How many lobes and segments does the right lung have?
3 lobes - oblique and horizontal fissure lines
10 total segments
How many lobes and segments does the left lung have?
2 lobes - oblique fissure line
8 segments
What are the muscles of inspiration?
Primary: diaphragm, intercostals
Accessory: scalenes, SCM, levator costarum and serratus, trapezius, pectorals
What are the muscles of expiration?
Primary: passive relaxation of inspiration muscles
Accessory: active - quadratus lumborum, intercostals, abdominals, triangularis sterni
What happens for patients without abdominal musculature for breathing?
Less advantageous
More upright = harder
Supine = easier
Abdominal binder may be helpful for support
What is tidal volume?
Volume of gas inhaled (or exhaled) during a normal resting breath
What is inspiratory reserve volume (IRV)?
Volume of gas that can be inhaled beyond a normal resting tidal inhalation
What is expiratory reserve volume (ERV)?
Volume of gas that can be exhaled beyond a normal resting tidal exhalation
What is residual volume (RV)?
Volume of gas that remains in the lungs after ERV has been exhaled
What is inspiratory capacity?
IRV + TV
Amount of air that can be inhaled from the resting end-expiratory position (REEP)
What is vital capacity?
IRV + TV + ERV
The amount of air that is under volitional control; conventionally measured as forced expiratory vital capacity (FVC)
What is functional residual capacity?
ERV + RV
Amount of air that resides in the lungs after a normal resting tidal exhalation
What is total lung capacity?
IRV + TV + ERV + RV
Total amount of air that is contained within the thorax during a maximum inspiratory effort
What is forced expiratory volume?
Measured in 1 second (FEV1)
Amount of air exhaled during the first second of FVC
In a healthy person, at least 70% of the FVC is exhaled within the first second (FEV1/FVC x100 >70%)
What is forced expiratory flow rate?
FEF 25-75%
Slope of a line drawn between the points 25% and 75% of exhaled volume on a forced vital capacity exhalation curve
This flow rate is more specific to the smaller airways and shows a more dramatic change with disease than FEV1
What is normal partial pressure of oxygen in arterial blood (PaO2)?
95-100 mmHg in healthy individual - decreases with age
Hypoxemia <90 mmHg
Hyperoxemia >100 mmHg
What is the fraction of oxygen in the inspired air (FiO2)?
0.21 (21%)
Increases with supplemental oxygen
0L = .2
1L = .24
2L = .28
3L = .32
4L = .36
5L = .40
6L = .44
Why should supplemental O2 be considered at 88%?
This is the point that oxygen dissociates from hemoglobin
What is alveolar ventilation?
Ability to remove carbon dioxide from the pulmonary circulation and maintain pH (pH indicates the concentration of free-floating hydrogen ions within the body
What is the partial pressure of carbon dioxide (PaCO2)?
35-45 mmHg
Hypercapnea >45 mmHg
Hypocapnea <35 mmHg
Increase in PaCO2 decreases pH
Decrease in PaCO2 increases pH
What is HCO3-?
Amount of bicarbonate ions within arterial blood
22-28 mEq/L
Increase in HCO3- increases pH
Decrease in HCO3- decreases pH
When does optimal respiration occur?
Ventilation and perfusion are matched
What is dead space?
A space that is well-ventilated, but in which no respiration (gas exchange) occurs
Two types: anatomical (conducting airways), and physiological (diseases such as pulmonary emboli)
What is shunt ventilation?
Complete atelectasis of a respiratory unit allows the blood to travel through the pulmonary capillary without gas diffusion
No respiration occurs due to such pathologies as pneumonia, pulmonary edema, or alveolar collapse
What is cyanosis?
A bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood - indicates hypoxemia
What is digital clubbing?
Configuration of distal phalanx of fingers or toes becomes bulbous - indicates hypoxemia
What is vesicular sound?
Normal breath sound - soft rustling heard throughout all of inspiration and the beginning of expiration
What is bronchial sound?
More hollow, echoing sound normally found only over the right superior anterior thorax - corresponds to an area over the right main stem bronchus heard throughout all of inspiration and the beginning of expiration
What is bronchovesicular sound?
Intermediate breath sound between bronchial and vesicular with equal periods of inspiration and expiration
What are crackles?
Adventitious (extra) sounds
Also termed rales, crepitations
A crackling sound heard usually during inspiration that indicates pathology (atelectasis, fibrosis, pulmonary edema)
What are wheezes
Adventitious (extra) sounds
A musically pitched sound heard on expiration. caused by obstruction (COPD, asthma, foreign body aspiration)
Severe airway constriction, as with croup, wheezes may be heard on inspiration as well
What is a bronchoscopy?
Endoscope used to view, biopsy, wash, suction, dilate, and/or brush the interior aspects of the tracheo-bronchial tree
What is a chest film xray?
Two-D radiographic, detects anormal material (exudate, blood) or a change in pulmonary parenchyma (fibrosis, collapse)
What is a fluoroscopy?
Continuous xray beam that allows observation of diaphragmatic excursion
What is a PET scan?
Radiographic tracer is injected or inhaled and images taken
Areas of increased uptake indicate active process
Used often in cancer diagnosis and treatment
What is a ventilation-perfusion scan?
Assesses airflow and blood flow to match the ventilation pattern of the lung to the perfusion pattern
A mismatch in radioactive tracer identifies the presence of pulmonary emboli
What are the 3 different sputum studies?
Gram stain: immediate identification of the category of bacteria and it's appearance
Culture and sensitivity: identifies the specific bacteria as well as the organism's susceptibility to various antiobiotics - available within a few days
Cytology: reports
What does a pulmonary function test do?
Evaluate lung volumes, capacities, and flow rates
Used to diagnose disease, monitor progression, and determine benefits of medical management
How does respiratory alkalosis present?
Inc pH
Dec PaCO2
WNL HCO3-
Cause: Alveolar hyperventilation
SX: Dizziness, syncope, tingling, numbness, early tetany
How does respiratory acidosis present?
Dec pH
Inc PaCO2
WNL HCO3-
Cause: Alveolar hypoventilation
SX: Early - Anxiety, restlessness, dyspnea, headache; Late - Confusion, somnolence, coma
How does metabolic alkalosis present?
Inc pH
WNL PaCO2
Inc HCO3-
Cause: Bicarbonate ingestion, vomiting, diuretics, steroids, adrenal disease
SX: Weakness, mental dullness, early tetany
How does metabolic acidosis present?
Dec pH
WNL PaCO2
Dec HCO3-
Cause: diabetic, lactic, or uremic acidosis, prolonged diarrhea
SX: hyperventilation, nausea, lethargy, coma
What PaO2 and PaCO2 levels would make you stop exercise?
PaO2 - dec >20mmHg or if value is <55mmHg
PaCO2 - inc >10mmHG or value is >65mmHg
What are obstructive pulmonary disorders characterized by?
Difficulty getting air out
Decreased expiratory flows
Increased residual volume and total lung capacity
CXR findings typically include hyperinflation, flattened diaphragms, and hyperlucency
What is COPD? What are the two types?
Slowly progressing, chronic disease that limits expiratory airflow (decreased FEV1) due to abnormalities in alveoli and/or airways usually from environmental exposure
1. Chronic bronchitis - inflammation of airways that causes increased mucous production,
What is the GOLD classification?
Measure of airflow limitation severity in COPD for patients with FEV1/FVC <0.7
GOLD 1: mild, FEV1 >80%
GOLD 2: mod, FEV1 50-80%
GOLD 3: severe, FEV1 30-50%
GOLD 4: very severe, FEV1 <30%
What is asthma?
Obstructive disorder - chronic inflammatory disease caused by reactivity of the trachea and bronchi to various stimuli
What is pnemonia? What are the three types?
Obstructive disorder
1. Aspiration: aspirated material causes an acute inflammatory reaction within the lungs - usually found in patients with impaired swallowing (dysphagia), fixed neck extension, intoxication, impaired consciousness, etc
2. Bacterial: a
What is bronchiectasis?
Chronic congenital or acquired disease characterized by abnormal dilatation of the bronchi and excessive sputum production
What is cystic fibrosis?
A genetically inherited disease characterized by thickening of secretion of all exocrine glands, leading to obstruction - may present as obstructive, restrictive, or mixed
Signs: meconium ileus, frequent respiratory infections, inability to gain weight
What is bronchopulmonary dysplasia?
An obstructive pulmonary disease, often a sequela of premature infants with respiratory distress syndrome; results from high pressures of mechanical ventilation, high fractions of inspired oxygen (FiO2) and/or infection
Lungs show areas of pulmonary immat
What is respiratory distress syndrome?
Alveolar collapse in a premature infant resulting from lung immaturity, inadequate level of pulmonary surfactant
What are restrictive pulmonary disorders characterized by?
Decreased vital capacity and normal inspiratory and expiratory flows
A pathology is decreasing the amount of air able to get in and out of the lungs
What are the three interstitial lung diseases?
1. Idiopathic pulmonary fibrosis: chronic, progressive, fibrotic pneumonia that causes irreversible scarring in the lung tissue
2. Scarcoidosis: multisystem inflammatory disease consisting of granulomas in multiple organs, most often the lungs, skin, lymp
What is atelectasis? What causes it?
Collapsed or airless alveolar unit, caused by hypoventilation secondary to pain during the ventilatory cycle (pleuritis, postoperative pain, or rib fracture), internal bronchial obstruction (aspiration, mucus plugging), external bronchial compression (tum
What is pleural effusion?
Excessive fluid between the visceral and parietal pleura, caused mainly by increased pleural permeability to proteins from inflammatory diseases (pneumonia, RA, systemic lupus), neoplastic disease, increased hydrostatic pressure within pleural space (CHF)
What is pulmonary edema? What are the three main causes?
Excessive seepage of fluid from the pulmonary vascular system into the interstitial space; may eventually cause alveolar edema
1. Cardiogenic: results from increased pressure in pulmonary capillaries associated with left ventricular failure, aortic valvul
What is pulmonary embolism?
A thrombus from the peripheral venous circulation becomes embolic and lodges in the pulmonary circulation
Small emboli do not necessarily cause infarction
What is pulmonary hypertension?
Increased arterial pressures within the pulmonary vasculature system due to idiopathic pulmonary hypertension, left heart disease, chronic lung disease/hypoxemia, pulmonary artery obstruction, or multifactorial issues
Exercise consistently has improved Qo
What is bronchogenic carcinoma?
Most common type is non-small cell lung cancer (adenocarcinoma > squamous cell carcinoma > large cell carcinoma) and the other is small cell lung cancer
Smoking is largest risk factor, followed by radiation, environmental exposure, pulmonary fibrosis, gen
What is tuberculosis? What is infection period and precautions to take?
Mycobacterium tuberculosis infection spread by aerosolized droplets from an untreated infected host
Incubation period: 2-10 weeks
Primary disease lasts 10 days-2 weeks
Postprimary infection is reactivation of dormant tuberculous bacillus, which can occur
What is Potts disease?
Tuberculous spondylitis - form of spinal TB that primarily affects the thoracic and upper lumbar vertebrae
Arthritic changes often result in kyphosis
What is postural drainage and when is it indicated?
Gravity drainage of secretions with manual assistance
Indications: increased pulmonary secretions, aspiration, atelectasis or collapse
Postural drainage: upper lobes apical segments
Sitting, leaning back 30deg
Therapist over clavicle and top of scapula
Postural drainage: upper lobes posterior segments
Sitting, leaning forward at 30deg over pillow
Therapist over upper back
Postural drainage: upper lobes anterior segments
Supine with pillow under knees
Therapist between clavicle and nipple line
Postural drainage: right middle lobe
Left sidelying with feet elevated 16" - right arm rotated 1/4 backward with pillow behind for support, knees flexed
Therapist over right nipple area
Postural drainage: left upper lobe
Right sidelying with feet elevated 16" - left arm rotated 1/4 backward with pillow behind for support, knees flexed
Therapist over left nipple area
Postural drainage: lower lobe anterior basal segments
Sidelying with feet elevated 20" - pillow between knees with knees flexed
Therapist over lower ribs
Postural drainage: lower lobe lateral basal segments
Prone, then rotating back 1/4 with feet elevated 20" - pillow between knees with knees flexed
Therapist over uppermost portion of lower ribs
Postural drainage: lower lobes posterior basal segments
Prone with feet elevated 20"
Therapist over lower ribs over paraspinals
Postural drainage: lower lobes superior segments
Prone with two pillows under hips
Therapist over tip of scapula over middle back
What are some precautions to trendelenburg position during drainage?
Pulmonary edema, CHF, hypertension, pregnancy, increased ICP, aneurysm, SOB
What are some precautions to sidelying position during drainage?
Axillo-femoral bypass graft, humeral fractures
How long do you perform percussion?
3-5 min over involved lung segment
When do you use vibration?
Typically after percussion, following a deep inhalation throughout exhalation
For removal of secretions from tracheobronchial tree
How long do you do vibration?
Typically 5-10 exhales
What are some precautions to percussion and vibration?
Increased PTT, decreased platelet count, fractured rib, flail chest
What are some airway clearance techniques?
Cough
Huff
Assisted cough (with hand in subcostal angle and providing force inward and upward)
Tracheal stimulation (for infants, finger above suprasternal notch with inward and downward force to elicit cough reflex)
Endotracheal suctioning (when others d
What is autogenic drainge? What are the different phases?
Used to sense peripheral secretions and clear them without the tracheobronchial irritation from coughing
Unstick phase: quiet breathing at low lung volumes to effect secretions
Collect phase: breathing at mid lung volumes to affect secretions in the middl
What are oscillatory positive expiratory pressure (PEP) devices?
External device that vibrates the airways on exhalation to improve airway clearance with intermittent PEP
Pt breathes in a normal tidal volume through the nose or around the mouthpiece of the device, then exhales through the device, setting up a vibration
What is the low-pressure positive expiratory pressure (PEP) mask?
PEP through face mask or mouth piece to help remove airway secretions (low pressure = 10-20 cm H2O)
Seated, breathes at tidal volumes with mask in place
After 10 breaths, mask is removed for coughing or huffing to clear secretions
Repeat as needed
What is high frequency chest wall oscillation?
Pt wear a vest that fills with air and then rapidly increases/decreases pressure
Pressure oscillation loosens secretions in the airway
Frequency: 12-16Hz
Pressure: until snug
Time: 20-30min with breaks to cough
Can be done in postural drainage positions
What does diaphragmatic breathing improve?
Ventilation, gas exchange, decreases work of breathing, facilitate relaxation, maintains or improves mobility of chest wall
What does segmental breathing improve?
Ventilation to hypoventilated lung segments, alters regional distribution of gas, maintains or restores functional residual capacity, maintains or improves mobility of chest wall, and prevents pulmonary compromise
Contraindication: intractable hypoventila
What is sustained maximal inspiration (SMI)?
Used to increase inhaled volume, sustain or improve alveolar inflation, and maintain or restore functional residual capacity - used in acute situations
Breathe in through nose or pursed lips, hold 3 sec, passively exhale the volume
Incentive spirometers c
What does pursed lip breathing do?
Reduce respiratory rte, increase tidal volume, reduce dyspnea, decrease mechanical disadvantages of impaired ventilatory pump, improve gas mixing for COPD, facilitate relaxation
What is an inspiratory muscle trainer (IMTs)?
Load muscles of inspiration by breathing through a series of graded aperture openings
Aperature should require 30-70% of MIP and allow 10-15 min of training per session
Higher intensities - 10-20 reps
Progression first focuses on increasing to 30 min, the
What is a pneumonectomy?
Removal of an entire lung
What is a lobectomy?
Removal of an entire lobe of the lung
What is segmental resection?
Removal of a segment of a lobe
What is a wedge resection?
Removal of a portion of a lung without anatomical divisions
What is lung volume reduction surgery (LVRS), pr pneumectomy?
Removes large emphysematous, nonfunctioning areas of the lung to normalize thoracic mobility and improve gas exchange of the remaining lung
What is a thoracotomy?
Used fro most lung resections - incision follows the path of the fourth intercostal space; full ROM should be encouraged postoperatively