Interventions

Question 1

Interventions

Goal

Answer 1

The end goal is to optimize gas exchange at all levels
This in turn will imrpove the patient’s condition, DEC symptoms, & optimize their function

Patient’s general status should be assessed prior to every treatment session & reassessed after treatment (See if Tx was effective)

Question 2

Interventions: LIST

(5)

Answer 2

1. Positioning
2. Breathing Exercises
3. Airway Clearance Techniques
4. Forced Expiratory Techniques
5. Exercise

Question 3

Positioning: V/Q Matching

Answer 3

Cardiorespiratory patients may experience greater distress when placed in certain positions. This distress can be explained by V/Q inequalities

Positioning is often the first step in every treatment procedure

Optimal Positioning for V/Q mismatching:
1. UNI-lateral Lung Disease: lie on unaffected side - good lung down
DEPENDENT blood will pool - all the perfusion goes to areas of good ventilation
2. BI-lateral Lung Disease: Lie in prone
Will improve oxygenation & putting thorax into a mechanically advantagous position
3. Pneumonectomy: do not lie with affected side up - lie on affected side
“Bad” lung down - do not want hardening saline to seep out of surgicial tie & into the “good lung” - solution could harden & cause complications on the unaffected side
4. ARDS: Lie is prone “proning”

Question 4

Positioning to DEC Dyspnea in COPD

(4)

Answer 4

Standing: lean back against a wall with hands bearing onto thighs to unload thorax
OR
Leaning against a table
- U/E is supported therefore requiring less energy
- Supporting BW > Accessory mm can relax = using less energy = less use of O2
- CPP: putting other mm into advantageous positions

Sitting: Leaning forward with elbows resting on thighs
OR
Leaning forward against a table (Kid in detection)

Question 5

Breathing Exercises: LIST

(5)

Answer 5

1. Deep Diaphragmatic Breathing
2. Pursed Lip Breathing
3. Inspiratory Muscle Training
4. Segmental Breathing
5. Sustained Maximal Inspiration

Question 6

Deep Diaphragmatic Breathing

Answer 6

Teaching patients deep diaphragmatic breathing (DDB) helps promote decrease use of accessory mm of breathing & promote increase use of the diaphragm mm for breathing

Also known as “BELLY BREATHING”

• DDB is more efficient (DEC energy costs) than using accessory mm for breathing
• Patient performs long, slow breaths = promotes relaxation
  All (more) mm will relax

May use hands on the belly to guide diaphragmatic breathing or may cue DDP by instructing the patient to take a quick sniff through the nose (feel diaphragm getting activated)

Question 7

Pursed Lip Breathing (PLB)

(7)

Answer 7

• Perfomed by taking a breath in through the nose & exhaling through tightly pressed pursed lips
  “Smell the roses, blow out the candles”
• Exhalation phase should be 3x as long as the inspiration
  Gets junk air out - pt that are hyperinflated
• Creates positive pressure that splints small airways open longer
• Helps control & reduce respiratory rate
• More efficient emptying of the lung (DEC hyperinflation)
• Improves gas exchange
• Promotes relaxation

Question 8

Inspiratory Muscle Training

2 + parameters

Answer 8

Resistive exercise training for the mm of respiration aimed at increasing the strength or endurance of respiratory

Inspiratory mm training is commonly performed using an Inspiratory muscle trainer (MT) device

Parameters:
Strength:
- F: 2-4 x/week
- I: 60-85% PImax
- T: 8-12 reps, 1-3 sets

Endurance:
- F: 4-6 x/week
- I: 40-85% PImax
- T: >15 minutes (as tolerated)

Question 9

Segmental Breathing

Answer 9

Localized breathing towards a segment of a lung that requires greater expansion or ventilation
- Usees tactile input to increase expansion of specific areas
- (bullshit) - questionable whether a person can expand a localized area of lung specifically while not expanding others

Question 10

Sustained Maximal Inspiration

Explanation + 2 Types

Answer 10

Patient performs sustained maximal inspiration to TLC for 3-5 seconds

Incentive Spirometer (IS) - is a method of performing sustained maximal inspiration (SMI) using a device to measure flow or volume

• Often used post-op to prevent atelectasis or airway closure
• IS provides visual feedback & help provide incentive/goal for patient which in turn helps with patient compliance

2 Types:
1. FLOW Meter: Instruct the patient to keep the balls up & level as much as possible when inhaling
2. VOLUME Meter: Instruct the patient to inhale deeply w/ a constant flow keeping the flow indicator within the prescribed ranges

Question 11

Airway Clearance: LIST

(6)

Answer 11

1. Postural Drainage
2. Percussion
3. Vibrations
4. PEP Device
5. Independent Breathing Technique
6. Suctioning

Question 12

Postural Drainage

Answer 12

Patient is placed in a position that allows drainage of secretions from bronchial airways via gravity

• Often used in conjunction with percussion &/or vibrations
• Patient maintains postural position for 5-10 minutes or longer (if tolerated) per segment
• The patients face & SpO2 should be monitored during treatment
• Signs of treatment intolerance include
  Increased SOB
  Anxiety
  Nausea
  Dizziness
  HTN
  Bronchospasm

SEGMENT affected needs to be UP & GRAVITY DEPENDENT so mucus flows down

Page 102 for visiual respresentation

Question 13

Postural Drainage: Contra-indications

(15)

Answer 13

1. Intracranial pressure (ICP) > 20 mmHg
2. Head & neck injury (spinal instability) until stabilized
3. Active hemorrhage w/ hemodynamic instability
4. Recent spinal surgeyr or acute spinal injury
5. Active hemoptysis
6. Empyema (collection of pus in a cavity)
7. Bronchopleural fistula
8. Pulmonary edema associated with HF
9. Large pleural effusion
10. Elderly, confused, or anxious patients
11. Rib fracture (initially)
12. Surgicial wound or healing tissue (initially)
13. Pulmonary embolism
14. Untreated Pneumothorax
15. && more - use your judgement

Question 14

Postural Drainage: Tendelenburg position is contra-indicated in adults for…

Answer 14

1. Patients in whom increased ICP is to be avoided
2. Uncontrolled HTN
3. Distended abdomen
4. Esophageal Sx or GERDs
5. Recent gross hemoptysis related to recent lung carcinoma
6. Uncontrolled airway at risk of aspiration

Modified = just do not tip the bed

Question 15

Percussion

Answer 15

Percussion is a traditional secretion mobilization technique which uses rhythemical force of a therapist (caregiver) hands in a cupped position against the thorax of a patient

Percussions are performed over specific lung segments believed to have INC secretion retention w/ the aim of loosening or dislodging the bronchial secretions from the airways so that they may be expelled through the central airways via coughing or suctioning

• Avoid bony prominences (scapula, spine, clavicle, floating ribs), breast tissue, and directly over the heart
• Patient’s face & SpO2 should be monitored during treatment

Question 16

Percussion: Contraindications

Answer 16

1. Severe osteoporosis
2. Rib Fracture
3. Pulmonary embolism (do not want to dislodge)
4. Pneunothorax
5. Anticoagulation therapy - bruising/internal bleeding
6. Malignancy - INC metabolism to tumor
7. Burn/ skin grafts - may not tolerate - could affect healing
8. Open wounds
9. INC ICP
10. Subcutaneous emphysema
11. GI bleeding

Question 17

Vibrations

Answer 17

Vibration is a traditional secretion mobilization technique in which a vibratory force is applied while applying pressure over a patient’s chest wall over the involved lung segment
- Performed only on EXHALATION
- Proposed: vibrations enhance mucociliary transport from periphery to central airways
Stretch of rspiratory mm may also improve inspiratory effort & lung volume

Question 18

Vibrations: Types

(2)

Answer 18

1. Coarse (shaking): Large amplitude, low frequency (2Hz)
2. Fine: Low amplitude, high frequency (12-20 Hz)
   Better tolerated & dec risk of #
   Better tolerated than percussion

Mechanical vibration devicees may be used to decrease caregiver strain, or patient strain when performing vibrations

Question 19

Vibrations: Contra-indications

(11)

Answer 19

1. Severe osteoporosis
2. Rib fracture
3. Pulmonary embolus
4. Pneumothorax
5. Anticoagulation therapy
6. Malignancy
7. Burns/skin graft
8. Open wounds
9. INC ICP
10. Subcutaneous emphysema
11. GI bleeding

Question 20

PEP Device

Defintion + Parameters

Answer 20

Positive Expiratory Flow (PEP) devices are hand-held devices that create back pressure to splint airways while exhaling through the device

Back pressure allow for air to pass through inter-alveolar connectios with pressure to dislodge or move mucous proximally

Can be used with aerosolized medication

Performed: > 15 minutes x 2-3 times per day

Question 21

PEP: Types

(5)

Answer 21

Low Pressure PEP
- 10-20 cm H2O
- More commonly used ***
- Provides equal effectiveness as high-pressure PEP, but with lower presumed risk of pneunothorax

High Pressure PEP
- 50-120 cm H2O
- PEP mask is used
- Less commonly used d/t increase risk of pneunothorax

Non-Oscillating PEP Devices (TheraPRP, Threshold PEP)
- smooth flow
- Creates back pressure in a similar way as PLB

Oscillating PEP Devices (Acapella, Flutter, Cornet, Quake, bubble PEP)
- Provided accelerated expiratory flow rates & interrupts airflow through oscillation of airways which loosens secretions & help move them centrally
- Back pressure + vibrations

Flutter: Plastic pipe with a steel ball and perforated cover
- Moving ball end up: INC pressure
- Moving ball end down: DEC pressure

Question 22

PEP Devices: Pros/Cons

Answer 22

Pros:
- Less attention / cognitive demand
- Maintenance OR exacerbation
- Postural drainage positions d/t need to be used = no risk of aspiration OR bronchospasm
- Portable, easy to learn & can do it independently

Cons:
- Need to carry a device around all the time -potential social stigma to using a device

Question 23

Independent Breathing Techniques:
Active Cycle of Breathing (ACBT)

Explanation & Parameters

Answer 23

ABCT is a breathing technique used to help clear bronchial secretions using three ventilatory phases

Repeated cycles of 3 ventilatory phases:
1. Breathing Control (BC): gentle tidal volume breathing (relaxed upper chest & shoulder)
2. Thoracic Expansion Exercises (TEE): deep inspiration (DDB)
This phase loosens the secretions
May be accompanied by percussion or vibrations
3. Forced Expiration Technique (FET): 1 or 2 huffs or coughs

Total Tx Time:
- 10 mins/ per segment
Or
- 10-30 min for total treatment

Question 24

Independent Breathing Techniques:
Active Cycle of Breathing (ACBT)

Pros & Cons

Answer 24

Pros:
- No DEC O2 so they will not be destating (constantly breathing)
- Can be done in sitting BUT more effective in postural drainage positions
Can do both
- Can be used for a wide range of populations
- No equipment required
- Portable - can do it anytime/ anywhere

(+/-) = required active participation of patients
- Created & promotes independence for pt

Cons
- Compliance
- Time

Question 25

Autogenic Drainage (AD)

Answer 25

AD is performed using varying expiratory flow at various lung volumes to help mobilize secretions from peripheral airways into central airways to be expelled through huffing or coughing 3 Phases: 1. Unstick: exhaling to **low volumes** (ERV) will mobilize mucus 5-6 reps, 3 second holds 2. Collect: mucus will collect when breathing in **mid lung volumes** 5-6 reps, 3 second holds 3. Evacuate: evacuation of mucus occurs when breathin ginto larger lung volumes 5-6 reps, 3 second holds - May perform expectoration via huff or cough at end **Breathing is always done though the nose using diaphragmatic breathing** At the end of one cycle perform **2-3 huffs/coughs** followed by deep breathing to prevent collapse of airways Treatment time = **30-40 mins/ session once a day** | Page 106 - Visual Representation

Question 26

Autogenic Drainage (AD) Pros & Cons

Answer 26

Pros: - Independent technique - Can do it anywhere/ anytime - Doe snot cost - Less risk/ contraindications - ** Suitable for pt w/ hyperactive airways (asthma) Cons: - Requires: Lots of concentration (need cognitive capacity) - Not effective for young children - Need good proprioception, tactilem & auditory skills - Low compliance if wanting passive techniques

Question 27

Suctioning | Decription & Indications & Port of Entry

Answer 27

A procedure used to remove secretions through insertion of a catheter or device via the nasopharynx, oropharynx, or an artificial airways (ie endotrachael tube, tracheostomy tube) General indications: - To remove secretions or stimulate cough when patient is unable to do so **independently** (ie pt is mechanically ventilated) - Suctioning should be performed when **clinically indicated, not routinely** Clinical Indicated: INC secretion retention How to know: - Visible secretion sin airway - Chest auscultations: crackles (inspire/expire) - Pt describes feelings of secretions in chest or through exam findings (ie tactile fremitus) - Suspected aspiration of gastric or upper airway secretions - INC SOB or INC work of breathing - ABGs: hypoxaemia or hypercarbia - CXR evidence Port of Entry - Via nose/mouth - Via nose/mouth via artificial airway - Via endotrachael tube or traacheostomy tube

Question 28

Suctioning: Contraindications | (5)

Answer 28

1. Severe DEC O2 saturation (< 92%) 2. INC ICP 3. Hemoptysis 4. Malignant arrhythmia 5. Hyperinflation post-CABG & head injury

Question 29

Suctioning: Potential Complicatins | (10)

Answer 29

1. Infection (invasive) 2. Mucosal (tracheal & bronchial) trauma - hit something 3. Hypoxia/ hypoxaemia - suction inside lung OR for too long 4. Hemodynamic instability 5. Laryngospasm/bronchospasm - reactive airway 6. Atelectasis - hypoxia - sucking out gases 7. Pneunothorax - go past the carina (split bronchi) 8. INC ICP 9. Pain 10. Anxiety

Question 30

Suctioning: Methods to minimize complications | (5)

Answer 30

1. Infection control measures (sterile environment/equipment, handwashing) 2. Hyperoxygenation 3. Hyperinflation - pump up w/ O2 beforehand = DEC risk of ICP 4. Limit suction time (no greater than **10-15 seconds** per pass) & allow recovery time b/t each pass (**30 seconds** b/t pass) *Going DOWN - not suctioning* 5. Medication & sedation prior to procedure

Question 31

Suctioning: Outcome | (4)

Answer 31

1. Improved breath sounds 2. Removal of secretions 3. Improved blood gas data or pulse oximetry 4. Decrease work of breathing (DEC respiratory rate or dyspnea)

Question 32

Forced Expiratory Techniques: LIST | (4)

Answer 32

1. Cough 2. Huff 3. Assisted Cough 4. Cough Assist Machine

Question 33

Cough | Description + Phases (4)

Answer 33

A cough is a forced expiratory technique with a **closed glottis** that may be used to help expel secretions 4 Stages of Coughing: 1. Inspiration: adequate inspiratory volumes for a cough are approx **60% of predicted VC** *INC air = INC thoracic pressure* 2. Glottal Closure: closure of the glottis 3. Compression: active contraction of abdominal & intercostal mm causing an increase in intrathoraxix pressure **DISTAL** to the glottis *Expiratory mm will contract* 4. Expulsion: opening of the glottis & forceful exulsion of air

Question 34

Huff | Description

Answer 34

A huff is a forced expiration technique with an **open glottis** that may assist to mobilize & clear secretions from airways - A deep breath is followed by forced expiration w/ mouth & glottis open - Cue: "imagine you are trying to fog up a pair of glasses" - Huff is perferred to coughing in patients with obstructive lung diseases d/t the risk of small airways collapse from the high intra-thoracic pressure created with coughing Huff from **mid-low lung volumes** = clearing **peripheral** airways Huff from **mid-high lung volumes** = clearing **proximal** airways More tolerated in pt who have pain w/ coughing: 1. splint 2. regress to huff

Question 35

Assisted Cough | 2 Types + Descriptions

Answer 35

**Costophrenic Assist** - Therapist hands are placed on the **costophrenic angles** of the rib cage - PT times patient's next exhalation & applied a quick manual stretch down & in towards patient's navel > this quick stretch facilitates a stronger contraction of the diaphragm & intercostals for the inhalation that follows ***RIB SPRING*** - The patient holds their breath for **3 seconds** & then coughs maximally w/ PT provides a sustained pull pressure on the costophrenic angle **Heimlich-Type Assist (Abdominal Thrust)** - PT places the heel of their hand over the epigastric are. **Avoid** the xiphoid process - Pt is instructed to take a deep breath in & hold ofr **3 seconds** - Pt is instructed to cough on the **count of 3** & then the PT provides a quick pressure up & in (**"J stoke" motion**) as in Heimlich manuever ** This method is contraindicated for those with GERD or recent abdominal surgery

Question 36

Cough Assist Machine (Mechanical Insufflator-Exsufflator) | Description

Answer 36

- A CoughAssist Machine stimulates a cough & pulling of secretions form the airways through alternating positive & negative pressures - A CoughAssist Machine unit is used with a mask, mouthpiece, or tracheostomy adaptor - Positive pressure created by the machine delievers a large volume of air on inspiration - The machine creates a rapid reversal to negative pressure which stimulates a cough (negative pressure externally)

Question 37

Assisted Cough: Long Sitting

Answer 37

Patient is in long-sitting Patient takes a deep breath > thrust forward to INC intrathoracic pressure > long sitting > sudden flexion = cough