question

cartilaginous Airway

answer

Trachea, main stem bronchi, lobar bronchi, segmental bronchi, subsegmental bronchi

question

non cartilaginous Airways

answer

bronchioles, terminal bronchioles

question

gas exchange

answer

respiratory bronchioles, alveolar ducts, alveolar sacs

question

upper lobe Right lung

answer

apical segment, posterior segment, anterior segment

question

middle lobe Right lung

answer

lateral segment, medial segment,

question

lower lobe Right Lung

answer

superior segment, medial basal segment, anterior basal segment, lateral basal segment, posterior basal segment

question

Right lung has how many segments?

answer

10

question

Left lung has how many segments?

answer

8

question

Upper lobe Left (upper division)

answer

Apical/ posterior segment, anterior segment

question

Lingular Division

answer

Superior lingula segment, inferior lingula segment

question

Lower Lobe

answer

superior segment, anterior medial segment, lateral basal segment, posterior basal segment

question

Goals of Chest PT

answer

To treat the accumulation of secretions. To improve the mobilization of secretions. To promote more efficient breathing patterns. To improve the distribution of ventilation. To improve cardiopulmonary exercise tolerance.

question

Indications for Chest PT

answer

acute conditions, chronic conditions, preventative use

question

Acute Conditions

answer

-copius secretions, acute respiratory failure with retained secretions, acute lobar atelectasis, V/Q abnormalities caused by unilateral lung disease

question

Chronic conditions

answer

copious secretions like cystic fibrosis or bronchiectasis, COPD with insufficient breathing patterns or decreased exercise tolerance

question

Preventative Use

answer

postoperative respiratory complication, neuromuscular conditions, exacerbation of COPD

question

Initial Assessment of Need for CPT

answer

patient and medical history

question

medial history

answer

-history of pulmonary problems causing increased secretions -abdominal or thoracic surgery -artificial airway -chest x-ray indicating atelectasis or infiltrates -results of PFT's and ABG's, Oximetery

question

patient

answer

-posture, muscle tone -effectiveness of cough -sputum production -breathing pattern -general physical fitness -breath sounds -vital signs, heart rate, and rhythm

question

Theraputic positioning primary objectives

answer

1. promote lung expansion and prevent retention 2. improve arterial oxygenation 3. help mobilize secretions 4. relieve dyspnea

question

Turning Indications

answer

Inability or reluctance of the patient to change body position due to mechanical ventilation, neuromuscular disease, or drug- induced paralysis

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Absolute contraindications for Turning

answer

unstable spinal cord injury, traction of arm abductors

question

Efficacy for Turning

answer

reduced incidence of major pulmonary complications such as atelectasis and pneumonia

question

Postural Drainage

answer

-use of gravity to help move respiratory tract secretions from lung lobes or segments into the central airways -accomplished by placing segmental bronchus to be drained in a vertical position relative to gravity

question

postural drainage is effective in conditions characterized by

answer

excessive sputum production of 25-30 ml or more per day

question

to be effective postural drainage requires

answer

head down positions in excess of 25 degrees

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adequate systemic and airway hydration is a prerequisite for

answer

effective mucocilliary clearance in general

question

postural drainage indications

answer

-difficulty clearing secretions -sputum production > than 25- 30 cc/day (adult) -retained secretions in pts with artificial airways -atelectasis due to mucous plugging -diagnosis of diseases such a cystic fibrosis, brochietasis, or cavitating lung disease -presence of a foreign body in the airway

question

absolute postural drainage contraindications

answer

head and neck injuries until stabilized, active hemorrhage with hemodynamic instability

question

relative postural drainage contraindications

answer

-ICP > 20 mmHg and patients in whom ICP increase is to be avoided -recent spinal surgery or acute spinal injury -emphysema, bronchopulmonary fistula, cardiogenic pulmonary edema, pulmonary embolism, rib fracture, uncontrolled hypertension, distended abdomen, active hemoptysis, uncontrolled airway at risk of aspiration

question

for Postular Drainage Technique

answer

-identify proper lobes and segments for drainage

question

Post drainage pt should be in a what position?

answer

head down position (Trendelenburg)

question

trendelenburg should be used with caution for patients with

answer

-unstable cardiovascular status -hypertension -cerebrovascular disorders -orthopnea (shortness of breath lying flat)

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When should you schedule postural drainage?

answer

before or at least 1.5 to 2 hours after meals

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the positioned patient should do PD for

answer

a minimum of 3-15 minutes as tolerated

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total treatment for PD should not last longer than

answer

30- 40 minutes

question

Trendelenburg positioning

answer

bed flat, feet elevated 14-18 inches

question

Reverse trendelenburg

answer

bed flat, head elevated 14-18 inches

question

fowler's

answer

patient sitting at 60- 90 degree angle

question

semi fowlers

answer

patient sitting at 45- 60 degree angle

question

prone

answer

laying on your stomach

question

outcomes for postular drainage

answer

-increased sputum production -improvement in breath sounds -restoration of normal vital sounds -resolution of abnormal chest x ray -normalization of ABG values or saturation -improved ventilator variables -patients positive subjective response to therapy

question

percussion and vibration

answer

application of mechanical energy to the chest wall using either the hands or various electrical or pneumatic devices

question

the purpose of percussion and vibration

answer

augment secretion clearance

question

percussion (CPT)

answer

jars secretions loose

question

Vibration

answer

aids in movement of secretions

question

efficacy of percussion and vibration is

answer

difficult to assess

question

percussion and vibration therapy is usually

answer

combined with other therapies

question

indications of percussion and vibration

answer

adjunct to postural drainage and coughing when these methods alone fail to mobilize secretions

question

absolute contraindications of vibration and percussion

answer

head and neck injuries until stabilized or active hemorrhage with hemodynamic instability

question

relative contraindications of percussion and vibration

answer

-ICP > 20 mmHg -subcutaneous emphysema -recent epidural spinal infusion or spinal anesthesia -recent skin grafts, or flaps on the thorax -recently placed transvenous or subcutaneous pacemaker -removal of chest tubes for at least one hour -suspected pulmonary tuberculosis -bronchospasm -osteomyelitis of the ribs -coagulopathy -complaint of chest wall pain

question

How is percussion CTP Technique done?

answer

accomplished with hands in a cupped position. finger and thumbs closed. air is trapped between the hand and chest wall, elbow should be partially flexed and wrist loose. strike chest in a waving position alternating hands in sequence

question

you should proceed in a circular pattern over localized area for a period of

answer

3 to 5 minutes

question

when doing CPT avoid:

answer

tender areas, sites of trauma or surgery, bony prominences

question

vibration technique should be limited to application during

answer

exhalation

question

vibration technique

answer

lay one hand on the patients chest over the involved area and place the other hand on top of the first. after a deep inspiration, exert sight to moderate pressure on the chest wall with a rapid vibratory motion of hands throughout expiration

question

mechanical percussion and vibration is a

answer

electrical or pneumatic device that generates energy waves

question

advantages of mechanical percussion and vibration

answer

-does not tire -delivers consistent rates, rhythms, and impact forces

question

components of high frequency chest wall compression

answer

-variable air pulse generator -non stretch inflatable vest

question

mechanism of action for high frequency chest wall compression

answer

-small gas volumes are alternately injected into and withdrawn from the vest by the air- pulse generator - fast rate creates an oscillatory motion against the thorax

question

duration of therapy of high frequency chest wall compression

answer

30 minute sessions at frequencies between 5- 25 Hz

question

complications and adverse effects of chest physical therapy

answer

-pulmonary hemorrhage -fractured ribs -cardiac arrhythmias -increased intracranial pressure -hypoxemia -impaired cardiac output -impaired coronary and cerebral perfusion -increased airway resistance -neurological symptoms

question

pulmonary hemorrhage

answer

-underlying cause usually attributed to pulmonary abcess or bronchopleural fistula -avoid when active hemoptysis is present

question

fractured ribs

answer

remote possibility if improperly performed

question

one in 3 patients will develop a

answer

cardiac arrhymia

question

10 % of patients develop a serious arrhythmia causing

answer

a drop in BP and HR

question

increased intracranial pressure

answer

can increase as high as 23 mm Hg in the trendelenburg position

question

what type of patients will develop hypoxemia

answer

likely in patients with cardiovascular instability or profuse bronchial secretions

question

hypoxemia can worsen in unilateral lung disease when positioned with

answer

the bad lung down

question

the higher the ____ before CPT, the greater the drop in the _____

answer

PaO2

question

impaired cardiac output can decrease as much as

answer

50%

question

impaired cardiac output is a result of

answer

decreased venous return

question

avoid patients who are

answer

hypovelemic, in shock, unable to regulate blood pressure and flow

question

impaired coronary and cerebral perfusion is a result from

answer

spiked in intrathoracic pressure during coughing

question

increased airway resistance occurs in patients who

answer

exhibit signs of bronchospasm during therapy

question

to minimize increased airway resistance

answer

by first administering a bronchodilator

question

neurological symptoms are

answer

headache, dizziness, numbness and visual disturbance

question

cause of neurological symptoms are

answer

reduced cerebral perfusion due to cough

question

Mechanical Insufflation exsufflation (MIE)

answer

MIE devices apply positive pressure of 30 to 50 cm H2O to the airway for 1 to 3 seconds, then the device abruptly reverses the airway pressure to -30 to -50 cm H2O

question

treatment sessions consist of about

answer

five cycles of MIE followed by normal spontaneous breathing

question

mucus clearance devices are

answer

devices used to help loosen mucous in the airways of the lungs so it can be more easily mobilized and excreted

question

examples of mucus clearance devices

answer

flutter, acapella, PEP, EzPAP, Mechanical percussors, vest therapy, intrapulmonary ventilation (IPV), Metaneb, MIE (cough assist), threshold pep

question

intrapulmonary ventilation

answer

use a mask or mouth piece to create vibrations inside patients airways

question

metneb

answer

causes vibrations in airway and has PEP too

question

threshold pep-

answer

dial in number you want and exhale through it

question

each mucus clearance device uses

answer

vibration or pressure in the chest to help loosen secretions

question

using breathing exercises as well as effective cough maneuvers combined with these devices significantly improves

answer

clearance of secretions in the airwat

question

mucus clearance devices can be used as an alternative to

answer

CPT (manuel chest PT)

question

Indications for need of mucus clearance devices

answer

acute and chronic conditions that cause retained secretions like with cystic fibrosis, chronic bronchitic or any disease that causes retained secretions `

question

patient must be able to generate

answer

good breathing technique and lung volume

question

patient with muscle weakness such as MS will not be able to do

answer

manuevers effectively

question

patient must

answer

actively participate, generate a deep breath and cough

question

side effects of mucus clearance devices

answer

Tachypnea Tachycardia Dyspnea Hypoxia Bronchospasm (from excessive coughing) Chest pain Lightheaded

question

other considerations of mucus clearance devices

answer

-Possible source of infection -Pt. may have an insufficient expiratory time to use device effectively.

question

flutter

answer

the flutter uses a steel ball to be moved up and down while exhaling into the device

question

the movement of the steel ball caused a

answer

vibration that is felt in the chest that will help loosen mucous

question

the patients may have an

answer

insufficient expiratory time to use device effectively

question

patient instructions fo flutter

answer

Hold device so that the stem is parallel with the floor Slowly tilt the device upward to obtain maximal vibration

question

loosening breaths

answer

Inhale slowly through the nose Hold breath for 2-3 seconds Passively exhale at a constant speed keep cheeks hard and flat

question

loosening breaths should be repeated

answer

5-15 times, surpressing any urge to cough

question

mucuous eliminating breaths

answer

1. Inhale slowly through the nose 2. Hold breath for 2-3 seconds 3. Forcefully exhale as long as possible 4. Cough in a stair-step fashion 5. Repeat 1-2 times, coughing after each breath

question

if mucous can't be expectorated, try

answer

huffing maneuvers . (Short, rapid exhalations, like trying to "huff" a bread crumb out of the throat)

question

for pep therapy first start by selecting

answer

the largest fixed orifice

question

instruct patient to

answer

inspire through the device a larger than normal volume while preforming diaphragmatic breathing

question

have patient perform an inspiratory hold for

answer

3 seconds

question

instruct patient to exhale through

answer

exp. resistor to FRC

question

ensure that the 10- 20 cm H2o is generated through the

answer

majority to exhalation

question

adjust fixed orifice to achieve an

answer

I:E ratio of 1:3 while maintaing desired PEP Level

question

during PEP therapy, a series of ___ breaths is performed

answer

10

question

remove the PEP device and have the patient perform several

answer

forced expiratory maneuvers to raise secretions

question

selection of a port that is too large will have

answer

short exhale time, PEP level will not be attained

question

secession of a port that is too small will have

answer

prolonged expiratory time, increased WOB, air trapping

question

Acapella

answer

uses resistance which can be increased or decreased by adjusting a dial

question

the vibration os acapella helps to

answer

loosen the mucous

question

using the huff maneuver helps to

answer

remove the secretions.proper breathing technique improves effictiveness

question

Lung Expansion Therapy

answer

Incentive spirometry, IPPB, CPAP, PEP

question

Incentive Spirometry

answer

the most common form of lung expansion therapy. designed to mimic the natural sighing by encouraging patients to take slow deep breaths

question

healthy people sigh about

answer

6 times an hour

question

IS is performed by using devices that

answer

provide visual cues to the patients that the desired flow or volume has achieved

question

the basic maneuver for IS

answer

sustained maximal inspiration (SMI)

question

SMI

answer

a slow deep inhalation from function residual capacity up to the total lung capacity followed by a 5 to 10 second breath hold

question

indications for IS

answer

presence of pulmonary atelectasis, presence of conditions predisposing to atelectasis, presence of restrictive lung defect associated with quadriplegic and/or dysfunctional diaphragm

question

Presence of conditions predisposing to atelectasis:

answer

Upper abdominal surgery Thoracic surgery Surgery in patients with Chronic Obstructive Pulmonary Disease (COPD).

question

contraindications of IS

answer

-unconscious patients or those unable to cooperate. -A patient who cannot properly use IS device after instruction. -Patient unable to generate adequate inspiration

question

Patient unable to generate adequate inspiration will have

answer

VC < 10 ml/kg or IC < 1/3 of predicted normal.

question

hazards and complications of IS

answer

hyperventilation and respiratory alkalosis

question

symptoms include

answer

-Dizziness and/or numbness of fingers, or around the mouth -Alleviated by instructing patient to take frequent breaks between usages

question

discomfort is secondary to

answer

adequate pain control. instruct patient to use after adequate pain relief is obtained

question

more IS hazards

answer

pulmonary barotrauma, hypoxemia, exacerbation of bronchospasm, fatigue

question

types of incentive spirometers

answer

volume and flow

question

Volume Oriented devices

answer

shows true volume displacement -paitent inhales through a mouth piece and the plastic bellows rise during inspiration. an indicator shows the approx volume achieved. pt is then instructed to hold their breath for 5-10 seconds

question

atelectasis

answer

abnormal collapse of distal lung parenchyma

question

two primary types of atelectasis

answer

resorption and passive

question

resorption atelectasis

answer

mucus plugs block ventilation and gas distal to blockage is absorbed causing non ventilated alveoli to collapse

question

passive atelectasis

answer

caused by persistent use of small tidal volumes (Vt) pt does not take deep breaths

question

clinical signs of atelectasis

answer

medical history and physical signs

question

medical history

answer

surgery, chronic lung disease, smoking

question

physical signs of atelectasis

answer

Increased RR - Tachypnea Fine late inspiratory crackles Bronchial or Diminished breath sounds Tachycardia if hypoxemia present Chest X-ray

question

first step in administration of incentive spirometry

answer

asess pt for indication for therapy

question

Patients scheduled for abdominal or thoracic surgery should be

answer

instructed prior to surgery

question

the initial goal for IS is determined by the patients

answer

gender, height, and age

question

the setting of an accurate goal provides

answer

the patient with an incentive to achieve the goal

question

instruct pt to take slow deep breaths in order to

answer

maximize the distribution of ventilation

question

instruct pt to hold their breath for

answer

5-10 seconds

question

a normal exhalation should follow the breath hold, give pt the opportunity to ___ before next deep breath

answer

rest

question

what does the rest period help with?

answer

helps to avoid a common tendency for some pts to repeat too rapidly, causing hyperventilation and respiratory alkalosis

question

what is the goal for IS?

answer

It is NOT rapid partial lung inflation but intermittent maximal inflation

question

pts should be instructed to use the IS on their own approx ___

answer

10 times per hour

question

potential outcomes of IS

answer

absence of or improvement in signs of atelectasis

question

absence of or improvement in signs of atelectasis

answer

Decreased respiratory rate. Normal pulse rate. Resolution of abnormal breath sounds. Normal or improved chest x-ray. Improved PaO2 and decreased P(A-a)O2. Increased VC and peak expiratory flows. Improved inspiratory muscle performance. Attainment of preoperative flow and volume levels. Increased forced vital capacity (FVC).

question

what to document for IS

answer

-Patient's predicted (using gender, age and Ht) inspiratory goal (chart usually packaged with device). -Patient's actual achieved volume. -Breath sounds. -Cough evaluation. -Any adverse effects.

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