1
Q
What are the general parts of pulmonary anatomy?
A
- upper respirator tract
- lower respiratory tract
- alveoli
- primary inspiratory muscles
- primary expiratory muscles
2
Q
What does the upper respiratory tract consist of?
A
- nasal cavity
- oral cavity
- larynx
- pharynx
3
Q
What is the function of the upper respiratory tract?
A
- warm, humidify, and filter inspired air
- mucocilliary escalator
4
Q
What does the lower respiratory tract consist of?
A
- trachea
- bronchi
- bronchioles
- alveoli
5
Q
What is the function of the lower respiratory tract?
A
- houses immune cells
- complete pulmonary defense
6
Q
What should be noted about the R mainstem bronchus?
A
it is more vertically aligned than the L and is more likely to be the site of aspiration
7
Q
What is the function of alveoli?
A
primary site of gas exchange
8
Q
Name the primary inspiratory muscles
A
- diaphragm
- external intercostals
- accessory muscles (SCM, scalenes, pecs, traps)
9
Q
Name the primary expiratory muscles
A
- rectus abdominus
- external obliques
- internal obliques
- internal intercostals
10
Q
What are the parts and normal values of V/Q ratio
A
V - ventilation
Q - perfusion
Normal value: 0.8
11
Q
What affects V/Q ratio?
A
- concentration gradient
- surface area
- thickness of membrane
12
Q
When does dead space occur?
A
- decreased perfusion (Q)
- example: pulmonary embolism
13
Q
When does shunting occur?
A
- decreased ventilation (V)
- example: atelectasis, COPD, pneumothorax
14
Q
What are the types of lung volumes?
A
- VC: vital capacity
- TV: tidal volume
- IC: inspiratory capacity
- ERV: expiratory reserve volume
- RV: residual volume
15
Q
Define vital capacity
A
- the greatest volume of air that can be expelled from the lungs after taking the deepest possible breath
16
Q
Define tidal volume
A
- the amount of air that moves in or out of the lungs with each respiratory cycle (quiet breathing)
17
Q
Define inspiratory capacity
A
- the max volume of air that can be inspired after reaching the end of a normal, quiet expiration
18
Q
Define expiratory reserve volume
A
- the amount of extra air, above a normal breath, exhaled during a forceful breath out
19
Q
Define residual volume
A
the volume of air remaining in the lungs after maximum forceful expiration
20
Q
Name the types of breathing patterns (13)
A
- apnea
- biot’s respirations
- bradypnea
- cheyne-stokes respirations
- hyperpnea
- hyperventilation
- hypoventilation
- kussmaul respirations
- orthopnea
- paradoxic ventilation
- sighing respirations
- tachypnea
- hoover’s sign
21
Q
Define apnea and its causes
A
- lack of airflow to the lungs for >15 seconds Causes: - airway obstruction - cardiopulmonary arrest - alterations to the respiratory center - narcotic overdose
22
Q
Define Biot’s respirations and its causes
A
- constant increased rate and depth of respiration followed by periods of apnea of varying lengths
Causes: - increased ICP
- meningitis
23
Q
Define bradypnea and its causes
A
- ventilation rate <12 breaths per minute Causes: - sedatives - narcotics - alcohol - neurologic or metabolic disorders - excessive fatigue
24
Q
Define Cheyne-Stokes respirations and its causes
A
- increasing depth of ventilation followed by a period of apnea Causes: - increased ICP - CHF - narcotic overdose
25
Define hyperpnea and its causes
```
- increased depth of ventilation
Causes:
- activity
- pulmonary infections
- CHF
```
26
Define hyperventilation and its causes
```
- increased rate and depth of ventilation resulting in decreased PCO2
Causes:
- anxiety
- nervousness
- metabolic acidosis
```
27
Define hypoventilation and its causes
- decreased rate and depth of ventilation resulting in increased PCO2
Causes:
- sedation/somnolence
- neurologic depression of respiratory centers
- overmedications
- metabolic alkalosis
28
Define Kussmaul respirations and its causes
- irregular rate and depth of respirations
Causes:
- diabetic ketoacidosis
- renal failure
29
Define orthopnea and its causes
- dyspnea that occurs in a flat supine position; relief occurs with more upright sitting or standing
Causes:
- chronic lung disease
- CHF
30
Define paradoxic ventilation and its causes
```
- inward abdominal or chest wall movement with inspiration and outward movement with expiration
Causes:
- diaphragm paralysis
- ventilation muscle fatigue
- chest wall trauma
```
31
Define sighing respirations and its causes
```
- the presence of a sigh 2-3x/minute
Causes:
- angina
- anxiety
- dyspnea
```
32
Define tachypnea and its causes
```
- ventilation rate >20 breaths per minute
Causes:
- acute respiratory distress
- fever
- pain
- emotions
- anemia
```
33
Define Hoover's sign and its causes
- the inward motion of the lower rib cage during inhalation
Causes:
- flattened diaphragm
--> often related to decompensated or irreversible hyperinflation of the lungs
34
What are the arterial blood gasses (ABGs)?
- acid-base balance (pH)
- ventilation (CO2)
- oxygenation (O2)
35
What are ABGs used for?
to guide medical or therapeutic interventions such as mechanical ventilation settings or breathing assist techniques
36
What might disturbances in acid-base balance be caused by?
- pulmonary dysfunction
| - metabolic dysfunction
37
In what order are ABGs typically written?
pH / PaCO2 / PaO2 / HCO3
38
What is PaCO2?
partial pressure of dissolved CO2 in plasma
39
What is PaO2?
partial pressure of dissolved O2 in plasma
40
What is HCO3?
the level of bicarbonate in the blood
41
What is the difference between PaO2 and SaO2?
- PaO2 is the partial pressure of dissolved O2 in plasma
| - SaO2 is a percentage of the amount of hemoglobin sites filled(saturated) with O2 molecules
42
Define air trapping
retention of gas in the lung as a result of partial or complete airway obstruction
43
Define bronchospasm
smooth muscle contraction of the bronchi and bronchiole walls resulting in a narrowing of the airway lumen
44
Define consolidation
transudate, exudate, or tissue replacing alveolar air
45
Define hyperinflation
over-inflation of the lungs at resting volume as a result of air trapping
46
Define hypoxemia
a low level of oxygen in the blood
| - PaO2 <60-80mmHg
47
Define hypoxia
a low level of oxygen in the tissues available for cell metabolism
48
Define respiratory distress
the acute or insidious onset of dyspnea, respiratory muscle fatigue, abnormal respiratory pattern and rate, anxiety, and cyanosis related to inadequate gas exchange
- this clinical presentation usually precedes respiratory failure
49
Define Acute Respiratory Distress Syndrome (ARDS)
acute inflammation of the lungs associated with
- aspiration
- drug toxicity
- inhalation injury
- pulmonary trauma
- shock
- systemic infection
- multi organ failure
50
Describe the sequelae and treatment for ARDS
- variable latent pulmonary sequelae (none to mild exertional dyspnea to mixed obstructive-restrictive abnormalities)
- prone positioning in ICU
- -> facilitates improved aeration to dorsal lung segments, improves VQ matching, and secretion drainage
51
Define pleural effusion and describe its causes and treatment
```
- fluid in the pleural space (transudate or exudate) which can be unilateral or bilateral
Causes:
- compressive atelectasis
Treatment:
- fluid must be drained
```
52
Define pneumothorax
- air in the pleural space which can be open or closed
53
What can pneumothorax cause? (VQ)
decreased ventilation = shunting
54
Define hemothorax
blood in the pleural space
55
Define cystic fibrosis
a genetic anomaly in which there is an issue with sodium channels that results in an excessive amount of fluid in the lungs (mild to severe cases)
56
Define atelectasis and what it may cause
- collapsed alveoli
| - May cause decreased ventilation = shunting
57
Define flail chest and what it may lead to
- a case in which you have a double fracture of 3+ adjacent ribs which separates the chest from the rib cage
- this leads to paradoxical breathing patterns and can lead to atelectasis if not treated quickly
58
Define subcutaneous emphysema
bubbles popping under the skin from the presence of air in subcutaneous tissue
59
Name the different breath sounds
- bronchial breath sounds
- bronchovesicular breath sounds
- bronchial breath sounds in place of vesicular sounds
- decreased/diminished breath sounds
- absent breath sounds
- extrapulmonary sounds
- whispered pectriloquy
- bronchophony
- egophony
60
Describe bronchial breath sounds
- a pause between inspiration and expiration
| - inspiratory and expiratory phases are equal
61
Describe bronchovesicular breath sounds
- no pause between inspiration and expiration
| - inspiration longer and louder than expiration
62
Describe bronchial breath sounds in place of vesicular sounds
- fluid or secretion consolidation that could occur with pneumonia
63
Describe decreased/diminished breath sounds
- hypoventilation
- severe congestion
- emphysema
64
Describe absent breath sounds
- pneumothorax
| - lung collapse
65
Describe extrapulmonary sounds
- from dysfunction outside of lung tissue
| - most common: pleural friction rub
66
Describe whispered pectriloquy
patient whispers 1,2,3
+ Consolidation: phrases are clearly audible
+ Hyperinflation: phrases less audible in distal lung fields
67
Describe bronchophony
patient repeats 99
+ Consolidation: phrases are clearly audible
+ Hyperinflation: phrases less audible in distal lung fields
68
Describe egophony
patient repeats the letter 'e'
| + fluid in air spaces: 'e' sounds like an 'a' in the distal lung fields
69
Name the different types and subtypes of adventitious breath sounds
```
Continuous breath sounds
- wheeze
- stridor
- rhonchi
Discontinuous breath sounds
- crackles
```
70
Describe wheezing
caused by airway obstruction, more common with expiration
Continuous breath sound
71
Describe stridor
a high-pitched wheeze on inspiration and expiration
Continuous breath sound
72
Describe rhonchi
low-pitched, caused by airway obstruction
Continuous breath sound
73
Describe crackles
bubbling and popping sounds from fluid/secretions or sudden opening of closed airway
Discontinuous breath sounds
74
What is mediate percussion and why is it performed?
- place palmar surface of index and middle fingers flatly against chest wall within intercostal spaces; strike the distal 1/3 of fingers with tips of other fingers; proceed in cephalocaudal, side to side pattern
- evaluates tissue densities within the thoracic cage
75
What are the different sounds heard from mediate percussion?
- resonant
- hyperresonant
- tympanic
- dull
- flat
76
What do resonant sounds indicate?
normal lung tissue
77
What do hyperresonant sounds indicate?
tissue with emphysema or pneumothorax
78
What do tympanic sounds indicate?
gas bubbles in the abdomen
79
What do dull sounds indicate?
increased tissue density or decreased air
80
What do flat sounds indicate?
dense tissue
sound like extreme dullness
81
What are the different types of pulmonary pharmacologic agents?
- glucocorticoids
- antihistamines
- bronchodilators
- leukotriene modifiers
- mast cell stabilizers
- nebulizer treatments optimally active 15-20mins after administration
82
Name the goals of PT treatment for pulmonary patients
- promote independent functional mobility
- maximize gas exchange
- increase aerobic capacity
- increase respiratory muscle endurance
- patient education about condition
83
Name general interventions for pulmonary PT
- breathing retraining exercises
- secretion clearance techniques
- positioning
- functional activities
- exercise
- patient education
- monitoring VS
84
Name some more specific interventions for pulmonary PT
- improve endurance
- improve strength
- improve functional mobility
- use positioning to promote hemodynamic stability
- work on breathing techniques
- airway clearance with effective coughing
- energy conservation techniques
- ROM to stimulate alveolar ventilation
- postural drainage and manual techniques
- suctioning
85
What are appropriate outcome measures for pulmonary patients?
- CPAx
- 2MWT
- 6MWT
- AM-PAC 6 Clicks
- DEMMI
- FSS-ICU
86
What is the purpose of mechanical ventilation?
to maintain homeostasis between gas concentrations of O2 and CO2
87
When is mechanical ventilation indicated?
- airway protection
- cardiac arrest
- management of ICP
- airway obstruction
- surgery/trauma
88
What are the different values PTs need to know for mechanical ventilation?
- FiO2
- tidal volume
- PEEP
- O2 flow
- RR
89
What is FiO2?
fraction of inspired oxygen
| - shown as %
90
What is tidal volume?
normal amount of air ventilated at rest
| - shown as mL
91
What is PEEP?
positive end expiratory pressure
| - shown as cmH2O
92
What is O2 Flow?
how fast the oxygen is flowing
| - shown as L/min
93
What is RR?
respiration rate
| - shown as breaths/min
94
Name the types of mechanical ventilation (11)
- invasive mechanical ventilation
- non-invasive mechanical ventilation
- tracheostomy
- volume control (VC)
- pressure control (PC)
- assist control (AC)
- pressure regulated volume control (PRVC)
- synchronous intermittent mandatory ventilation (SIMV)
- pressure support ventilation (PSV)
- volume support (VS)
- CPAP
95
What is invasive mechanical ventilation and what does it consist of?
- intubation of artificial ariway into trachea
- endotracheal tube
- nasotracheal tube
- tracheostomy
96
What is non-invasive mechanical ventilation? What is key about it?
- BiPAP or CPAP
| - KEY: the last step before intubation
97
When is a tracheostomy indicated?
- when a patient is unable to be weaned from the ventilator
- difficulty intubating patient (severe morbid obesity)
- airway blocked or obstructed (tumor, traumatic injury)
98
What is VC and what are its characteristics and indications?
- preset tidal volume delivered at a set respiratory rate
Indication:
- pt with no spontaneous breathing
Characteristics:
- peak pressure can vary depending on pts lung compliance and resistance
99
What is PC and what are its characteristics and indications?
a predetermined amount of pressure at a set rate
Indication:
- pt with no spontaneous breathing
Characteristics:
- ventilator determines inspiratory time
- PEEP used to increase arterial O2 and improve lung compliance
100
What is AC and what are its characteristics and indications?
```
delivers a specific amount of tidal volume
Indications:
- pt can initiate breaths
Characteristics:
- forces air into lungs
- pt or vent initiates breaths
- high level of respiratory support
```
101
What is PRVC and what are its characteristics and indications?
combines PC and VC ventilation
- a preset tidal volume is delivered at a set rate but with the lowest possible pressure
Indications:
- prevent barotrauma
102
What is SIMV and what are its characteristics and indications?
allows pts to breathe in between each machine assisted breath and delivers a certain number of breaths in coordination with respiratory effort of pt
Indications:
- pts with some but not sufficient breathing
- weaning
Characteristics:
- increased work of breathing
103
What is PSV and what are its characteristics and indications?
a small, specific amount of pressure occurs on inspiration
Indications:
- pt can initiate all breaths
Characteristics:
- ventilator assists pt with spontaneous breaths
- pt regulates RR and TV
104
What is VS and what are its characteristics and indications?
```
tidal volume and PEEP are set
Indications:
- pt can initiate all breathing
Characteristics:
- vent delivers support in proportion to pt's inspiratory effort and target volume
```
105
What is CPAP and what are its characteristics and indications?
continuous pressure is maintained in the airways to prevent collapse
Indications:
- pt regulates all other respiratory functions
106
What medications are used with mechanical ventilation?
- propofol
- precedex
- fentanyl
107
What are causes of red alarms with mechanical ventilation?
- apnea
- disconnection
- high pressure
108
What are causes of yellow alarms with mechanical ventilation?
- low tidal volume
- high respiratory rate
- low minute ventilation
- low inspiratory pressure
109
What does weaning off mechanical ventilation mean?
- a process of decreasing or discontinuing mechanical ventilation
- a condition that led to ventilation support needs to be resolved
110
What factors should be considered during weaning?
- respiratory demand and ability of NM system to cope with O2 demand
- oxygenation
- cardiovascular performance
- psychological factors
- adequate rest and nutrition
111
What are signs of distress during weaning?
- tachypnea (>30 breaths/min)
- decreased pH (<7.25-7.30 with increased PaCO2)
- paradoxical breathing patterns
- O2 Saturation <90%
- HR change of >20bpm
- BP change > 20mmHg
- agitation
- panic
- diaphoresis
- cyanosis
- angina
- arrhythmia
112
What are contraindications to PT for mechanical ventilation?
- comatose
- unresponsive
- does not follow commands
- severe agitation/combativeness
- PEEP >10cmH2O
- FiO2 > 0.6 or 60%
- uncontrolled active bleeding
113
What are complications of mechanical ventilation?
- skin breakdown
- joint contractures
- deconditioning
Acute Care
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