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Flashcards in Pulmonary Deck (116)
1

Upper airways

nose or mouth: entry point into respiratory system

pharynx: common area used for both respiratory and digestive systems

larynx: connects the pharynx to the trachea, including the epiglottis and vocal cords

2

lower airways

the conducting airways, trachea to terminal bronchioles, transport air only. No gas exchange occurs.

The respiratory unit: respiratory bronchioles, alveolar ducts, alveolar savs and alveoli. Diffusion of gas occurs through all these structures

3

R lung

divided into 3 lobes by the oblique and horizontal fissures; each lobe divides into segments- total of 10

4

L lung

divided into 2 lobes by the oblique fissure; each lobe divides into segments- total of 8

5

pleura

Parietal pleura covers the inner surface of the thoracic cage, diaphragm and mediastinal border of the lung

visceral pleura: wraps the outside surface of the lung, including the fissure lines

Intracellular space is the potential space between the 2 pleurae that maintains the approximation of the rib cage and lungs, allowing forces to be transmitted from 1 structure to another

6

primary muscles of inspiration

Primary muscle: diaphragm
-made up of 2 hemidiaphragms, each with a central tendon.
-at rest, the hemidiaphragms are arched high into the thorax
-when the muscle contracts, the central tendon is pulled down, flattening the dome resulting in a protrusion of the abdominal wall during inhalation

Additional primary muscles: portions of the intercostals

7

Accessory muscles of inspiration

used when a more rapid or deeper inhalation is required or in disease states

upper 2 ribs are raised by the scalenes and SCM

rest of the ribs are are raised by the elevator costar and serrates

by fixing the shoulder girdle- the trap, pecs and serratus can become muscles of inspiration

8

expiratory muscles of ventilation

resting expiration results from a passive relaxation of the inspiratory muscles and the elastic recoil tendency of the lung
-normal abdominal tone holds the abdominal contents directly under the diaphragm, assisting the return of the diaphragm to the normal high domed position

expiratory muscles are used when a quicker/fuller expiration is desired
-QL, portions of the intercostals, muscles of the abdomen and triangularis sterni

9

ventilation with patients who lack abdominal musculature (SCI)

have a lower resting position of the diaphragm, decreasing inspiratory reserve

the more upright the body position, the lower the diaphragm and the lower the inspiratory capacity

the more suing the more advantageous the position of the diaphragm

an abdominal binder may be helpful in providing support to the abdominal viscera, assisting ventilation. Care must be taken not to constrict the thorax

10

Resting end expiratory pressure (REEP)

the point of equilibrium where inspiratory/expiratory forces are balanced
-occurs at end tidal expiration

Forces on the rib cage/breathing mechanics:
-elastic recoil of the lung parenchyma pulls lungs, and bony thorax into a position of exhalation (inward pull)
-bony thorax pulls into a position of inspiration (outward pull)

11

Tidal volume (TV)

volume of gas inhaled (or exhaled) during a normal resting breath

normal adult: 500mL
normal infant: 20 mL

12

inspiratory reserve volume (IRV)

volume of gas that can be inhaled beyond a normal resting tidal inhalation

13

Expiratory reserve volume (ERV)

volume of has that can be exhaled beyond a normal resting tidal expiration

14

Residual volume (RV)

volume of gas that remains in the lungs after ERV has been exhaled

15

Inspiratory capacity (IC)

IRV + TV

the amount of air that can be inhaled from REEP

16

Vital capacity (VC)

IRV + TV + ERV

the amount of air that is under volitional control; conventionally measured as forced expiratory vital capacity (FVC)

17

Functional residual capacity

ERV + RV

the amount of air that resides in the lungs after a normal resting tidal exhalation

18

Total lung capacity

IRV + TV + FRV + RV

the total amount of air that is contained within the thorax during a maximum inspiratory effort

19

Forced expiratory volume (FEV1)

the amount of air exhaled during the 1st second of FVC

in the healthy person, at least 70% of FVC is exhaled within the first second

FEV1/FVC x100 --- >70%

20

ventilation vs. respiration

ventilation= movement of gas in and out of the pulmonary system

respiration= diffusion of gas across the alveolar capillary membrane

21

arterial oxygenation

=the ability of arterial blood to carry oxygen

22

PaO2 in the arterial blood

Partial pressure of oxygen in the arterial blood

depends on the integrity of the pulmonary system, the circulatory system and the atmosphere.

95-100% in a young, health person
decreases with age

Hypoxemia 100%

23

alveolar ventilation

ability to remove CO2 from the pulmonary circulation and maintain pH

24

pH

indicates the concentration of free floating hydrogen ions within the body

normal range: 7.35-7.45

25

PaCO2

the partial pressure of CO2 within the arterial blood

normal: 35-45 mmHg

removal or retention of CO2 by the respiratory system alters the pH of the body in an inverse relationship
-increase in the PaCO2 decreases the body's pH
-decrease in PaCO2 increases pH

26

hypercapnea

PaCO2 >45 mmHg

increase in the PaCO2 decreases the body's pH

27

hypocapnea

PaCO2

28

HCO3-

amount of bicarbonate ions within the arterial blood

normal: 22-28 mEq/mL

removal or retention of HCI3- alters the pH of the body in a direct relationship
-increase in HCO3- increases body's pH
-decrease in HCO3- decreases body's pH

29

optimal respiration occurs when:

ventilation and perfusion (BF to the lungs) are matched

different ventilation and perfuse relationships exist

30

dead space

anatomical (conducting airways) or physiological (diseases such as PE)

space that is well ventilated but in which no respiration (gas exchange) occurs

"gravity independent areas"

31

shunt

no respiration occurs because of a ventilation abnormality

complete atelectasis of a respiratory unit allows the blood to travel through the pulmonary capillary without gas diffusion

"gravity dependent areas"

32

effects of body position on the ventilation/perfusion relationship:

UPRIGHT POSITION:
-perfusion (Q) is gravity dependent- most pulmonary blood is found at the base of the lung
-ventilation: at the static point of REEP, the apical alveoli are fuller than those at the base. During the dynamic phase of inspiration, more air will be delivered to the less filled alveoli at the bases causing a greater change in Ve at the bases
-V/Q ratio: apices are gravity independent with the lowest blood flow (Q). Although relatively low, there is still more air than blood, resulting in a high V/Q ratio (dead space).
-V/Q of the middle zone of the lung are evenly matched.
-V/Q of the bases are gravity dependent and therefore, have the most Q. Although Ve is relatively high, there is more blood than air, resulting in a (relatively) low V/Q ratio (shunt)


OTHER POSITIONS:
-gravity independent area-- dead space
-gravity dependent area-- shunt

33

Ventilation/perfusion ratio (V/Q ratio):

the ratio of pulmonary alveolar ventilation to pulmonary capillary perfusion

34

central control centers for ventilation

cortex, pons, medulla and ANS

35

patient interview:

chief complaint
-usually loss of function, ADLs

present illness
-initial onset
-progression
-worsens of improves

history
-occupation and exposures
-PMH- heart disease? long term steroid?
-current meds that can mask (steroids) or alter (BB, bronchodilators) VS
-social habits: smoking, alcohol, drugs
-exercise
-cough/sputum
-family history

36

tachypnea

RR > 20 bpm

37

key observations during examine

peripheral edema seen in gravity dependent areas and jugular venous distention indicates possible heart failure
-RV hypertophy and dilation (cor pulmonale) are common sequelae to chronic lung disease

body positions: stabilizing the shoulder girdle places the thorax in the inspiratory position and allows the additional recruitment of muscles for inspiration (pectorals)

color: cyanosis (sign of hypoxemia)

digital clubbing (sign of chronic hypoxemia)

Neck:
-observe the trachea- should be midline
-use of accessory muscles of ventilation

Thorax:
-changes in body thorax- pectus excavate, cranium
-ant-post:lat dimension-- 1:2 ratio (With obstructive pulmonary disease, the lung recoil force is decreased, resulting in a barreled chest and increased AP dimension)
-R and L thorax should be symmetrical
-healthy thoracic excursion should be 2-3 inches

38

lung auscultation: normal lung sounds

intensity of inspiration and expiration is quieter at the bases than the apex

vesicular- normal breath sound: a soft rustling sound heard t/out all of inspiration and the beginning of expiration

Bronchial: a more hollow, echoing sound normally found only over the R superior anterior thorax- corresponds to an area over the R main stem bronchus.
-all of inspiration and most of expiration are heard with bronchial breath sounds

*Decreased: a very distant sound not normally heard over a healthy thorax; allows only some of the inspiration to be heard. often associated with obstructive lung diseases

39

adventitious (extra) lung sounds:

Crackles: "rales, crepitations"
-crackling sound heard usually during inspiration that indicates pathology
-could be result of air bubbles in secretions or movement of fibrotic tissue during breathing
-atelectasis, fibrosis, pulmonary edema, LV CHF

Wheezes/rhonci: a musically pitched sound, usually heard during expiration, caused by airway obstruction (asthma, COPD, foreign body aspiration)
-with severe airway constriction, as with croup, wheezes may be heard on inspiration as well

40

vocal sounds

normal:
-loudest near trachea and main stem bronchi
-softer and less clear at more distal areas

abnormal:
-may be heard through fluid-filled areas of consolidation, cavitation lesions or pleural effusions
-Egophony
-bronchopony
-whispered pectoriloquy

41

egophony

nasal or bleating sound heard during auscultation

"E" sounds are transmitted to sound like "A"

-may be heard through fluid-filled areas of consolidation, cavitation lesions or pleural effusions

42

Bronchophony

characterized by an intense, clear sound during auscultation, even at the lung bases
"99" "66"

-may be heard through fluid-filled areas of consolidation, cavitation lesions or pleural effusions

43

Whispered pectoriloquy

occurs when whispered sounds are heard clearly during auscultation

-may be heard through fluid-filled areas of consolidation, cavitation lesions or pleural effusions

44

pulmonary radiographic exam

chest x-ray: 2D radiographic film to detect presence of abnormal material (exudate, blood) or a change in pulmonary parenchyma (fibrosis, collapse)

CT: cross sectional plane

MRI

Ventilation perfusion (V/Q) scan: matches the ventilation pattern of the lung to the perfusion pattern to identify the presence of PE

Fluroscopy: continuous x ray beam allows observation of diaphragmatic excursion

45

Respiratory alkalosis

high pH
low PaCO2
normal HCO3-

causes: alveolar hyperventilation

S&S:
-dizzy
-syncope
-tingling
-numbness
-early tetany

46

respiratory acidosis

low pH
high PaCO2
normal HCO3-

causes: alveolar hypoventilation

S&S
-Early: anxiety, restless, SOB, HA
-Late: confusion, drowsy, coma

47

metabolic alkalosis

high pH
normal PaCO2
high HCO3-

causes:
-bicarbonate ingestion
-vomiting
-diuretics
-steroids
-adrenal disease

S&S
-weakness
-mental dullness
-possibly early tetany

48

metabolic acidosis

low pH
normal PaCO2
high HCO3-

causes:
-diabetic, lactic or uremic acidosis
-prolonged diarrhea

S&S:
-secondary hyperventilation
-nausea
-lethargy
-coma

49

pulmonary function tests

evaluate lung volumes, capacities and flow rates

used to diagnose disease, monitor progression and determine the benefits of medical management

50

bronchoscopy

endoscope used to view, biopsy, wash, suction and/or brush the interior aspects of the tracheobronchial tree

51

list of acute pulmonary diseases

bacterial pneumonia

viral pneumonia

aspiration pneumonia

tuberculosis (TB)

pneumocystis pneumonia

SARS (severe acute respiratory syndrome)

52

bacterial pneumonia

an intra-alveolar bacterial infection

gram-positive bacteria usually acquired in the community: streptococcal

gram-negative bacteria usually develop in a host with underlying, chronic, debilitating conditions, severe acute illness and recent antibiotic therapy
-result in early tissue necrosis and abscess formation

pertinent physical findings:
-shaking chills
-fever
-chest pain if pleuritic involvement
-cough becoming productive or purulent, blood streaked or rusty sputum
-decreased or bronchial break sounds and/or crackles
-tachypnea
-increased WBC count
-hypoxemia
-hypocapnea, initially, hypercapnia with increasing severity
-CXR confirmation of infiltrate

53

Viral pneumonia

an interstitial or intra-alveolar inflammatory process caused by viral agents (influenza, adenovirus, cytomegalovirus, herpes, parainfluenza respiratory syncytial virus, measles)

Pertinent physical findings:
-recent hx of upper respiratory infection
-fever
-chills
-dry cough
-headaches
-decreased breath sounds and/or crackles
-hypoxemia and hypercapnea
-normal WBC count
-CXR confirmation of interstitial infiltrate

54

aspiration pneumonia

aspirated material causes an acute inflammatory reaction within the lungs
-usually found in patients with impaired swelling (dysphagia), fixed neck extension, intoxication, impaired consciousness, neuromuscular disease, recent anesthesia

Pertinent physical findings:
-symptoms begin shortly after aspiration event (hours)
-cough may be dry at the onset, progresses to produce putrid secretions
-dyspnea
-tachypnea
-cyanosis
-tachycardia
-wheezes and crackles with decreased breath sounds
-hypoxemia, hypercapnea in severe cases
-chest pain over the involved area
-fever
-WBC count shows varying degrees of leukocytosis
-CXR initially shows pneumonitis; chronic aspiration shows necrotizing pneumonia with cavitation

55

Tuberculosis (TB)

mycobacterium tuberculosis infection spread by aerosolized droplets from an untreated infected host
-incubation period: 2-10 weeks
-primary disease lasts 10 days to 2 weeks

post primary infection is reactivation of dormant TB bacillus, which can occur years after primary infection

2 weeks on appropriate anti tuberculin drugs renders the host noninfectious.
-during infectious stage, patient must be isolated from others in a negative-pressure room
-anyone else must wear TB mask and follow universal precautions
-if patient leaves the room they wear mask

meds taken for prolonged periods: 3-12 months

increased incidence of TB in patients with HIV

Pertinent findings of primary disease: can go unnoticed, as it causes only mild symptoms:
-slight nonproductive cough
-low grade fever
-possible CXR changes consistent with primary disease

Pertinent findings of post primary infection:
-fever
-weight loss
-cough
-hilar adenopathy: enlargement of the lymph nodes surrounding the hilum
-night sweat
-crackles
-hemoptysis: blood streaked sputum
-WBC - increased lymphocytes
-CXR shows upper lobe involvement with air space densities, cavitation, pleural involvement, and parenchymal fibrosis

56

pneumocystis pneumonia (PCP)

pulmonary infection caused by a fungus in immunocompromised hosts
-patients with transplantation, neonates or HIV

Pertinent physical findings:
-insidious progressive SOB
-nonproductive cough
-crackles
-weakness
-fever
-CXR shows interstitial infiltrates
-CBC shows no incidence of infection

57

hemoptysis

blood streaked sputum

58

SARS

severe acute respiratory syndrome

an atypical respiratory illness caused by a corono-virus

initial outbreak in southern mainland China with worldwide spread

Pertinent physical findings:
-high temperature
-dry cough
-decreased WBC, platelets, lymphocytes
-increased liver function tests
-abnormal CXR with borderline breath sound changes

59

List of chronic obstructive diseases

Chronic obstructive pulmonary disease (COPD)

Asthma

Cystic fibrosis

Bronchiectasis

Respiratory distress syndrome (RDS)

Bronchopulmonary dysplasia

bronchitis

emphysema

60

COPD

chronic obstructive pulmonary disease

characterized by airflow limitation that is not fully reversible
-usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases


Physical findings: increase in severity as the stages of disease advance
- cough/sputum production/hemoptysis
- dyspnea on exertion
- breath sounds decreased with adventitious sounds
- increased RR
- weight loss/anorexia
- increased AP diameter of chest wall
- cyanosis
- clubbing
- postures to structurally elevate shoulder girdle
- ABG changes of hypoxemia, hypercapnea
- PFT showing obstructive disease (decreased FEV1, FVC, FEV1/FVC ratio; increased FRC and RV)

61

stages of COPD

stage 1 (mild)
-FEV1/FVC 80% predicted
-with or without chronic symptoms

Stage 2 (moderate)
-FEV1/FVC

62

Asthma

increased reactivity of the trachea and bronchi to various stimuli (allergens, exercise, cold); reversible in nature

manifests by widespread narrowing of the airways due to inflammation, smooth muscle constriction and increased secretions

even during remission, some degree of airway inflammation is present

Physical findings during exacerbation:
-wheezing, possible crackles and decreased breath sounds
-increased secretions of variable amounts
-dyspnea
-increased accessory muscle use
-anxiety
-tachycardia
-tachypnea
-hypoxemia
-hypocapnea: responding to hypoxemia, there is an increased RR and minute ventilation. This will decrease PaCO2. with severe airway constriction- an increase in minute ventilation can't occur and hypercapnia can be found
-cyanosis
-PFTs show impaired flow rates
-CXR shows hyper lucency and flattened diaphragms during exacerbation

63

Cystic fibrosis

a genetically inherited disease characterized by thickening of secretions of all exocrine glands, leading to obstruction (pancreatic, pulmonic, gastrointestinal)

may present as an obstructive, restrictive or mixed disease

clinical signs: meconium, ileus, frequent respiratory infections, (especially staphylococcus), and inability to gain weight despite adequate caloric intake.

Diagnosis made postnatally by a blood test indicating trypsinogen or later by a positive sweat electrolyte test

Pertinent physical findings:
-onset of symptoms in early childhood
-dyspnea, especially on exertion
-productive cough
-hypoxemia, hypercapnea
-cyanosis
-clubbing
-use of accessory muscles
-tachypnea
-crackles, wheezes and/or decreased breath sounds
-abnormal PFTs showing an obstructive pattern, restrictive pattern or both
-CXR shows increased markings, findings of bronchiectasis and or pneumonitis

64

bronchectasis

a chronic congenital or acquired disease characterized by abnormal dilation of the bronchi and excessive sputum production

pertinent physical findings:
-cough and expectoration of large amounts of mucopurulent secretions
-frequent secondary infections
-hemoptysis
-crackles, decreased breath sounds
-cyanosis
-clubbing
-hypoxemia
-dyspnea
-CXR shows increased bronchial markings with interstitial changes.
-bronchograms can outline bronchial dilation, but rarely needed

65

respiratory distress syndrome (RDS)

formerly known as "hyaline membrane disease"

alveolar collapse in a premature infant resulting from lung immaturity, inadequate level of pulmonary surfactant

Physical findings:
-respiratory distress
-crackles
-tachypnea
-hypoxemia
-cyanosis
-accessory muscle use
-expiratory grunting, flaring nares
-CXR shows a classic granola pattern ("ground glass") caused by distended terminal airways and alveolar collapse

PT considerations:
-increased breathing effort caused by handling a premature infant must be carefully weight against possible benefits of PT

66

Bronchopulmonary dysplasia

obstructive pulmonary disease, often a sequela of premature infants with RDS

results from high pressures of mechanical ventilation, high fractions of inspired oxygen (FiO2) and/or infection

lungs show areas of pulmonary immaturity and dysfunction due to hyperinflation

Physical findings:
-hypoxemia, hypercapnea
-crackles, wheezing and/or decreased breath sounds
-increased bronchial secretions
-hyperinflation
-frequent lower respiratory infections
-delayed growth and development
-cor pulmonale
-CXR shows hyperinflation, low diaphragms, atelectasis and/or cystic changes

67

chronic restrictive diseases

typified by difficulty expanding the lungs, causing a reduction in lung volumes

68

restrictive disease due to alterations in lung parenchyma and pleura

fibrotic changes within the pulmonary parenchyma or pleura due to idiopathic pulmonary fibrosis, asbestosis, radiation pneumonitis, oxygen toxicity

Physical findings:
-dyspnea
-hypoxemia, hypocapnea (hypercapnea with severity)
-crackles
-clubbing
-cyanosis
-PFTs reveal a reduction in vital capacity, functional residual capacity and total lung capacity
-CXR shows reduced lung volumes, diffuse interstitial infiltrates and/or pleural thickening

69

restrictive disease due to alterations in the chest wall

restricted motion of bony thorax, with diseases such as ankylosing spondylitis, arthritis, scoliosis, pectus excavate, arthrogryposis or integumentary changes of the chest wall such as thoracic burns or scleroderma

Physical findings:
-shallow, rapid breathing
-dyspnea
-hypoxemia, hypocapnea (hypercapnia with increasing severity)
-cyanosis
-clubbing
-crackles
-reduced cough effectiveness
-PFTs show reduced VC, FRV, and TLV
-CXR shows reduced lung volumes, atelectasis

70

Restrictive disease due to alterations in the neuromuscular apparatus:

decreased muscular strength results in an inability to expand the rib cage
-seen in MS, MD, PD, SCI or CVA

Physical findings:
-dyspnea
-hypoxemia
-hypocapnea (hypercapnea with severity)
-decreased breath sounds, crackles
-PFTs show reduced VC, and TLC
-CXR shows reduced lung volumes, atelectasis

71

Bronchogenic carcinoma

tumor arising from the bronchial mucosa

smoking and occupational exposures most frequent causal agents

secondary changes due to tumor: obstruction or compression of an airway, blood vessel or nerve

local metastases in the pleura, chest wall, mediastinal structures
-distant metastases in lymph nodes, liver, bone, brain and adrenals

Physical findings:
-chest pain
-dyspnea
-tracheal and mediastinal shift away from injured side
-absent or decreased breath sounds
-increased tympany with mediate percussion
-cyanosis
-respiratory distress
-confirmation by CXR

Management:
-chemo, radiation, surgery

PT considerations
-pneumonias that develop behind a completely obstructed bronchus can't be cleared with PT techniques. Hold tx until palliative therapy reduces tumor size and relieves bronchial obstruction
-possible fractures from thoracic bone metatasis with chest compressive maneuvers and coughing
-ecchymosis (bruising) in patients with low platelet count
-fatigue that restricts necessary activities

72

list of trauma conditions

rib fracture, flail chest

pleural injury
-pneumothorax
-hemothorax

lung contusion

73

rib fracture

usually due to blunt trauma

flail chest= 2 or more fractures in 2 or more adjacent ribs

physical findings:
-shallow breathing
-splinting due to pain-especially with deep inspiration or cough
-crepitation may be felt during ventilatory cycle over fracture site
-paradoxical movement of a flail section during ventilatory cycle (inspiration-pulls in, expiration-pulls out)
-confirmation by CXR

74

pneumothorax

air in the pleural space
-usually through a lacerated visceral pleura from a rib fracture or ruptured bull
-causes lung to collapse due to loss of negative pressure

Physical findings: (increase with severity)
-chest pain
-dyspnea
-tracheal and mediastinal shift away from injured site
-absent or decreased breath sounds
-increased tympany with mediate perfusion
-cyanosis
-respiratory distress
-confirmation by CXR

TX: chest tube:
-pulls air/fluid out of pleural space
-restores negative pressure and allows the lung to inflate
-chest PT is a precaution in the area of the tube

75

hemothorax

blood in the pleural space
-usually from a laceration of the parietal pleura

Physical findings: (increase with severity)
-chest pain
-dyspnea
-tracheal and mediastinal shift away from side of injury
-absent or decreased breath sounds
-cyanosis
-respiratory distress
-confirmation by CXR
-possible signs of blood loss

76

lung contusion

blood and edema within the alveoli and interstitial space due to blunt chest trauma with or without rib fractures

Physical findings:
-cough with hemoptysis
-dyspnea
-decreased breath sounds and/or crackles
-cyanosis
-confirmation by CXR of ill-defined patchy densities

77

pulmonary edema

excessive seepage of fluid from the pulmonary vascular system into the interstitial space; may eventually cause alveolar edema

cardiogenic: results from increased pressure in pulmonary capillaries associated with LV failure, aortic valvular disease or mitral valvular disease

non-cardiogenic: results from increased permeability of the alveolar capillary membranes due to inhalation of toxic fumes, hypervolemia, narcotic overdose or adult respiratory distress syndrome (ARDS)

Physical findings:
-crackles
-tachypnea
-dyspnea
-hypoxemia
-peripheral edema if cardiogenic
-cough with pink, frothy secretions
-CXR shows increased vascular markings, hazy opacities in gravity dependent areas of the lung in a typical butterfly pattern. Atelectasis is possible if the surfactant lining is removed by alveolar edema

TX:
-meds- O2 and diuretics
-reduction of salt intake
-bed rest (head elevated)

78

Pulmonary emboli

a thrombus from the peripheral venous circulation becomes embolic and lodges in the pulmonary circulation
-small emboli don't necessarily cause infarction

Physical findings without infarction:
-history consistent with PE: DVT, oral contraceptives, recent abdominal or hip surgery, polycythemia, prolonged bed rest
-sudden onset of dyspnea
-tachycardia
-hypoxemia
-cyanosis
-anxiety, restlessness
-auscultatory findings: may be normal or show crackles and decreased breath sounds
-V/Q scan shows perfusion defects with concomitant normal ventilation

Added physical findings consistent with pulmonary infarction:
-chest pain
-hemoptysis
-fever
-CXR shows decreased vascular markings, high diaphragm, pulmonary infiltrate and/or pleural effusion

TX:
-low dose heparin
-analgesics
-pulmonary vasodilators

79

pleural effusion

excessive fluid between the visceral and parietal pleura caused mainly by:
-increased pleural permeability to proteins from inflammatory diseases (pneumonia, RA, systemic lupus)
-neoplastic disease
-increased hydrostatic pressure within pleural space (CHF)
-decrease in osmotic pressure (hypoproteinemia)
-peritoneal fluid within the pleural space (ascites, cirrhosis)
-interferene of pleural reabsorption from a tumor invading pleural lymphatics

Physical findings:
-decreased breath sounds over effusion; bronchial breath sounds around the perimeter. Pleural friction rub may be possible with inflammatory process
-mediastinal shift away from large effusion
-breathlessness with large effusions
-CXR shows fluid in the pleural space in gravity-dependent areas of the thorax if >300mL
-pain and fever only if the pleural fluid is infected (empyema)

80

Atelectasis

collapsed or airless alveolar unit caused by:
-hypoventilation secondary to pain during the ventilatory cycle (pleuritis, post-op pain, or rib fracture)
-internal bronchial obstruction (aspiration, mucus plugging)
-external bronchial compression (tumor or enlarged lymph nodes)
-low tidal volumes (narcotic overdose, inappropriately low ventilator settings)
-neuralgic insult

Physical findings:
-decreased breath sounds
-dyspnea
-tachycardia
-increased temp
-CXR with platelike streaks

81

list of manual secretion removal techniques

postural drainage

percussion

vibration/shaking

airway clearance techniques:
-cough
-huff
-assisted cough
-tracheal stimulation
-endotracheal suctioning

82

postural drainage

placing patient in varying positions for optimal gravity drainage of secretions and increased expansion of the involved segment

indications:
-increased pulmonary secretions
-aspiration
-atelectasis or collapse

duration up to 20 minutes

83

percussion

a rhythmic force applied with cupped hands to the specific area of the chest wall that corresponds to the involved lung segment

used to increase the amount of secretions cleared from tracheobronchial tree

used in conjunction with postural drainage

indications:
-increased pulmonary secretions
-aspiration
-atelectasis or collapse due to mucous plugging obstructing airways

3-5 minutes
force of percussion causes the patient's voice to quiver

84

vibration/shaking

following a deep inhalation, a bounding maneuver is applied to the rib cage throughout exhalation; to hasten the removal of secretions from the tracheobronchial tree

commonly used following percussion in appropriate postural drainage position

indications:
-increased pulmonary secretions
-aspiration
-atelectasis or collapse of an airway from mucous plugging

as patient inhales deeply, PT's hands are placed with fingers parallel to ribs

as patient exhales, PT hands provide a jarring, bouncing motion to rib cage below

duration: 5-10 minutes
->10 risks hyperventilation (increased Ve resulting in hypocapnea)

85

airway clearance techniques

COUGH:
-upright sitting after each area has been treated
-clears secretions from major central airways

HUFFING:
-more effective in patients with collapsible airways (COPD)
-prevents high intrathoracic pressure that causes premature airway closure
-ask patient to deeply inhale, immediately forcibly expel the air saying "HA"

ASSISTED COUGH:
-used when pt's abdominal muscles can't generate an effective cough (SCI)
-PT's fist becomes the force; force depends on patient tolerance and abdominal sensation
-hand placed below subcostal angle (similar to Heimlich)
-patient inhales; as patient attempts to cough, hand pushes inward and upward, assisting the rapid exhalation of air

TRACHEAL STIMULATION:
-used with patients unable to cough on command (infants, TBI, CVA)
-finger placed just above suprasternal notch; quick inward and downward pressure on the trachea elicits cough reflex

ENDOTRACHEAL SUCTIONING
-used only when above techniques fail
-suctioning time: 10-15 seconds- intermittent so not to damage inner lining of trachea
-complications: hypoxemia, bradycardia, HTN , increased intracranial pressure, atelectasis, tracheal damage, infections

86

considerations prior to use of percussion or shaking

pain made worse by technique

circulatory system: aneurysm precautions, hemoptysis

coagulation disorders or meds that interfere with coagulation

MS system: fractured ribs, DJD, bone metastases

87

considerations prior to use of postural drainage

TRENDELENBURG PRECAUTIONS
1-Circulatory:
-pulmonary edema
-CHF
-HTN

2-Abdominal problems:
-obesity
-ascites
-pregnancy
-hiatal hernia
-nausea/vomiting
-recent food consumption

3-Neurologic system:
-recent neurosurgery
-increased intracranial pressure
-aneurysm precautions

4- Pulmonary system:
-SOB


SIDELYING PRECAUTIONS
1-Circulatory
-axillo-femoral bypass graft

2- MS system:
-humeral fractures
-need for hip ABD brace

88

independent secretion removal techniques

active cycle of breathing

autogenic drainage

FLUTTER or acapella device

low pressure positive expiratory pressure (PEP) mask

high pressure positive expiratory pressure (PEP) mask

89

active cycle of breathing

independent program to assist in the removal of more peripheral secretions that coughing may not clear

1-breathe in controlled, diaphragmatic fashion

2-deep inhalations with a hold at the top

3-if no secretions seem to be mobilized, the patient returns to step 1 &2 and reassess. Continue if secretions can be cleared.

4- inhale at a resting tidal volume- contract the abdominal muscles to produce 1 or 2 forced expiratory huffs from mid to low lung volume to raise secretions

5- huff from high lung volume or cough to clear

6- controlled diaphragmatic breathing

7- repeat

90

autogenic drainage

used to sense peripheral secretions and clear them without the tracheobronchial irritation from coughing

amount of time spent in each of the following stages determined by patient feels with secretions

1-unstick phase: quiet breathing at low lung volumes to effect peripheral secretions

2- collect phase: breathing at mid lung volumes to affect secretions in the middle airways

3- evacuation phase: breathing from mid to high lung volumes to clear secretions from central airways; replaces coughing

4- repeat

91

FLUTTER or acapella device

external device that vibrates the airways on exhalation to improve airway clearance with intermittent, positive expiratory pressure

1-inhale normal through nose or without device

2- exhales through device, setting a vibration within airways. 5-10 times

3- full inhalation, 3 second hold

4- rapid, forced exhalations through flutter 2-3x

5- huff or cough to clear

92

PEP mask

positive expiratory pressure mask

low pressure: 10-20 cm H20

high pressure: 50-120 cm H20

normal tidal volume breaths; after ~ 10 breaths, mask is removed for coughing/huffing

93

diaphragmatic breathing

used to:
-increase ventilation
-improve gas exchange
-decrease work of breathing
-facilitate relaxation
-maintain or improve mobility of chest wall
-patients post-op, post-trauma, pulmonary diseases

semi fowler position (to start)

hand gently over subcostal angle
-apply pressure t/o exhalation; firm pressure at the end
-inhale against resistance; release to allow full inhalation

progress to independent

94

segmental breathing

used to:
-improve ventilation to hyperventilated lung segments
-alter regional distribution of gas
-maintain or restore functional residual capacity
-maintain or improve chest wall mobility
-prevent pulmonary compromise

used for patients with pleuritic, incisional or postpartum pain that causes decreased movement in the portion of the thorax (splinting) and those at risk of developing atelectasis

postural drainage positions

apply gentle pressure to thorax over area of hypoventilation during exhalation
-increase to firm pressure just prior to inspiration
-inhale against resistance
-release to allow full inspiration

95

sustained maximal inspiration

used to:
-increase inhaled volume
-sustain or improve alveolar inflation
-maintain or restore functional residual capacity

used in acute situations: post-trauma pain, post-op, acute lobar collapse

inspire slowly through nose or pursed lips to max inspiration
-hold 3 seances
-passively exhale

Incentive spirometes

96

pursed lip breathing

used to:
-reduce respiratory rate
-increase TV
-reduce dyspnea
-decrease mechanical disadvantages of impaired ventilatory pump
-improve gas mixing at rest for patients with COPD
-facilitate relaxation

primarily used for patients with obstructive disease who experience dyspnea at rest or with minimal activity, or with ineffective breathing patterns during activity

inhale through mouth or nose
exhale through pursed lips (prolong)

97

paced breathing

activity pacing

usd to spread out the metabolic demands of an activity over time by slowing its performance

used for patients who become dyspneic during activity

break down any activity into manageable components
-inhale at rest
-exhale with pursed lips, complete the 1st component of activity
-stop and inhale at rest
-repeat

ex: ascend 1 stair with exhalation, pause and inhale

98

pneumonectomy:

lobectomy:

segmental resection:

wedge resection:

pneumoectomy: lung removal

lobectomy: removal of a lobe of a lung

segmental resection: removal of a segment of a lobe

wedge resection: removal of a portion of a lung without anatomical divisions

99

midsternotomy:


Thoracotomy:

midsternotomy: sternum is cut in half lengthwise and rib cage is retracted
-used in most heart surgery

thoracotomy: used for most lung resections; incision of 4th intercostal space

100

rescue drugs

used for immediate relief of breakthrough symptoms: tightness, wheezing, SOB

Short acting beta 2 agonists: sympathomimetics
-mimic activity of SNS that produce bronchodilation
-can increase HR and BP
-topically through inhaler

ex:
ventolin (albuterol)
alupent (metaproterenol)
maxair (pirbuterol)

101

maintenance drugs

regular schedule to maintain optimal airway diameter

1- long acting beta 2 agonists

2- anticholinergics

3- methylxanthines

4- leukotriene receptor antagonists

5- cromolyn sodium

6- anti-inflammatory agents

7- vaccinations

102

long acting beta 2 agonists

(sympathomimetics)
-mimic SNS, allow bronchodilation
-may decrease need for rescue drugs and inhaled anti inflammatories
-ex: serevent (salmeterol)

103

anti-cholinergics

inhibit the PSNS
increase HR, BP and bronchodilation

side effects:
-lack of sweating
-dry mouth
-delusions

atrovent

104

methylxanthines

reduce smooth muscle relaxation

but use is limited due to serious toxicity, increased BP, HR, arrhythmias, GI distress, nervousness, headache and seizures

105

leukotriene receptor antagonists

block leukotrienes released in allergic reactions

inhibit airway edema and smooth muscle contraction

106

mechanical ventilation

maintains adequate Ve for patients who can't independently

endotracheal (oral)
nasotracheal (nasal)
tracheal (through tracheostomy directly into trachea)

no contraindications for PT

107

chest tubes

used to evacuate air or fluid trapped in intracellular space

sutured in place

no contraindications to PT

108

IVs

intravenous catheters used to deliver meds

no PT contraindications
-UE should not be raised above level of IV or back flow may occur

109

supplemental oxygen

if SaO2

110

sputum characteristics

foul smell-- indicates anaerobic infection

purulent (yellow or green) -- indicates infection

frothy-- usually pulmonary edema

mucoid (clear, thick)-- indicates cystic fibrosis or conditions with a chronic cough

hemoptysis -- blood in the sputum

111

Valsalva's maneuver

attempting to forcibly exhale with the glottis, nose and mouth closed

causes increased intrathoracic pressure and decreased return of blood to the heart

112

bronchodilator meds

epinephrine
alupent (metaproterenol)
ventolin (albuterol)
proventil

relax smooth muscle and open airway lumen to assist in breathing

113

corticosteroids

prednisone
cortisol

decrease edema and inflammation associated with COPD

side effects:
-osteoporosis
-muscle wasting
-slow wound healing

114

bronchitis

chornic inflammation of the tracheobronchial tree with cough and sputum production lasting 3 months-2 consecutive years

S&S
-wheezing or rhonchi breath sounds
-productive mucoid or purulent sputum with infection
-may have fever

Tx:
-bronchopulmonary hygiene
-positions of relax
-paced breathing
-endurance exercise
-education

115

emphysema

permanent abnormal enlargement and destruction of air spaces distal to terminal bronchioles

may develop following smoking history with chronic cough and sputum production

S&S
-barreled chest
-use of accessory muscles
-decreased breath sounds
-wheezing
-dyspnea

TX:
-pursed lip breathing-exhalation
-education
-endurance

116

SaO2

arterial oxygen saturation

the ratio of the amount of O2 present in a known volume of blood to the amount of oxygen that could be carried by that volume of blood

measured by pulse oximeter