CHEST PULMOPHYSIOTHERA PY

Prepared by: Floriza P. de Leon, PTRP

Evaluation

History

Interview Medical Hx Relevant occupation and social history Assessment of home or family environment

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 in hypoxia 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)

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)

Analysis of Chest Shape and Dimension 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

Analysis of Chest Shape and Dimension 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 Lower part of sternum is depressed and lower ribs flare out Diaphragmatic breathers Sternum prominent and protrudes anteriorly

Pectus Excavatum (funnel chest)

Pectus carinatum (pigeon chest)

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

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

Breathing Pattern

Abnormal breathing Pattern

Dyspnea: SOB, distressed, labored breathing Tachypnea: rapid, shallow respiration; decreased TV but increased rate; associated with COPD/CRPD and use of accessory mm Bradypnea: slow rate with shallow or normal depth and regular rhythm; may be associated with drug overdose Hyperventilation: deep, rapid respiration; increased TV and increased 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 a series of gradually decreasing TV, and then a period of apnea; seen in severe head injury

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 sterna notch Extend fingers above the clavicle Fully exhale and inhale deeply Face px Place tips of thumbs at the xiphoid process Extends fingers laterally around the ribs Breathe in deeply Place tips of thumbs along the pxs back at the spinous process (lower thoracic level) Extend fingers around the ribs Breathe in deeply

Middle-lobe expansion

Lower lobe expansion

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. Note amount of space between thumbs after the px takes a deep inspiration Vocal (tactile) fremitus: vibration felt as px speaks Procedure in the presence of secretions in the airways

Fremitus

Chest wall pain

Identify specific areas or points of pain

Identify mediastinal shift

Mediastinum (position of trachea)

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 greater than (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)

Auscultation

Listening to sound with in the body, specifically to breath sounds in an evaluation of the lungs Breath sounds, normal and abnormal, occur because 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 drainage treatment To determine whether or not the lungs are clear and whether or not postural drainage should be discontinued

Procedure (T2, T6, T10

Auscultation

(N) breath sounds

Tracheal loud, harsh and very high pitched; heard only over trachea; tracheal breath sounds are heard equally during inspiration and expiration Bronchial loud, hollow and high-pitched; heard between clavicles and on manibrium anteriorly and between scapulae posteriorly; heard longer with expiratory than inspiratory phase Bronchovesicular softer, medium-pitched sounds; heard equally 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 between scapulae; sounds are audible much longer on inspiration than on expiration

Auscultation

Abnormal and adventitious (extra) breath sounds

Breath sounds may be totally absent indicating total obstruction of airways and lack of aeration, or may be diminished due to bronchospasm (asthma) or collapse of an 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 are rapidly reopening Continuous high or low-pitched sometimes musical tones heard during exhalation but occasionally audible during inspiration Secondary to bronchospasm

Wheezes (ronchi)

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

(clear and white normal; yellow, green infection; blood streaked hemoptysis) Consistency (viscious, thin, frothy) Amount
Color

Management

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 retained secretions Deficits in CNS that leads to mm weakness (high SCI, myopathic or neuropathic diseases Orthopedic abnormalities (kyphosis, scoliosis)

Stress management and relaxation procedures

Breathing Exercises

Goals:
Improve

ventilation Increase the effectiveness of the cough mechanism Prevent pulmonary impairments Improve the strength, endurance and coordination of respiratory mm Maintain or improve chest and thoracic spine mobility Correct inefficient or abnormal breathing patterns Promote relaxation Teach the px how to deal with SOB attacks Improve a pxs overall functional capacity

Breathing Exercises

Precautions

Expiration should always be relaxed and passive. It should never be forceful as this increases turbulence which leads to bronchospasm 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 inspirations and expirations at a time to avoid hyperventilation Breathing exercises are performed in cycles of 3-4 breaths so that:

General considerations

Maximum effort is put into each breath Dizziness from overbeating is avoided

Shoulder tension is discouraged

Types of breathing exercises

Diaphragmatic
Controls

breathing

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

Types of breathing exercises

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 or inefficiency 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 prevent alveolar collapse in post-op conditions and to strengthen weak inspiratory mm in pxs with neuromuscular disorder

Types of breathing exercises

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

Types of breathing exercises

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

Exercises to Mobilize the Chest

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 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 Posture correction Manual stretching of chest wall, trunk and extremities

Specific exercises

Additional activities

Coughing

Necessary to eliminate respiratory obstructions and keep the lungs clear Cough mechanisms
Deep

inspiration occurs Glottis closes and vocal cords tighten Abdominal mm contract and diaphragm elevates, causing an increase in intrathoracic and intra abdominal pressures Glottis opens Explosive expiration of air occurs

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 generations of bronchi in the tracheobronchial tree) Ciliated epithelial cells are present up to the terminal bronchiole and raise secretions from the smaller to the larger airways in normal individuals

Coughing

Factors that decrease the effectiveness of the cough mechanism and cough pump

Decreased inspiratory capacity because of

Pain

Acute lung disease Rib fracture Trauma to the chest Recent thoracic or abdominal surgery High SCI Anterior horn cell disease (GBS)

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

Depression of the respiratory center associated with general anesthesia or pain medication

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

Coughing
Factors that decrease the effectiveness of the cough mechanism and cough pump Decreased action of the cilia in the bronchial tree secondary to

General anesthesia and intubation COPD such as chronic bronchitis, which is associated with decreased number of ciliated epithelial cells in the bronchi Smoking

Increase in the amount or thickness of mucus caused by

Cystic fibrosis Chronic bronchitis Pulmonary infections such as pneumonia Dehydration Intubation

Coughing
Teaching an effective cough Additional means of facilitating cough

Manual

assisted cough Splinting Humidification Tracheal stimulation (tracheal tickle)

Sunctioning: alternative to coughing

Postural Drainage

Means of mobilizing secretions in one or more lung segments to the central airways by placing the px in various position so that 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 Pneumonia, atelectasis, acute lung infection, COPD Weak or elderly px

Remove secretions already accumulated

Px with artificial airways

Postural Drainage

Contraindications

Hemorrhage (severe hemoptysis)

Copious amounts of blood in the sputum Note: this is different from lightly blood-streaked sputum Severe pulmonary edema Congestive heart failure Large pleural effusion Pulmonary embolism Pneumothorax Cardiac arrhythmia Severe hypertension or hypotension Recent myocardial infarction

Untreated acute conditions

Cardiovascular instability

Recent neurosurgery

Head down positioning may cause increased intracranial pressure

Manual techniques used during postural 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)

Manual techniques used during postural drainage

Vibration
Used

in conjunction with percussion Applied only during expiration

Shaking
More

vigorous form of vibration applied during exhalation using an intermittent bouncing maneuver coupled with wide movements of the therapists hands

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 further accumulation of secretions If chest x-ray is relatively clear If px is afebrile for 24-48 hours If normal or near-normal breath sounds are heard with auscultation If px is on a regular home program

Discontinue postural drainage

Modified postural drainage