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Fund II Exam 1
Ch 39 & 40 Egans
| Question | Answer |
|---|---|
| atelectasis | Incomplete expansion of the lungs and/or collapse of the lung |
| CPAP | continuous positive airway pressure- Method of ventilatory support whereby the pt breaths spontaneously without mechanical assistance against threshold resistance with pressure above atmospheric maintained at the airway throughout breathing |
| IPPB | Intermittent positive pressure breathing- Application of inspirtory positive pressure to a pt for as an intermittent or short period of time (10 to 20 minutes) |
| IS | Incentive spirometer- The process of encouraging the bedridden patient to take deep breaths to avoid atelectasis |
| lobar atelectasis | Alveolar collapse involving a specific lobe of the lung. When a large mucus plug blocks ventilation of a single lobe. |
| passive atelectasis | Collapse of distal lung units due to persistent ventilation with small tidal volumes. Occurs when patients do not take periodic deep breaths (sighs.) This is usually after surgery worsened with the pain of surgery |
| PEP | positive expiratory pressure- airway clearance technique in chich the pt exhales against a fixed orifice flow resistor inorder to help move secreatons into the larger airways for expectoration via coughing or swallowing |
| resorption atelectasis | Collapse of distal lung units due to mucus plugging of airways |
| describe the various causes of atelectasis | *obesity (can't raise chest) *neuromuscular disorders( lack of transmission to neurons/muscles) *Heavy sedation *surgery near the diaphragm *bedrest(not using muscles/not taking deep breaths) *poor cough *history of lung disease |
| state who needs lung expansion therapy | *atelectasis *thoracic or abdominal surgery *pneumonia *acute respiratory failure |
| identify the clinical findings seen in atelectasis | -breath sounds diminished -changes in ABG -Changes in CXR -resp rate will increase -inspiratory crackles -tachycardia -severe deviation of the trachea |
| describe how lung expansion therapy works | -maximum inspiratoin capacity breath hold -increases transpulmonary pressure gradient -greater the gradient the more alveoli expand -to prevent and correct atelectasis -improves FRC |
| indications for incentive spirometry | *presence of pulmonary atelectasis *presence of conditions predisposing to atelectasis: upper abdominal surgery, thoracic surgery, surgery in pts with COPD *presence of restrictive lung defect associated with quadriplegia and/or dysfunctional diaphragm |
| list hazards for incentive spirometry | Hazards are few (possibly hyperinflation and respiratory alkalosis). The patient usually can learn easily, perform, and self-administer with only occasional encouragement and checking from therapists. Patients need to be awake alert and motivatied. |
| describe the primary responsibilities of the respiratory therapist in planning, implementing, and evaluating lung expansion therapy | proper instruction (esp before surgery) proper follow up -coach and push to maintain appropraite goals -note volumes, amounts of sputum, stats, pre & post vitals |
| clinical signs of atelectasis | -history of recent major surgery -tachypnea -fine, late-inspiratory crackles -bronchial or diminished breath sounds -tachycardia -decrease SPO2 & PaO2 -low density and signs of volume loss on the chest xray |
| Indications for IS | *presence of pulmonary atelectasis *presence of conditions predisposing to atelectasis (upper abdominal surgery, thoracic surgery, surgery in copd pts) *Presence of a restrictive lung defect associated with quadriplegia and/or dysfunctional diapragm |
| effective patient teaching for IS | *demo and then observe the patient *patient should sustain his or her max inspiratory effort for 5-10 seconds *follow up (if patients are acheiving goals set higher ones) |
| Complications of IS | *hyperventilation and resp. alkalosis *discomfort *pulmonary barotrauma (caused by pressure) *exacerbation of bronchospam *fatique *acute respiratory alkalosis occurs when the pts perform IS too rapidly |
| Clinical situations contraindicating IS | *unconscious patients or those unable to cooperate *pts who can not properly use IS device after instruction *patients unable to generate adequate inspiration: VC < 10 ml/kg or IC<33% of predicted normal |
| Potential outcomes of IS | *absence or improvment of atelectasis *decreased resp rate *normal pulse rates *resolution of abnormal breath sounds *normal or improved CXR *improve PaO2 *decrease PaCO2 *Increase SpO2 *increased PEFR and VC |
| Indication for IPPB | *need to improve lung expansion *pts with atelectasis NOT responsive to other modalities such as IS *pts at high risk for atelectasis who cannot perform IS (trach pts, artificial airways) |
| contraindication for IPPB | *tension pneumothorax *ICP>15 mmHg *hemodynamic instability *active hemoptysis *tracheoesophageal fistula *recent esophageal surgery *active, untreated TB *radiographic evidence of b |
| the most common complication associated with IPPB | the inducement of respiratory alkalosis (this occurs when the pts. breathes to rapidly during treatment) |
| Administration of IPPB | *equipment prep *patient orientation *patient position *adjust paramenters (flow and pressure) |
| what should the patient do during IPPB? | *patients starts their breath;the machine turns on *pt relaxes and lets the machine fill their lungs *Pt should NOT be actively breathing after the machine turns on *pt will exhale normally |
| indications for CPAP | *treatment of atelectasis *treatment of cardiogenic pulmonary edema(mostly used; left ventricle failure) *post-operative atelectasis *short term ventilatory support |
| Hazards and complications of CPAP | *barotrauma *HYPOventilation *gastric distention *vomiting and aspiration *hemodynamic unstable *facial trauma *elevated ICP |
| List the four phases involved in a normal cough reflex? | 1st ohase:Irritation 2nd phase:inspiration 3rd phase:compression 4th phase:expulsion |
| Briefly describe each phase of a cough? | Irritation(tickle dryness), Inspiration (deep breath), Compression (glottis closed), Expulsion (get it out) |
| Describe the pathophysiologic changes created by retention of secretions and full or partial airway obstruction? | Full airway obstruction-hear nothing, Partial airway obstruction- hear grasping, stridor, (retaining sputum causes shunting,bacteria organisms can cause bronchiectesis |
| Describe which phase of the cough reflex are primarily affected in a patient with abdominal muscle weakness having difficulty developing an effective cough? | compression, expulsion |
| Describe which phases of the cough reflex that are primarily affect in a patient recovering from anaesthesia after abdominal surgery having difficulty developing an effective cough? | Irritation- anesthesia |
| Describe which phases of the cough reflex that are primarily affected in a neuromuscular disorder causing generalized muscle weakness is having difficulty developing an effective cough? | inspiration- restrictive process taking deep breath |
| List four conditions which bronchial hygiene therapy is indicated? | *treating acute condition: -Copious secretion -acute reps failure w/ retained secretions -acute lobar atelectasis -V/Q abnormalities *chronic condition may cause copious secretions -cystic fibrosis -bronchiectisis -ciliary dyskinetic syndrome -CB *rentens |
| List the primary goal of bronchial hygiene therapy? | To help mobilize and move secretions so patients can cough up, improve gas exchange and reduce work of breathing |
| Identify what volume of sputum production may indicate, chest physical therapy can be expected to improve airway clearence? | 30 ml/day (shot glass full 1 fluid oz) |
| What are the best-documented preventive uses of bronchial hygiene therapy include? | body positioning and pt mobilization to prevent retained secretions in the acutely ill and PDPV combined with exercise to maintain lung function in CF |
| List five methods that are considered bronchial hygiene therapy? | 1)posturaldrainage therapy(percussion and vibration 2)directed cough 3)positive airway pressure (PAP) 4)High-frequency compression/oscillation methods 5)mobilization and exercise |
| Identify the bronchial hygiene therapy best described by the application of gravity to achieve specific clinical goals? | Postural drainage therapy- improves V/Q balance, normalizes the FRC includes percussion and vibration |
| state and describe the position to recommend for a patient whose physician orders postural drainage for a patient with an abscess in the right middle lobe | left side w/pillow underneath |
| state and describe the position to recommend for a patient with aspiration pneumonia in the superior segments of the left lower lobe | right side w/pillow underneath (upper bases of segments) |
| state and desceibe the position to recommend for a patient w/aspiration pneumonia in the anterior segments of the upper lobes | leaning back (anterior upper segment) |
| list three responses that would indicate that postural drainage should be terminated | hemoctusis, severe in hypoxemia, patient not tolerated |
| what would be appropriate in management of a patient receiving postural drainage therapy, you notice that the patient tends to undergo mild desaturation during therapy (a drop in spo2 from 93% to 89% to 90%) | administer 02 while doing therapy, if sat keeps decreasing stop |
| describe the appropriate management for a postoperative patient who has a history of gastroesophageal reflux | 1 1/2 hr. betwn meals |
| describe what action would be appropriate for a postoperative surgery patient that pain may hinder implementation of postural drainage therapy | keep pain med. schedule in line |
| list the areas percussion should not be performed over | breasts, ribs, bony prominences, surgical sites |
| identify when properly performed chest vibration is applied in the resp. cycle | exhalation |
| identify factors that can hinder effective coughing | anasthesia, artificial airway, muscle weakness, pain, COPD |
| describe ideal patient position for directed coughing | sitting up |
| identify two lung segments are the most common sites of retained secretions among hospitalized patients? | bases rt. and lft. and right middle lobe |
| The most common problem with PAP | is system leaks |
| monitor required for PAP | for HYPOventilation and elevated CO2 and inspiratory flow must be adequate in order to flush out CO2. |
| the respiratory therapist should evaluate the following before choosing a specific modality | *level of pt cooperation *amount of pulmonary secretions *pts spontaneuos vital capacity |
| what is the minimum amount before you need to start implementing any kind of support | 10 cc per Kg |
| explain why strenuous expiratory efforts in some COPD patients limit the effectiveness of coughing | hyperinflation |
| make appropriate recommendation if a physician asks your advice on how best to improve bronchopulmonary clearance in a 17 yr old CF patient w/copious secretions | vest, CPT and postural drainage, ez pap, acapella |
| list 3 positive press. adjuncts | ez pap, bi pap, cpap, ipv, IPPB |
| list 3 potential indications for positive airway pressure therapies as they relate to lung clearance | CHF, atelectasis, IPV, IPPB==>cystic fibrosis, bronchiectasis |
| recognize the contraindications for positive airway pressure therapies | decrease CO, HR, BP, gastric inhalation |
| describe PEP therapy | exhaling resistance to flow |
| describe instructions for PEP | this is a device that will help you clear secretions, should feel like a workout, normal inhalation and exhale... |
| describe high frequency external chest wall compression (HFCC) | 10-20 min. vest (faster or slower) |
| explain how a patient can control a flutter valves pressure by changing what? | exhale harder and faster |
| the airway clearance technique that uses a pneumatic device to deliver compressed gas minibursts to the airway at rates above 100/min best describes which device? | IPV |
| List three primary objectives for turning? | Promotes lung expansion, improve oxygenation, and prevent retention of secretions. Also include reduction in venostasis and prevention of skin ulcers. |
| Briefly describe dependent positioning and why it would be used? | Good lung down to get good oxygen in the lung, prevent secretions |
| arrange the sequence of the following therapies in bronchopulmonary clearance...percussion, postural drainage, deep breathing and coughing, aerosol therapy | 1) aerosol therapy 2) postural drainage 3) percussion 4) deep breathing and coughing |
| give an explanation why a patient with a complete cervical fracture btwn C5-C6 would have the most trouble w/which aspect of bronchopulmonary clearance | paralyzed, inability to cough or deep breathe |
| Which bronchial hygiene therapy would be appropriate to recommend for a patient under your care who has x-ray and clinical evidence of severe unilaterial right lung infiltrates with a PO2 on a non-rebreathing mask is 49mmHG. w/o vent support? | BiPAP or CPAP, maybe if PaO2 try EZPAP if infiltrate on right lung lay them on left lung with percussor |
| Describe what the role of the prone position is in actue respiratory distress syndrom(ARDS) patients with a generalized decrease in lung volume? | Exceed the airway opening pressure in doral lung regions(where atelectasis,shunt and V/Q heterogeneity are most severe). Shifts blood flow away from shunt regions, thus increasing areas with normal V/Q balance( redistribution of blood flow).Prevent fur LI |
| List the absolute contraindications for postural drainage? | Unstable spinal injury (hemorrhage) |
| clinical s/s of partial airway obstruction | *v/q imbalance *airtrapping *overdistention *decreased expiratory flow rates |
| what causes/can lead a pt to have bronchiectasis | - Chronic obstructive lung diseases - Aspiration - Bronchiolitis - Chronic airway infection (not muscular dystrophy) |
| what are some neuromuscular diseases that would impair cough reflex? | -muscular dystrophy -amyotrophic lateral sclerosis (Lou Gehrig's, motor neuron disease) -spinal muscular atrophy -myasthenia gravis -poliomyelitis -cerebral palsy |
| selecting an approach for achieving a given clinical goal is always the safest,simplest, and most effective method for a given patient | *pt must meet the criteria for tx *pt having NO difficulty with secretions, IF VC >15 ml/kg or IC >33% predicted IS given *if VC & IC is less IPPB is given *excessive sputum PEP therapy is subs for IS *if fails CPAP considered |
| which types of pts are LEAST likely to benefit from postural drainage and CPT | COPD |
| what are essential data you should collect before admin cpt? | blood gases, IS, peak flow, chest films, |
| are any positive pressure adjuncts normal closest to normal breathing & which is most normal? | no,IS |
| what are the difference in full and partial airway obstructions? | partial-diminished breath sounds full-no breath sounds |
| what is the mechanism of action for pt with cystic fibrosis? | CPT |
| Atelectasis is caused by... | persistent ventilation with small tidal volumes or by resorption of gas distal to obstructed airways |
| lung expansion therapy corrects atelectasis by... | increase lung volume by increasing the transpulmonary pressure(PL)gradient |
| Transpulmonary pressure (PL)gradient reps... | the difference between the alveolar pressure (Palv) and the pleural pressure (Ppl) |
| If the patient is NOT alert what lung expansion therapy should you select? | IPPB therapy (10-15 ml/kg) |
| If the patient has problems with excess secretions with lung expansion tx should you select? | PEP therapy with bronchodilator and bronchial hygeine |
| Describe which conditions to consider modifying any head-down positions used for postural drainage? | Uncontrolled hypertension, at risk ICP,just ate, pressure transducer in the head |
| Identify how long, if tolerated, a specified postural drainage position should be maintained? | 3-5min |
| Explain the hazards of strenuous patient coughing during postural drainage in a head-down position? | high increase in ICP, hemorrhage |
| Describe what action would be appropriate if soon after you initiate postural drainage in a Trendelenburg position, the patient develops a vigorous and productive cough? | put them in a neutral position (sit up), correct trendelenburg,assess O2 if needed |
| Properly chart after completing a postural drainage treatment? | Position used, time in position, patient tolerance, indicators of effectiveness (amount of sputum), any untowards effects observed |
| Identify which postural drainage position should be recommended if a patients x-ray shows infiltrates in the posterior basal segments of the lower lobes? | Trandelenburg, on stomach, percussing bases |
| how long is each treatment and how often will they receive treatment via IPPB? | |
| how is positive pressure ventilation differs from normal breathing? | normal breathing, inspiratory pressures are negative while expiratory pressure are positive. In IPPB, both inspiratory pressures & expiratory pressure are positive. |
| resorption atelectasis? | a blockage occurs in the airway preventing ventilation downstream resulting in eventual removal of remaining gas & alveolar collapse. |
| resorption atelectasis is found in? | bronchial asthma, chronic bronchitis, brochiectasis, post-op states, and aspiration of foreign bodies |
| Compressive atelectasis? | occurs when something outside the lung presses on lung tissue causing it to collapse. |
| FRC | |
| would respiratory acidosis be hyperventilating or hypoventilating? | HYPOventilating |
| would resp ALKALOSIS be HYPOventilating or HYPERventilating? | HYPERventilating |
| Hazards of O2 therapy in Chronic ventilatory failure with Hypoxemia? | *may suppress ventilation *develop acute ventilation failure superimposed on the already chronic condition (hypercapnia) |
| PF ratio | divide PaO2/FiO2 and if it less than 300 it is ARDS |
| How does CPAP work? | splinting open the alveoli so increases gas exchange |
| in respiratory acidosis are you increasing or decreasing ventilation? | decreasing |
| acute on chronic HYPERventilation what ABGs would be in alka range and what would be acid range? | pH-alkalotic,CO2-alka,HCO3-acid,PaO2 mod-severe |
| Acute on Chronic HYPOventilation ABGS? | pH-ACID,CO2-ACID,HCO3-ALK,PaO2 mod range |
| what do you look for in ABGs classify for Chronic? | if there is NOT a relationship between pH & CO2 and HCO3 is alkalotic... |
| Bronchial hygiene therapy involve | postural drainage, percussion, and vibration (PDPV) combined with cough training |
| normal airway clearance requires... | a patent airway, a functional mucociliary escalator, and an effective cough |
| the most important protective mechanism | the cough |
| bronchiectasis | is an abnormal and permanent dilation of the airways due to destructive and inflammatory changes in the airway walls |
| mucus plugging can result in... | -atelectasis -shunting -hypoxemia |
| What can cause impaired mucocilliary clearance in intubated patients? | - Tracheobronchial suction - Inadequate humidification - High FIO2 values (not respiratory stimulants) |
| examples of impairments irritation | -anesthesia -CNS depression -narcotic analgesics - |
| examples of impairments in irritation phase | -pain -neuromuscular dysfunction -pulmonary restriction -abdominal restriction |
| examples of impairments compression phase | -laryngeal nerve damage -artificial airways -abdominal muscle weakness -abdominal surgery |
| examples of impairments in expulsion phase | -airway compression -airway obstruction -abdominal muscle weakness -inadequate lung recoil (ie emphysema) |
| inspissation | to undergo thickness or cause to thicken, as by boiling or evaporation;condense |
| ciliary dyskinetic syndromes | an impairment in the ability to control movements, characterized by spasmodic or repetitive motions or lack of coordination |
| in bronchiectasis the airway is | -permanently damaged, dilated, and prone to constant obstruction by retained secretions |
| "artificial cough machine" | in-exsufflator machine |
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