Pulmonary Interventions

Question 1

list primary and secondary muscles of inspiration

Answer 1

1. Primary
   
   1. diaphragm
   2. external intercostals
2. Secondary
   
   1. SCM
   2. scalenes
   3. pec major/minor
   4. serratus anterior

Question 2

list muscles of expiration

Answer 2

1. quiet breathing → passive recoil of lungs and rib cage
2. forceful breathing
   
   1. Rectus abdominus
   2. external oblique
   3. transverse abdomnius
   4. internal intercostals

Question 3

describe the rhythm, rate, depth and character that make up the normal breathing pattern

Answer 3

1. Rate → 12-20 bpm
2. Rhythm → I:E ration is 1:2
3. Depth → deeper or shallower than normal tidal volume
4. Character → quiet and effortless

Question 4

how is rhythm different in disorders like COPD?

Answer 4

I:E ratio is 1:3 or 1:4 due to trapped air, increased residual volume, and increased work

Question 5

describe an abnormal breathing pattern’s character

Answer 5

1. labored breathing
2. use of accessory muscles
3. audible wheezes and crackles

Question 6

describe the diaphragm

Answer 6

1. aids in inspiration (C3-5)
2. expands vertically and horizontally
3. type 1 muscle fiber
4. dome shaped

Question 7

diaphragm position and ROM are affected by ____________

Answer 7

1. body position and posture
2. stomach contents (distension)
3. size of intestines
4. size of liver
5. ascites
6. abdominal muscles
7. obesity

Question 8

when is diaphragmatic breathing training indicated?

Answer 8

1. post-surgical patients
2. dyspnea at rest
3. inefficiency with breathing/SOB during ADLs

Question 9

precautions/contraindications for diaphragmatic breathing training

Answer 9

1. moderate/severe COPD w/related hyperinflation of the lungs
2. pts with paradoxical breathing patterns
3. pts with increased dyspnea during diaphragmatic breathing

Question 10

describe the procedure for diaphragmatic breathing training

Answer 10

1. start in supine or with HOB elevated 30-45
2. pts places one hand on the upper chest and the other just below the rib cage
3. PT then instructs:
   
   1. “breath in slowly through your nose so that your stomach moves out against your hand.
   2. The hand on the chest should remain relatively still.
   3. Fell your abdomen gently rise into your hand
   4. exhale through pursed lips, let the hand on your abdomen descend, while the hand on your upper chest remains still”

Question 11

list the expected outcomes for diaphragmatic breathing training

Answer 11

1. decreased respiratory rate
2. decreased reliance on accessory muscles of inspiration
3. increased tidal volume
4. subjective improvement of dyspnea
5. improved activity tolerance

Question 12

what is pursed-lip breathing

Answer 12

a technique utilized to reduce respiratory rate and decrease dyspnea by maintaining positive pressure in the bronchioles.

this can help prevent airway collapse in pts with emphysema and helps trapped air escape in pts with COPD

Question 13

indications for pursed lip breathing

Answer 13

1. tachypnea
2. dyspnea

Question 14

precautions/contraindications for pursed lip breathing

Answer 14

forcing exhalation

Question 15

describe the procedure for pursed lip breathing

Answer 15

1. start in supine or seated position
2. PT then instructs
   
   1. breath in slowly through your nose with the mouth closed for 2 seconds
   2. pucker or purse your lips as if you were blowing out a candle, then gently breathe out through pursed lips, as if trying to make the candle flame flicker for a four count
   3. do not blow with force

Question 16

list expected outcomes for pursed lip breathing

Answer 16

1. decreased RR
2. decrease dyspnea
3. reduce PaCO2
4. improve tidal volume
5. improve O2 sats
6. prevent airway collapse in pts with emphysema
7. increase activity tolerance

Question 17

what is segmental breathing?

Answer 17

1. a technique intended to improve regional ventilation and treat pulmonary complications after surgery
2. goal is to facilitate or inhibit chest wall movement through:
   
   1. proper hand placements
   2. verbal cues
   3. coordination of breathing

Question 18

list indications for segmental breathing

Answer 18

1. decreased lung volumes
2. decreased chest wall compliance
3. VQ mismatch

Question 19

precautions for segmental breathing

Answer 19

none

but be careful with pain or tenerness

Question 20

when would you use segmental breathing?

Answer 20

when you notice that a pt has one side restricted during respiration

Question 21

describe the pt position for segmental breathing

Answer 21

1. sitting position for basal atelectasis
2. sidelying with affected lung uppermost
3. supine or sitting for bilateral expansion
4. postural drainage positions

Question 22

describe the procedure for segmental breathing

Answer 22

1. therapist applies firm pressure at the end of exhalation over the area that needs more expansion
2. pt inhales deeply and slowly expanding the rib cage under the therapist’s hand utilizing the tactile cue

Question 23

T/F: segmental breathing is a muscle training technique

Answer 23

FALSE
you are not actively pushing against the rib cage, rather you are providing a quick stretch like PNF

Question 24

list the expected outcomes for segmental breathing

Answer 24

1. increased chest wall mobility
2. expand collapsed alveoli
3. secretion loosening and clearance

Question 25

what is the purpose of a cough?

Answer 25

very important to aid in airway clearance and help reduce risk of pneumonia

Question 26

when would you need to teach compensatory techniques for a cough?

Answer 26

if unable to cough effectively for a variety of reasons such as: 1. post-surgical pain 2. SCI with lack of innervation to forced expiratory muscles 3. progressive weakness

Question 27

list the stages and components of a cough

Answer 27

1. deep inhalation 2. glottis closes 3. increased pressure gradient 4. glottis opens 5. forceful movement of air

Question 28

what can stimulate a cough?

Answer 28

reflexively by a mechanical/chemical stimulus to the larynx, trachea, carina, or lower bronchi

Question 29

what is the purpose of a directed cough?

Answer 29

can compensate for pt's inability to elicit max forced exhalation

Question 30

describe the procedure for a directed cough

Answer 30

1. inhale maximally, close glottis and hold breath for 2-3 seconds 2. contract the expiratory muscles to produce increased intrathoracic pressure against the closed glottis 3. cough strongly 2-3x through slightly open mouth \*post surgical pts may need to splint the chest/abdomen by applying pressure over incision with a pillow or soft blanket roll

Question 31

what is the purpose of splinting during coughing in post-surgical pts?

Answer 31

can help absorb all the vibrations which will reduce pain during coughing

Question 32

what is a huff cough?

Answer 32

utilizes forced expiratory maneuver with glottis open although it does not produce the airflow velocity a cough, it helps decrease the risk of airway collapse

Question 33

describe the procedure of a huff cough

Answer 33

1. inhale deeply through an open mouth 2. contract abdominal muscles during a rapid exhalation with glottis open saying “Ha Ha Ha”

Question 34

precautions/contraindications for Huff Cough

Answer 34

1. droplet precautions with inability to control secretions 2. elevated ICP 3. Acute MI 4. unstable head/neck injury 5. potential aspiration 6. untreated pneumothorax 7. osteoporosis 8. flail chest

Question 35

describe percussion/vibration

Answer 35

1. consist of positioning the pt properly so that gravity aids in drainage of bronchial secretions 2. followed by mechanical assistance to loosen secretions 3. after completion, pt is encouraged to cough/huff to clear airway

Question 36

important things to remember with percussion

Answer 36

1. skin must be covered (towel, t-shirt, hospital gown) 2. therapist rhythmically strikes the chest with a cupped hand for 2-3 minutes per affected lung segment. 1. can be done mechanically as well 3. cough!

Question 37

important things to remember with vibration

Answer 37

1. same positions as percussion 2. therapist places one hand over the affected area on each side of the rib cage 1. or hand over hand over affected segment 3. therapist vibrates the chest wall as the pt exhales rhythmically and with downward pressure 4. vibration in direction of rib movements during expiration 5. cough!

Question 38

list precautions/contraindications for percussion/vibration

Answer 38

1. elevated ICP 2. unstable head/neck injury 3. acute spinal injury 4. PE associated with CHF 5. PE 6. Rib fracture 7. osteoporosis 8. prolonged use of corticosteroids 9. suspected TB 10. bronchospasm

Question 39

describe active cycle of breathing techniques

Answer 39

1. start with relaxed diaphragmatic breathing (20-30 seconds) in sitting 2. perform 3-4 deep breaths with added thoracic expansion 3. may add inspiratory hold of 1-3 seconds 4. relaxed exhalation 5. may follow with huffs or FET as secretions move into large airways 6. relaxed, controlled breathing 7. repeat cycle 2-4x 8. cough at end of 3 cycles

Question 40

list outcomes of active cycle of breathing technique

Answer 40

1. loosen and clear secretions from the lungs 2. improve ventilation in the lungs 3. improve the effectiveness of a cough

Question 41

describe autogenic drainage

Answer 41

1. staged breathing at different lung volumes 1. start with small tidal breaths from ERV in sitting 1. repeated until secretions are felt gathering in the airways (10-20 breaths) 2. the cough is suppressed 2. a larger tidal volume is taken for another series of 10-20 breaths 3. followed by a series of larger (approaching VC breaths) 4. followed by several huff or coughs to expectorate sputum

Question 42

T/F: if you have to cough early in autogenic drainage do so

Answer 42

FALSE try to hold cough to the very end if possible

Question 43

list the outcomes of autogenic drainge

Answer 43

1. mobilize secretions by creating shearing forces induced by airflow 2. speed of expiratory flow helps mobilize secretions by shearing them from bronchial walls 3. once mobilized, secretions are transported from the periphery of the airways to the central airways to be cleared

Question 44

describe how to use an incentive spirometer

Answer 44

1. maximizes alveolar expansion utilizing sustained maximal inspiration 2. gives visual feedback to encourage the pt to take long, slow, deep inhalations 3. very important in post surgical pts or those on prolonged bedrest (atelectasis) 4. 5-10 breaths per hour when awake

Question 45

what is an Acapella Flutter Device?

Answer 45

1. positive expiratory pressure device with mechanical oscillation 2. creates circuit with lungs to allow for secretion mobilization 3. most allow for inhalation/exhalation without need to remove device 4. end with cough

Question 46

describe The Vest

Answer 46

1. great for children along with those in need of more regular airway clearance (CF, COPD exacerbation, etc.) 2. provides percussion over surface area of all bronchopulmonary segments 3. secretions are removed as they loosen