chest pulmophysiotherapy

7/31/2019 Chest Pulmophysiotherapy

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Evaluation


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History

Interview

Medical Hx

Relevant occupation and social history

Assessment of home or family environment


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General Appearance of Px

Vital signs (RR, PR, BP)

Level of consciousness (alert? Responsive? Lethargic? Cooperative?

Oriented?); changes in levels of consciousness can occur if px becomes

hypercarbic (PCO2) or hypoxic (PO2)

Color: cyanotic peripherally (nail beds); centrally? (lips). Cyanosis occurs inhypoxia

Head and neck region

Facial signs and expression (signs of respiratory fatigue or distress include

nostril flaring, focused or dilated pupil, sweating)

Mouth or nose breathing

Jugular vein engorgement (associated with venous pressure & sign of

ventricular heart failure)

Hypertrophy of accessory mm of ventilation (use at rest is seen is px with

chronic lung dse or weakness of diaphragm

Supraclavicular or intercostal retraction (indicates labored breathing)

Pursed-li breathin indicates difficult with ex iration and often seen in


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General Appearance of Px

Peripheral regions

Skin condition

Digital clubbing of fingers (associated with chronic

tissue hypoxia) Edema (sign of ventricular failure

Body type

Obese, normal, cachectic (may suggest tolerance to

exercise; marked obesity can alter breathing pattern)


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Analysis of Chest Shape andDimension and Posture

Symmetry of chest and trunk

Observe anteriorly, posteriorly & laterally

Mobility of the trunk

Check active movement especially thoracic

spine

Shape and dimension of chest AP and

lateral dimensions are usually 2:1


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Analysis of Chest Shape andDimension and Posture Common chest deformities

Barrel chest

Circumference of upper chest appears larger than that of lower chest

Sternum appears prominent

AP diameter of the chest in greater than (N)

Seen in COPD who are upper chest breathers

Pectus Excavatum (funnel chest)

Lower part of sternum is depressed and lower ribs flare out

Diaphragmatic breathers

Pectus carinatum (pigeon chest)

Sternum prominent and protrudes anteriorly

Posture

Px who have difficulty breathing secondary to COPD often lean forward on their

hands or forearm when sitting or standing and stabilize and elevate shoulder

girdle

Note postural deformity which can restrict chest movements and ventilation


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Breathing Pattern

Rate, regularity and location (N) I:E at rest 1:2

(N) I:E with activity 1:1

COPD 1:4 at rest

(N) sequence of inspiration Diaphragm contracts and descends and the

abdomen (epigastric area) rises

Lateral costal expansion as ribs moves up and out

Upper chest rises (N) individuals, neck mm (accessory mm of

inspiration) will act only during deep breathing


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Breathing Pattern

Abnormal breathing Pattern Dyspnea: SOB, distressed, labored breathing

Tachypnea: rapid, shallow respiration; decreased TV butincreased rate; associated with COPD/CRPD and use ofaccessory mm

Bradypnea: slow rate with shallow or normal depth and regularrhythm; may be associated with drug overdose

Hyperventilation: deep, rapid respiration; increased TV andincreased rate of respiration; regular rhythm

Orthopnea: difficulty breathing in supine position

Apnea: cessation of breathing in the expiratory phase

Apneusis: cessation of breathing in the inspiratory phase

Cheyne-stokes: cycles of gradually increasing TV, followed by aseries of gradually decreasing TV, and then a period of apnea;seen in severe head injury


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Palpation

Check for symmetry of chest movements Upper lobe expansion

Face the px

Place the tips of your thumbs at the midsternal line at the sternanotch

Extend fingers above the clavicle Fully exhale and inhale deeply

Middle-lobe expansion Face px

Place tips of thumbs at the xiphoid process

Extends fingers laterally around the ribs Breathe in deeply

Lower lobe expansion Place tips of thumbs along the pxs back at the spinous process

(lower thoracic level)

Extend fingers around the ribs

Breathe in deeply


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Palpation

Depth of excursion Can be measured by taking the girth of chest at 3 levels (axilla,

xiphoid, subcostal) during inspiration and expiration

Measured by placing (B) hands on pxs chest and back. Noteamount of space between thumbs after the px takes a deep

inspiration Fremitus

Vocal (tactile) fremitus: vibration felt as px speaks

Procedure

in the presence of secretions in the airways

Chest wall pain Identify specific areas or points of pain

Mediastinum (position of trachea) Identify mediastinal shift


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Mediate Percussion

An evaluation technique designed to assess

lung density, specifically air to solid ratio in the

lungs

Procedure

This maneuver produce a resonance; pitch

varies with density of underlying tissue

Sound will be dull and flat if there is greaterthan (N) amount of solid matter (e.g. tumor)

Sound will be hyper resonant (tympanic) if

there is a greater than (N) amount of air (e.g.

emphysema)


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Auscultation

Listening to sound with in the body, specifically tobreath sounds in an evaluation of the lungs

Breath sounds, normal and abnormal, occurbecause of movement of air in the airway during

inspiration and expiration To identify areas in which congestion exits and

postural drainage should be performed

To determine effectiveness of any postural drainagetreatment

To determine whether or not the lungs are clear andwhether or not postural drainage should bediscontinued

Procedure (T2, T6, T10


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Auscultation

(N) breath sounds Tracheal loud, harsh and very high pitched; heard only

over trachea; tracheal breath sounds are heard equallyduring inspiration and expiration

Bronchial loud, hollow and high-pitched; heard betweenclavicles and on manibrium anteriorly and betweenscapulae posteriorly; heard longer with expiratory thaninspiratory phase

Bronchovesicular softer, medium-pitched sounds; heardequally on inspiration and expiration only near sternum,

anteriorly and between scapulae, posteriorly Vesicular soft, breezy but faint sounds; heard over the

chest, except neat the trachea and bronchi, and betweenscapulae; sounds are audible much longer on inspirationthan on expiration


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Auscultation

Abnormal and adventitious (extra) breath sounds Breath sounds may be totally absent indicating total

obstruction of airways and lack of aeration, or may bediminished due to bronchospasm (asthma) or collapse ofan airway (atelectasis, emphysema) or blockage of airways

with secretions (pneumonia) Kinds

Crackles (rales) Fine, discontinuous sounds (similar to the sound of bubbles popping or

the sound of hairs being rubbed between your fingers next to your ears)

Heard primarily during inspiration

Result of secretions moving in the airways or in closed airways that arerapidly reopening

Wheezes (ronchi) Continuous high or low-pitched sometimes musical tones heard during

exhalation but occasionally audible during inspiration

Secondary to bronchospasm


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Cough and Sputum

Effective cough: sharp and deep

In respiratory px it may be superficial, soft,

throaty, shallow, dry or moist

Sputum should be checked

Color (clear and white normal; yellow, green

infection; blood streaked hemoptysis)

Consistency (viscious, thin, frothy)

Amount


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Management


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Breathing Exercises

Indications Acute or chronic lung disease

COPD

Pneumonia

Atelectasis

Pulmonary embolism Acute respiratory distress

Post op pain on thoracic or abdominal area

Airway obstruction secondary to bronchospasm or retainedsecretions

Deficits in CNS that leads to mm weakness (high SCI, myopathic

or neuropathic diseases Orthopedic abnormalities (kyphosis, scoliosis)

Stress management and relaxation procedures


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Breathing Exercises

Goals: Improve ventilation

Increase the effectiveness of the coughmechanism

Prevent pulmonary impairments Improve the strength, endurance and coordination

of respiratory mm

Maintain or improve chest and thoracic spine

mobilityCorrect inefficient or abnormal breathing patterns

Promote relaxation

Teach the px how to deal with SOB attacks

Improve a pxs overall functional capacity


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Breathing Exercises

Precautions Expiration should always be relaxed and passive. It should

never be forceful as this increases turbulence which leads tobronchospasm and increased airway restriction

Do not allow a px to take a prolonged expiration as this will

cause the px to gasp with the next inspiration Do not allow the px to initiate inspiration with the accessory mm

Deep breathing exercises are allowed to only up to 4 inspirationsand expirations at a time to avoid hyperventilation

General considerations Breathing exercises are performed in cycles of 3-4 breaths so

that: Maximum effort is put into each breath

Dizziness from overbeating is avoided

Shoulder tension is discouraged


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Types of breathing exercises

Diaphragmatic breathing

Controls breathing at an involuntary level, but a px

can be taught breathing control by correct use of the

diaphragm and relaxation of accessory mm

Designed to improve the efficiency of ventilation,

decrease the work of breathing, increase the

excursion of the diaphragm, and improve gas

exchange and oxygenation

Used to mobilize lung secretions during postural

drainage

Procedure


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Ventilator mm training Process of improving the strength or endurance of mm of

breathing

Focuses on training of mm of inspiration Used in treatment of pxs with a variety of acute or chronic

pulmonary disorders associated with weakness, atrophy orinefficiency of mm of inspiration (diaphragm and EI)

Forms Diaphragmatic training using weights Inspiratory resistance training

Incentive respiratory spirometry AKA sustained maximal inspiratory maneuver Form of low level resistance training that emphasizes

sustained maximal inspiration

volume of air inspired and has been used to preventalveolar collapse in post-op conditions and to strengthenweak inspiratory mm in pxs with neuromuscular disorder


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Segmental training

Hypoventilation occurs due to pain and mm

guarding (post op surgery, atelectasis, pneumonia)

Lateral costal expansion/lateral basal expansion

Posterior basal expansion

middle lobe or lingual expansion

Apical expansion


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Glossopharyngeal breathing Means of increasing a pxs inspiratory capacity when

there is severe weakness of mm of inspiration

Taught to px who have difficulty taking in a deep breath(for coughing)

Originally develop for post polio px Now taught to high SCI

Procedure

Pursed lip breathing

Preventing and relieving SOB attacks Controlled breathing, by pacing activities

E i M bili h


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Exercises to Mobilize theChest Chest mobilization techniques: exercises that combine active

movements of the trunks or extremities with deep breathing

Goals:

Maintain or improve mobility of the chest wall, trunk and shoulders

Reinforce or emphasize the depth of inspiration or controlled expiration

Specific exercises Mobilize one side of the chest

Mobilize upper chest and stretch pectoralis mm

Mobilize upper chest and shoulders

Increase expiration during deep breathing

Wand exercises Additional activities

Posture correction

Manual stretching of chest wall, trunk and extremities


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Coughing

Necessary to eliminate respiratoryobstructions and keep the lungs clear

Cough mechanisms

Deep inspiration occursGlottis closes and vocal cords tighten

Abdominal mm contract and diaphragm elevates,causing an increase in intrathoracic and intra

abdominal pressuresGlottis opens

Explosive expiration of air occurs


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Coughing

Normal cough pump

May be reflexive or voluntary

Cough pump is effective to the 7th generation

of bronchi (there are a total of 23 generationsof bronchi in the tracheobronchial tree)

Ciliated epithelial cells are present up to the

terminal bronchiole and raise secretions fromthe smaller to the larger airways in normal

individuals


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Coughing

Factors that decrease the effectiveness of the cough mechanismand cough pump

Decreased inspiratory capacity because of Pain

Acute lung disease

Rib fracture

Trauma to the chest Recent thoracic or abdominal surgery

Specific mm weakness that affects the diaphragm or accessory mm of inspiration High SCI

Anterior horn cell disease (GBS)

Depression of the respiratory center associated with general anesthesia or painmedication

Inability of the px to forcibly expel air as the result of SCI above T12

Myopathic disease and weakness such as muscular dystrophy

Tracheostomy

Critical illness that causes excessive fatigue

Chest wall or abdominal incision


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Coughing

Factors that decrease the effectiveness of the coughmechanism and cough pump

Decreased action of the cilia in the bronchial treesecondary to General anesthesia and intubation

COPD such as chronic bronchitis, which is associated withdecreased number of ciliated epithelial cells in the bronchi

Smoking

Increase in the amount or thickness of mucus causedby Cystic fibrosis Chronic bronchitis

Pulmonary infections such as pneumonia

Dehydration

Intubation


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Coughing

Teaching an effective cough

Additional means of facilitating coughManual assisted cough

Splinting

Humidification

Tracheal stimulation (tracheal tickle)

Sunctioning: alternative to coughing


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Postural Drainage

Means of mobilizing secretions in one or more lung segmentsto the central airways by placing the px in various position sothat gravity assists in the postural drainage

Includes use of manual techniques (percussion and vibration)

Goals: Prevent accumulation of secretions

Chronic bronchitis, cystic fibrosis

Prolonged bed rest

Post op px with general anesthesia

Px with ventilator

Remove secretions already accumulated Pneumonia, atelectasis, acute lung infection, COPD Weak or elderly px

Px with artificial airways


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Postural Drainage

Contraindications Hemorrhage (severe hemoptysis)

Copious amounts of blood in the sputum

Note: this is different from lightly blood-streaked sputum

Untreated acute conditions Severe pulmonary edema

Congestive heart failure

Large pleural effusion

Pulmonary embolism

Pneumothorax

Cardiovascular instability Cardiac arrhythmia

Severe hypertension or hypotension Recent myocardial infarction

Recent neurosurgery

Head down positioning may cause increased intracranial pressure

M l h i d d i


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Manual techniques used duringpostural drainage

Percussion

Used to further mobilize secretions by mechanically

dislodging viscious or adherent mucus from the

lungs

Avoid percussion over breast and bony

prominences

Relative contraindication

Over fx, spinal fusion, osteoporosis

Over tumor area

If px has pulmonary embolus

Prone to hemorrhage

If a px has unstable angina

If px has chest wall pain (post op)

M l t h i d d i


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Manual techniques used duringpostural drainage

Vibration

Used in conjunction with percussion

Applied only during expiration

ShakingMore vigorous form of vibration applied during

exhalation using an intermittent bouncing maneuver

coupled with wide movements of the therapists

hands


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Postural Drainage

Treatment procedures Never administer postural drainage directly after meal

Coordinate treatment with aerosol therapy

Choose a time of day that will be of benefit to the px

Frequency of treatments will depend upon the pathology of the

pxs condition Thick, copious mucus:2-4 times per day until lungs are clear

Maintenance: 1-2 times per day to prevent furtheraccumulation of secretions

Discontinue postural drainage

If chest x-ray is relatively clear If px is afebrile for 24-48 hours

If normal or near-normal breath sounds are heard withauscultation

If px is on a regular home program

Modified post ral drainage

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