weaning

Answer 22

IMV

Question 23

CPAP

Answer 23

Continuous Positive Airway Pressure

Ventilator provides an elevated baseline pressure to help a patient breathe spontaneously

Ventilator DOES NOT initiate breaths

less work for person to breath

Question 24

Weaning stages

Answer 24

Weaning can progress from:
CMV→
SIMV→
CPAP→
Tracheostomy Collar (with supp O2)
→Nasal Cannula (trach capped)
→Room Air

Question 25

FI O2 is recorded by and how is this different from a nasal cannula

Answer 25

Supplemental O2 is commonly used with a trach collar Record how much O2 is used by documenting FIO2 (Fraction of Inspired O2) (remember RA = 21% so an FIO2 of 60% is ≈ 3X RA) Differs from nasal cannula which is recorded in liters of O2

Question 26

Documented differences of O2 Levels between a | NC vs Collars

Answer 26

NC in l for liters Collars and masks in FIO2 for fraction of inspired oxygen

Question 27

Vented pts can: | PT treatment

Answer 27

Dangle Transfer to geri-chair or regular chair March in place Ambulate to limit of circuit

Question 28

Exclusion Criteria for | Pulmonary PT

Answer 28

``` Uncontrolled CHF Unstable angina Resting tachycardia (> 100 BPM, slightly higher for post op patients-120 hard cut off) Severe bradycardia (< 50 BPM) Uncontrolled HTN Uncontrolled Pulmonary HTN Other illness which precludes exercise Inability to learn Demonstrated poor motivation Refusal to participate in smoking cessation program Guilty of disruptive behavior ```

Question 29

Third Party Payers for Pulmonary rehab require

Answer 29

Documented Respiratory Disease Documented Functional Limitations PFTs, other tests (< 60% of normal function)

Question 30

Pulmonary Care

Answer 30

Respiratory treatment techniques for clearing secretions and relieving dyspnea Bronchial drainage Breathing techniques Cough facilitation Postural correction and positioning to improve breathing Relaxation techniques

Question 31

Types of Airway Clearance Techniques

Answer 31

Active Cycle of Breathing Autogenic Drainage (used for CF) Coughing Techniques

Question 32

ENERGY CONSERVATION TECHNIQUES | key points

Answer 32

``` Space tasks throughout the day Monitor how you feel throughout the day Take rest breaks after meals/throughout the day Rest BEFORE you are exhausted Perform strenuous activities when you feel you have the most energy Ask for help when you need it Slide things instead of carrying them Use a basket for rollator ```

Question 33

BODY MECHANICS AND MOVEMENTS

Answer 33

Maintain a straight back, bend from hips and knees Use large muscles over small NEVER RUSH Move slowly, keep your arms close to your body Sit if possible when dressing, grooming, preparing food

Question 34

BREATHING PATTERNS

Answer 34

Use breathing patterns before, during and after activities PLB Diaphragmatic Paced - exhale with effort

Question 35

Dealing with SOB Exacerbations

Answer 35

``` Stop activity Find a comfortable position Use PLB and diaphragmatic breathing Do not inhale through the mouth Breathe initially at whatever speed needed to regain control gradually slow rate of breathing ```

Question 36

What is Fremitus

Answer 36

Vibration Produced by voice or presence of secretions in airways Transmitted to chest wall Abnormal Finding Increased Fremitus indicates presence of secretions or consolidation Decreased Fremitus indicates presence of air or fluid in the pleural space

Question 37

Postural Drainage Contraindications

Answer 37

ICP > 20 mmHg Unstabilized head/neck injury Active hemorrhage Hemoptysis (use judgment) Empyema (pus) Bronchopleural fistula Pulmonary edema assoc with CHF Large pleural effusions PE Confused/anxious patients Rib fracture Surgical wound Post op where joint compression contraindicated

Question 38

Contraindications Trendelenburg

Answer 38

Neuro dx: Cerebral aneurysm, ICF drain, coma, recent CVA, uncontrolled sz ↑ ICP contraindicated Uncontrolled HTN Distended abdomen Post esophageal procedures Cardiovascularly unstable: Acute MI, pulmonary HTN, arrhythmias Aneurysm, esp AAA Continuous tube feedings Unstable fluid balance: CHF, during HD, ascites Recent hemoptysis related to lung CA Uncontrolled airway, aspiration risk

Question 39

Percussion is used for, and you should do it for at least (time)

Answer 39

``` Loosens secretions Use cupped hand Should sound hollow Percuss only over ribs Percuss for at least one minute ```

Question 40

Contraindications for percussion

Answer 40

Pneumothorax Platelets < 50,000 Cardiovascularly unstable pt Over rib fx or lesion Osteoporosis (dexa 3), CA mets, prolonged steroid use Over sx incisions/sternotomy Over recent graft, burn or wound ``` also: When blood too thin (↑ INR, etc.) Hemoptysis (use judgment) Undrained empyema Subcutaneous emphysema PE Flail chest Awaiting R/O for MI Acute TB Severe pain Recent spinal fusion ```

Question 41

Vibration, is it different from percussion

Answer 41

Gentler than percussion Uses flat hand Always go “down and in” Coordinate with exhale