Pulmonary

Question 1

1. upper airway
2. lower airway
3. terminal airway

Answer 1

1. upper airway: nasal cavity - pharynx - sinuses - larynx
2. lower airway: trachea - bronchi - bronchioles
3. terminal airway: alveoli

Question 2

arterial blood gases

1. PaO2
2. PaCO2
3. H+ (pH)
4. H2CO3 (bicarbonate)
5. O2 Sat

Answer 2

1. PaO2: 75-100mmHg
2. PaCO2: 35-45mmHg
3. H+ (pH): 7.35-7.45mm/mL (acidity)
4. H2CO3 (bicarbonate): 20-29 mEq/L
5. O2 Sat: 95-98+% / chronic resp. illness > 86%

Question 3

normal excursion of the chest wall

Answer 3

1. inspiration: active muscle contraction (diaphragm & intercostals) - intra-thoracic volume increases - changes in pressure gradients - bucket handle (lower ribs) increases transverse diameter - pump handle (upper ribs) increases AP diameter
2. expiration: passive recoil of lung structures (due to elastin) - intra-thoracic volume decreases
3. forced expiration: rectus abdominus - internal and external obliques, TA

Question 4

abnormal excursion of the chest wall

Answer 4

1. disease of respiratory muscles: muscular dystrophy - SCI - polio - ALS - neuropathies
2. rib cage movement problems: bony (kyphosis, scoliosis, trauma, ribs or thoracic fx) - pleural problems (infection, fibrosis, adhesions) - lung tissue problems (inflammation, infection) - altered abdominal motion (ascites, pregnancy)
3. altered movement into alveoli: blocked or narrowed airways, broncho-constriction, excess secretions, obstructions and/or consolidations

Question 5

common diagnoses

Answer 5

asthma - bronchitis - emphysema - COPD - cystic fibrosis - pneumonia - restrictive lung dysfunction
*non cardiac chest pain

Question 6

pulmonary interventions

Answer 6

1. airway clearance techniques
2. breathing exercises
3. exercise progressions
4. patient education

Question 7

airway clearance: secretion management

Answer 7

• secretions = mucus, phlegm, sputum
• normal adults produce ~1L mucus / day
• mucus functions to trap foreign particles along with cilia that help to propel mucus/foreign particles back towards the upper airway to be expelled = mucociliary clearance
• abnormal clearance = infection, respiratory exacerbations, decreased exercise/activity tolerance

Question 8

secretion characteristics

1. amount
2. color
3. consistency

Answer 8

1. amount: normal (none/scant) or abnormal (measurable amount mL, tsp, or cups)
2. color
   - red = blood
   - purple = neoplasm
   - yellow = infection
   - green = pus
   - pink = pulmonary edema
3. consistency: thin/watery, thick, frothy, purulent (pus)

Question 9

secretion removal techniques

Answer 9

• postural drainage
• chest PT
• coughing/huffing
• active cycle of breathing and autogenic drainage
• breathing techniques
• positioning

Question 10

postural drainage

Answer 10

uses gravity and positioning to drain secretions from various lung lobes into larger airways to be expelled

• lung segments are positioned 90degrees from horizontal
• secretions are moved from peripheral to central airways
• minimum of 10 minutes per position

Question 11

contraindications to postural drainage (6)

Answer 11

1. unstable head or neck injury
2. recent spinal injury or surgery
3. cranial hemorrage with ICP > 20 mmHg
4. large pleural effusion
5. pulmonary edema due to CHF
6. PE

Question 12

chest PT

Answer 12

use of mechanical energy through the chest wall to loosen airway secretions

• manual: percussion, vibration, clapping, shaking, cupping
• mechanical: high velocity chest wall oscillator, chest vibrators
• can use in conjunction with postural drainage positions

Question 13

contraindications for CPT (6)

Answer 13

1. acute asthma attack or severe bronchospasm
2. burns, open wounds, recent skin grafts, infection
3. flail chest
4. lung contusion
5. osteoporosis/osteopenia
6. osteogenesis imperfecta or other brittle bone disease

Question 14

flail chest

Answer 14

occurs when a segment of the thoracic cage is separated from the rest of the chest wall

• defined as at least two fractures per rib (producing a free segment) in at least two ribs
• a segment of the chest wall that is flail is unable to contribute to lung expansion

Question 15

positive airway pressure

Answer 15

splints the airways open during inspiration and/or expiration to prevent alveolar collapse

• positive expiratory pressure (PEP)
• positive end expiratory pressure (PEEP): 15min treatments performed in sitting
• intermittent positive pressure breathing (IPPB): 15-30min treatments sitting or lying
• continuous positive airway pressure (CPAP): short or longer durations, usually worn at night

Question 16

cough characteristics

Answer 16

1. dry: non-productive
2. moist: productive or non-productive
3. paroxysmal: sudden fit of severe coughing
4. weak: usually without glottis closed and limited increase in intra-thoracic pressure

Question 17

huff

Answer 17

1. inhale deeply through the mouth

2. forcefully and rapidly exhale while contracting abdominal muscles and say “ha ha ha” (glottis remains open)

Question 18

cough

Answer 18

1. inhale maximally, close glottis and hold 1-2 sec
2. high velocity maneuver with closed glottis after deep inspiration
3. forces secretions out of large/upper airways
4. repeat 2-3x

Question 19

active cycle of breathing (ACB)

Answer 19

used for breathing control, thoracic expansion, and forced expiration

• normal relaxed breathing at pt’s own tidal volume x 5-10sec or 2-3 cycles
• SLOW deep breathing to maximal volume, with passive exhalation x 3-4 cycles
• 1-2 huffs at mid-low tidal volume
• brisk adduction of upper arms to torso to self compress the chest/thorax with exhalation
• normal tidal breathing can be added as needed between steps

Question 20

autogenic drainage

Answer 20

cyclic breathing that “milks” secretions from smaller to larger airways

• ACBT performed with huffs at low lung volumes
• ACBT performed with huffs at mid lung volumes
• ACBT performed with huffs at high lung volumes

Question 21

apnea

Answer 21

absence of breathing

Question 22

tachypnea

Answer 22

fast RR, decreased depth (shallow)

Question 23

bradypenea

Answer 23

slow RR, increased or normal depth

Question 24

orthopnea

Answer 24

difficulty breathing in positions other than upright/erect

Question 25

cheyne-stokes

Answer 25

alternating bouts of increased RR and apnea

Question 26

dyspnea

Answer 26

shortness of breath

Question 27

breathing techniques

Answer 27

1. diaphragmatic breathing 2. inspiratory muscle re-training (IMT) 3. paced breathing and exhale with effort 4. pursed ip breathing (PLB) 5. segmental breathing 6. incentive breathing

Question 28

paced breathing with activity

Answer 28

- inhale before or during "easier" parts of an activity - exhale upon exertion/effort - breaks activity up into slower tempo/manageable intervals - avoid valsalva or holding breath

Question 29

pursed lip breathing (PLB)

Answer 29

- breathe in slowly through nose for 2 counts - pucker your lips as if you were going to whistle - gently and slowly exhale as if you were trying to make a candle flicker for 4 counts - creates a relaxing effect - assists with emptying of lungs

Question 30

segmental breathing

Answer 30

- localized breathing or thoracic expansion - position patient as indicated: PD positions may be used - therapist places hand on area to be expanded: have pt breath into hand (minimal to no force applied) - on exhalation: therapist applied firm pressure to area at the end of exhalation - can add a quick stretch at end of exhalation if indicated

Question 31

incentive spirometry (sustained maximal inhalation)

Answer 31

- sit or lie upright in a comfortable position - hold incentive spirometer upright with both hands - slide indicator to desired level and slowly raise it as pt improves - with lips tightly sealed around mouthpiece, breath in slowly and deeply - hold breath for at least 3 sec and let piston fall back down

Question 32

exercises for chest wall expansion

Answer 32

- pectoralis and cervical stretches - shoulder ROM activities - postural muscle strengthening and re-education - PNF (D2) - foam roller

Question 33

aerobic exercise prescription

Answer 33

1. mode: rhythmical activities using large muscle groups, better with total body activity, performed continuously 2. intensity: THR 55-90% depending on variety of factors 3. duration: 20-60min or 10min bouts cumulatively 4. frequency: 3-5x/wk

Question 34

pulmonary symptom aggravatros

Answer 34

- anything that increases work of breathing - pain - edema (pulmonary) - anxiety/stress/fear

Question 35

pulmonary symptom alleviaters

Answer 35

- secretion removal, breathing techniques and positioning - reassurance and relaxation - offer oxygen and/or bronchodilator if prescribed by MD - splinting or supportive overpressure - pacing, activity modification - education

Question 36

oxygen

Answer 36

* MD prescription - dosage in L (2L O2 via nasal cannula) - titration: ability to change to dose (titrate to 90% O2 sat)

Question 37

tools to assess efficacy of treatment

Answer 37

- ausculation - pulse ox - sputum production - dyspnea rating (borg, RPE) - functional and exercise tolerance tests - observations - compare pre and post treatment