Resting End Expiratory Pressure (REEP)
the point of equilibrium where the forces are balanced; occurs at end of tidal expiration
Partial pressure of oxygen
in the arterial blood and expressed as PaO2; dependent on the integrity of the pulmonary system, circulatory system, and PaO2. Room air is 95-100 mmHg and when it drops below 55, supplemental oxygen is provided; partial pressure of oxygen at sea level = 7
Fraction of oxygen in the inspired air (FiO2)
percentage of oxygen in air, based on total of 1.00. The FiO2 of room air is 21% or 0.21; supplemental oxygen increases the FiO2 in the patient's atmosphere
Arterial oxygenation
the ability of arterial blood to carry O2; partial pressure of oxygen in relation to fraction of inspired O2 is used to determine arterial oxygenation
Alveolar ventilation
the ability to remove CO2 from pulmonary circulation and maintain pH; pH, bicarbonate ions, PaCO2 are lab values that determine alveolar ventilation
Partial pressure of CO2 in arterial blood
Normal: PaCO2=35-45mmHg Hypercapnia: PaCO2 >45mmHg Hypocapnia: PaCO2<35mmHg; increase in PaCO2 decreases pH in blood and a decrease in PaCO2 increases pH in blood
HCO3-
bicarbonate ions; increase in HCO3- will increase pH and a decrease in HCO3- will decrease pH
Optimal respiration
when ventilation and perfusion are matched
Dead space
Ventilation, but no perfusion of blood therefore no respiration (gas exchange) occurs
Shunt
Perfusion, but no ventilation; ie: atelectasis (collapse of lung)
Ventilation to Perfusion ratio (V/Q)
Apical of lung: V/Q>1 (gravity independent; acts as dead space); at the base of lung V/Q<1; in the middle of the lug V/Q=1 (gravity dependent; acts as a shunt)
Respiratory central control centers
cortex, pons, medulla, and ANS evaluate receptor information
Infant vital signs
HR: 120bpm BP: 75/50mmHg RR: 40br/min PaO2: 75-80mmHg PaCO2: 34-54mmHg pH: 7.26-7.41 TV: 20ml
Observation of pts with pulmonary
Peripheral edema, body positions (people will lean forward to allow for compensation by other muscles), color, digital clubbing
Obstructive pulmonary disease expected posture
Barrel chest-increase in AP diameter due to decreased lung recoil force
Normal thoracic excursion
2-3 inches from full exhalation to full inhalation
Lung Auscultation
1) Intensity of respiration 2) adventitious (extra sounds) 3) Vocal sounds
Intensity of respiration
Quieter at the base than the apex of the lungs; Vesicular: heard throughout all of inspiration and beginning of expiration Bronchial: more hollow, echoing sound found only over right anterior superior thorax (over the right main bronchus) Decreased: dista
Adventitous lung sounds
1) Crackles (rales): cracking heard usually on inspiration 2) Wheezes: typically heard on exhalation. Musically pitched sound- asthma, COPD, foreign aspiration
Vocal sounds (normal)
loudest near the trachea and main stem bronchi; words intelligible, though softer and less clear in more distal areas
Vocal sounds (abnormal)
heard in fluid filled areas of consolidation, cavitation lesions, or pleural effusions; a) Egophony: nasal or sound heard during auscultation "E" sounds like "A"; b) bronchophony-intense clear sound during auscultation even at base of lung; c) whispered p
Lab tests
1) Arterial blood gas (alveolar ventilation and arterial oxygenation) 2) ECG 3) sputum studies 4) pulmonary function tests 5) Blood values
Blood values
1) WBC: 4000-11000 2) Hematocrit: 35-48% 3) Hemoglobin: 12-16 g/dl
Respiratory alkalosis
increase in pH, decrease in PaCO2, bicarb is WNL, causes- alveolar hyperventilation, symptoms-dizziness, syncope, tingling, numbness
Respiratory acidosis
decrease in pH, increase in PaCO2, bicarb WNL,causes- alveolar hypoventilation, symptoms- anxiety, restlessness, dyspnea, HA, confusion, somnolence, coma
Metabolic alkalosis
increase in pH, PaCO2 WNL, bicarb increases,causes- vomiting, diuretics, bicarb ingestion, steroids, adrenal disease, symptoms-weakness, mental dullness, early tetany, vague signs
Metabolic acidosis
decrease in pH, PacO2 WNL, bicarb decreases, causes-diabetic, lactic or uremic acidosis, prolonged diarrhea, symptoms-secondary hyperventilation, nausea, lethargy, coma
Table 4-4 on page 224
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Table 4-3 on page 224
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Types of chronic obstructive diseases
1) COPD 2) Asthma 3) Cystic fibrosis 4) Bronchiectasis 5) Respiratory distress syndrome (RDS) 6) Bronchopulmonary dysplasia
Chronic restrictive disease etiology
difficulty epanding the lungs causing a reduction in lung volumes
Chronic restrictive disease (alterations in lung parenchyma and pleura)
fibrotic changes within the pulmonary parenchyma or pleura due to idiopathic fibrosis, asbestos, radiation pneuomitis, oxygen toxicity
Chronic restrictive disease (alterations in chest wall)
Due to bony deformity in thorax; ankylosing spondylitis, arthritis, scoliosis, pectus excavatum, arthrogryposis or integ changes (burns, scleroderma)
Chronic restrictive disease ( alterations in neuromuscular apparatus)
Decreased muscular strength results in inability to expand rib cage (ie PD, MS, SCI, CVA, muscular dystrophy)
Chronic restrictive disease signs (alterations in lung parenchyma and pleura)
1) cyanosis 2) hypocapnia (hyper later on) 3) crackles 4) clubbing 5) dyspnea 6) reduction in VC, FRC, and TLC
Chronic restrictive disease signs (alterations in chest wall)
1) cyanosis 2) hypocapnia, hypoxia (hyper later on) 3) crackles 4) clubbing 5) dyspnea 6) reduction in VC, FRC, and TLC 7) decrease cough effectivenes 8) shallow, rapid breathing
Chronic restrictive disease signs (alterations in neuromuscular apparatus)
1) dyspnea 2) hypoxemia, hypocapnea 3) decreased breath sounds, crackles 4) cyanosis 5) clubbing 6) reduced cough effectiveness 7) reduced VC and TLC, reduced lung volumes and atelectasis
Bronchogenic carcinoma description
tumor arises from bronchial mucosa; small cell carcinoma and non-small cell carcinoma; secondary changes due to the tumor include compression of an airway, blood vessel, or nerve
Bronchogenic findings
1) weight loss 2) fatigue 3) hemopytsis 4) dyspnea 5) weakness 6) wheezing 7) pneumonia with productive cough due to airway compression 8) hoarse with laryngeal nerve compression
Bronchogenic PT considerations
possible fx from thoracic bone metasis with chest compressive maneuvers and coughing; pneumonias that develop behind a completely obstructed bronchi cannot be cleared with PT techniques and must wait for palliative care to shrink the tumor
Rib Flail chest
2 or more fractures in 2 or more adjacent ribs
Pneumothorax
air in the pleural space, usually from a lacerated visceral pleura or rib fx or ruptured bullae
Hemothorax
blood in the pleural space, usually from a laceration of the parietal pleura
Indications for postural drainage
1) increased pulmonary secretions 2) aspiration 3) atelectasis or collapse; up to 20 minutes per position
Indiications for percussion
1) increased pulmonary secretions 2) aspiration 3) atelectasis or collapse; 3-5 minutes per position
Indications for shaking
1) Excessive pulmonary secretions 2) aspiration 3) atelectasis or collapse of an airway from mucous plugging; 5-10 deep inhalations with shaking techniques is generally acceptable practice; more than 10 increase risk of hyperventilation and less than 5 is
Postural drainage for upper lobe apical segment
Patient leans back 30 degrees from upright sitting; percuss between clavicle and top of scapula
Postural drainage for upper lobe posterior segment
Patient leans over a folded pillow in sitting at 30 degrees; clasps hands over upper back both sides
Postural drainage for for upper lobe anterior segment
Patient lies in supine with pillow under knees; PT percusses between clavicle and nipple
Postural drainage for right middle lobe
Foot of bed is elevated 16 inches and patient lays in 3/4 supine with right shoulder up and with knees flexed. Percussion over the right nipple area
Postural drainage for left upper lobe, lingular segments
foot of table is elevated 16 inches and patient lays in 3/4 supine with left shoulder up; percuss over the left breast inferior to axilla
Postural drainage for lower lobe, anterior basal segments
Foot of table elevated 20 degrees; patient lays on side and percussion occurs over lower ribs (repeat on both sides)
Postural drainage for lower lobe, lateral basal segments
foot of bed elevated 20 degrees and patient lies in 3/4 prone and percussion over the lower ribs; repeat on the other side
Postural drainage for lower lobe, posterior basal segments
foot of table is elevated 20 degrees and patient lies prone and percussion occurs over lower ribs, close to the spine on both sides
Postural drainage for lower lobe, superior segments
table is flat; patient lies prone and percussion is over the middle of back at the tip of scapula on either side of spine
Consideration before postural drainage
Precautions for trendelenberg position: pulmonary edema, CHF, HTN, obesity, pregnancy, ascites, hernia, nausea, vomiting, food ingestion, neurosurgey, increase intracranial pressure, SOB Precautions for sidelying position: axillo-femoral bypass; humeral f
Consideration before percussion
pain made worse by technique, aneurysm precautions, hemoptysis, increased partial thromboplastin time, decreased platelet count, medication that interferes with coagulation; fracture rib, flail chest, degenerative bone disease, bone metastasis
Airway clearance techniques
1) Cough 2) Huff- for pts with collapsible airways; prevents high intrathoracic pressure that causes premature airway closure 3) assisted cough 4) tracheal stimulation- finger placed just above the suprasternal notch and a quick inward and downward pressu
Independent secretion removal techniques
1) active cycles of breathing 2) autogenic drainage 3) Flutter/Acapella 4) Low pressure positive expiratory pressure mask (PEP); 10-20 cm H2O 5) high pressure positive expiratory pressure maske (PEP)- for an unstable airway and pt can exhale a larger FVC
Diaphragmatic breathing - Purpose and indications
increases ventilation, improve gas exchange, decrease work of breathing, facilitate relaxation and maintain or improve mobility of chest wall; used with post-op patients, post trauma, and pts with obstructive or restrictive pulmonary lung disease
Segmental breathing- purpose and indications
used to improve ventilation to a hypoventilated lung segment, alter regional distribution of gas, maintain or restore FRC, prevent pulmonary compromise, and improve chest wall mobility; patients with pleuritic, incision or post traumatic pain, those at ri
Segmental breathing contraindications
intractible hypoventilation; palliative care to reduce bronchogenic tumor size or chest tube to reduce pneumothorax
Pursed lip breathing-purpose and indications
used to reduce RR, increase tidal volume to reduce dyspnea, decrease mechanical disadvantages of impaired ventilatory pump, improve gas mixing at rest for patients with COPD; pts with obstructive pulmonary disease who experience dyspnea at rest or with mi
Sustained maximal inspiration (incentive spirometer)
increase inhaled volume, sustain or improve alveolar inflation, and maintain FRC; acute situations-post op, post trauma pain, acute lobar collapse
Inspiratory muscle trainer-purpose and indications
loads muscles of inspiration by breathing through a series of graded aperture openings and increasing strength and endurance of ventilatory muscles; appropriate for patients with decreased compliance, decreased intrathoracic volume, resistance to airflow,
Short acting beta-2 agonists
produce bronchodilation; can increase HR and BP (though inhaler)-rescue drug
Long acting beta-2 agonists
produce bronchodilation; may decrease need for rescue drugs; maintenance drug
Anticholinergics
inhibit parasympathetic system; increase HR, BP, and bronchodilate
Methylxanthines
produces smooth muscle relaxation; limited use due to toxicity, increase BP, increase HR, arrhythmias, GI distress, nervousness, headache, and seizures
Leukotriene receptor antagonists
blocks leukotrienes that are released in allergic reactions; inhibit airway edema and smooth muscle contraction
Cromolyn sodium
prevents release of mast cells after contact with allergens; prevents exercise induced bronchospasm and severe bronchial asthma via oral inhalation
Anti-inflammatory agents
decreases mucosal edema, inflammation, and airway reactivity; side effects: GI irritation, muscle wasting, osteoporosis, hypercholesteremia, high BP, sodium retention