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What is the physiological rationale for positioning for lung collapse?

- Regional volume (i.e. uppermost lobe will stretch open the most due to gravity pulling down)
- Lung volumes (e.g. FRC)
- V/Q matching


What does positioning to increase regional lung volume involve?

- Imposes stretching force on alveoli
- Placing the collapsed segment of the lung uppermost
- Causes passive increase in lung volume


What does positioning to increase lung volume involve?

- Increasing FRC by standing patient (or as close as possible)
- Keeping FRC above closing capacity at all times (to prevent collapse)


What is the best way to increase a patient's FRC?

Stand them up


What does positioning to improve V/Q matching involve?

- Placing the collapsed segment of the lung uppermost
- Results in the V/Q occurring in the good lung due to gravity
- Improves the patient's O2 sats


What are the precautions for positioning?

- Pain
- Anxiety
- Limitations due to recent surgery e.g. hip, vascular
- Pneumonectomy (upright only)
- Attachments, esp ICC
- Orthopaedic injuries, e.g. pelvic/spinal fractures
- Intracranial injury (raised IC pressure)
- Recent angiography (avoid hip flexion)
- Critically ill/unstable patients
- Head down position


What are the practical considerations of positioning?

- Can't stay in one position all day
- Educate patients, carers, nursing staff
- Manual handling 'no lift' policy
- Safety of staff & patient
- Equipment
- Prepare the environment


What are the physio techniques for improving lung volume?

- Positioning
- Mobilisation
- Deep breathing & thoracic expansion exercises


What does mobilisation include?

- Tilt table
- Standing
- Marching on spot
- Walking


What is the aim of mobilisation?

Stimulate increase in ventilation (TV x RR)


What are the other benefits of mobilisation?

- Cardiovascular
- Musculoskeletal
- Functional treatment, important ADL
- Independence
- Psychological
- One requirement for discharge from hospital


What has evidence found in regards to mobilisation and PPCs?

Patients 3 times more likely to develop PPCs for each day they do not mobilise away from bed


What are the precautions for mobilisation?

- Respiratory: PaO2/FiO2 ratio <300
- Attachments
- CV status
- WB status
- Nausea & vomiting
- Patient cooperation
- Environmental risks (prepare space, chair, slippers)
- Prepare for emergency situation


What are the practical considerations for mobilisation?

- Know/assess patient's pre op level of mobility
- Dose & intensity (need to increase TV & RR)
- Prepare self, patient, environment
- Walking frames are useful in early post op period, esp for attachments
- Always have assistance, esp at the start
- Includes transfers from bed/chair
- Stairs prior to discharge


What is the physiological rationale of using PEP for lung collapse?

Same as sputum clearance
- Uses positive pressure of blowing to create back pressure in airways
- Uses collateral ventilation to re-open collapsed airways


What are the contraindications for PEP?

- Undrained pneumothorax
- Frank haemoptysis
- Extensive bullae or cysts
- Recent pneumonectomy


What are the precautions for PEP?

- Altered consciousness, confusion (risk of drinking the water)
- Paediatric patients (risk of drinking, aspirating)
- Patients requiring high/continuous O2 therapy


What is the physiological rationale for deep breathing exercises?

- Slow deep inspiration from FRC to TLC
- Results in increased alveolar filling time, encourages ventilation to dependent lung regions
- Inspiratory hold/sustained max inspiration redistributes gas via collateral channels, sustained alveolar stretch


What are the benefits of deep breathing exercises?

- Increase lung volumes, FRC, minute ventilation
- Increase surfactant secretion
- Increase lung compliance
- Decrease dead space ratio
- Improve regional ventilation, V/Q matching, oxygenation


What are the precautions for deep breathing exercises?

- Pneumothorax without chest drain
- Recent insertion of central line until CXR assessment
- CV instability (low BP)
- Pain
- Extreme SOB
- Dizziness
- Hyperventilation


What are the practical considerations for deep breathing exercises?

- Recommendations from literature (5 deep breaths, 3s inspiratory hold hourly)
- Manual feedback (hands for LBE)
- Verbal coaching
- Independent practice of correct technique


What was the physiological rationale behind incentive spirometry?

- Device that provides visual feedback on inspiratory flow & volume during a deep breathing manoeuvre


Why should incentive spirometry not be used?

11 studies about incentive spirometry, evidence shows that it has no effect in the prevention of PPCs


What are the practical considerations for incentive spirometry?

- Does not encourage inspiratory hold
- Some devices can encourage fast inspiratory flow
- Therapist needs to monitor pattern of breathing
- Can increase WOB
- Some doctors still request routinely
- Disposable


What is pre op IMT for cardiac & major abdominal surgery associated with?

- Reduced incidence of pneumonia
- Reduced incidence of atelectasis
- Reduced LOS