Tech and Theory II test #1

Complications of chest physical therapy

1. Hypoxemia 2. Rib fractures 3. Increased airway resistance 4. intracranial pressure (ICP) 5. Hemorrhage 6. Decreased cardiac output 7. Aspiration

Indications for chest physical therapy

1. Lung conditions resulting in an increased difficulty in mobilizing pulmonary secretions: a. bronchiectasis b. cystic fibrosis c. lung abscess 2. Acute respiratory failure with the presence of retained pulmonary secretions 3. Acute atelectasis 4. Ventilation/perfusion abnormalities resulting from retained pulmonary secretions 5. COPD patients with inefficient breathing patterns 6. Preventative use for postoperative respiratory complications

Types of Chest physical therapy (CPT)

1. Postural drainage 2. Chest percussion 3. Chest vibration 4. Cough techniques

Goals of chest physical therapy

1. Prevent the accumulation of pulmonary secretions 2. Improve the mobilization of retained secretions 3. Improve the distribution of ventilation 4. Decrease airway resistance

Intrapulmonary (Intermittent) Percussive Ventilation (IPV)

1. This is another airway clearance technique that utilizes a pneumatic ventilator to deliver a series of small tidal volumes at high frequency (110-225 cycles/min). 2. The length of each percussive cycle is controlled by either the practitioner or patient using a thumb control button. 3. These pressurized bursts of gas are delivered to the patient via a mouthpiece. Bronchodilators or mucolytics may be administered through a pneumatic nebulizer during this 15-20 minute treatment. 4. It has been demonstrated that the pulsed gas flow is as effective in breaking up secretions for easier mobilization than postural drainage and percussion on cystic fibrosis patients. 5. It has the advantage over conventional CPT in that fatigue and practitioner technique is not a factor.

High Frequency Chest Wall Oscillation

1. This is yet another newer technique to improve sputum clearance for the airways. 2. An inflatable vest is wrapped around the patients chest that is attached to an air-pulse generator which intermittently injects small volumes of air into and out of the vest at a high rate. This creates oscillatory movement that has shown to aid in the mobilization of secretions. 3. The duration of therapy is usually about 30 minutes, using an oscillation frequency of between 5 and 25 Hz (300 - 1500 cycles/min.) 4. This technique has proven in studies to be as effective as postural drainage/percussion on cystic fibrosis patients.

Cough technique

1. While sitting, the patient should be instructed to inhale deeply through the nose and hold the breath for 3-5 seconds. 2. Clasp their arms across the abdomen and produce 2-3 sharp coughs without taking a breath while pressing the arms into the abdomen. 3. A pillow should be used to splint thoracic or abdominal incisions to decrease pain and improve the cough effort.

Percussion should be performed over each specified area for _______minutes.

2-5

While assessing the patient during the therapy, and it appears to be ineffective at the pressure being used, increase the PEP level by _____cm H2O and continue to monitor.

3-5

percussion

A means of improving the mobilization of pulmonary secretions by manually striking the chest wall with a cupped hand or placing a mechanical ________ on the chest wall. Both of these techniques are generally performed with the patient in postural drainage positions.

EzPAP setup

A small volume nebulizer may be attached to the device for delivery of a bronchodilator. In this case, two flowmeters are used, one for the nebulizer and one to provide airway pressure.

Which is a potential hazard related to incentive spirometry

Acute respiratory alkalosis

What are the coterm-56ntradictions to intermittent positive pressure breathing (IPPB) therapy? Select all that apply.

Air swallowing Hemodynamic instability

Which of these mechanisms are examples of modified directed coughing?

Autogenic drainage Forced expiratory technique

Guidelines for effective incentive spirometry

Cooperative patient Motivated patient Patient's respiratory rate should be less than 25/min Patient's vital capacity (VC) should be greater than 10 ml/kg of body weight (IPPB may be indicated if VC is less than 10 ml/kg)

The most common device is the _____________________ made by Phillips Respironics forMechanical Insufflation-Exsufflation

CoughAssist

Which device measures and visually indicates the degree of inspiratory flow?

Flow-oriented incentive spirometer

Autogenic drainage phase 1

From the resting expiratory level, the patient is instructed to take the deepest breath possible (inspiratory capacity maneuver) followed by breathing at low lung volumes for several breaths.

4-5

Generally, 5 breaths followed by coughing or suctioning, and repeated ________ times is the suggested treatment regimen for Mechanical Insufflation-Exsufflation

Hazards of incentive spirometry

Hyperventilation Pneumothorax (unlikely; has a higher incidence in COPD patients) Increased intrapleural pressure and stimulation of the vagal reflex, causing bradycardia if the sustained maximal inspiratory pause is performed against a closed glottis (Valsalva maneuver)

face mask or endotracheal tube

Mechanical Insufflation-Exsufflation treatments may be administered via ____________________

adjust the acapella

PEP levels are adjusted by a control knob at the end of the device. Turning the knob clockwise will increase the PEP level.

_______________ may be an effective alternative to postural drainage and percussion with the added benefit that the patient can perform this simple task independently with fewer side effects than percussion and postural drainage.

PEP therapy

Important points concerning incentive spirometry

Patient should be positioned upright in the Fowler's or semi-Fowler's position. The initial inspiratory goal should be twice the patient's tidal volume. The inspiratory time should be 5 to 15 seconds with a 2-to 3-second pause at end inspiration. Incentive spirometry is an alternative to IPPB in treating atelectasis if the patient is able to achieve a VC of greater than 10 ml/kg of body weight.

Which minimum performance characteristic feature should a noninvasive ventilator in an acute care setting provide?

Provide inspiratory flow rate up to 180 L/min at 20 cm H2O

is another PEP device that utilizes a counterweighted lever and magnet to produce PEP and airflow vibrations. As exhaled air passes through the device, flow is intermittently blocked by a plug attached to the lever producing the vibrations.

The Acapella

Mechanical Insufflation-Exsufflation method

The device can generate positive pressures of 30-50 cm H2O on inspiration for 1-3 seconds. The pressure is then reversed to -10 to -50 cm H2O during exhalation. This rapid change in pressure during the different phases of breathing (inspiration and expiration) helps make the cough stronger and more effective.

Why would the directed cough technique be avoided for a patient with chronic bronchitis? Select all that apply.

The patient has a hiatal hernia. The patient has bleeding diathesis. The patient has an intracranial aneurysm

Autogenic drainage phase 2

The patient is instructed to increase their tidal volume to low to middle volumes for several breaths. (These breaths are slightly larger the than normal tidal volume.)

flutter vaulve methodology

The patient should be instructed to inhale slowly, just beyond a normal breath (not totally filling the lungs), and hold the breath for 2-3 seconds. The patient should then exhale reasonably fast, but not forcefully through the _________________ which causes a stainless steel ball to be pushed up into the angled portion of the device to produce a PEP. The angle causes the ball to oscillate up and down. The oscillations are transmitted down the respiratory tract creating vibrations resulting in mobilization of secretions.

Autogenic Drainage prep

The patient should be placed in a sitting position and instructed in a breathing pattern that varies lung volume and expiratory flow in three different phases:

Autogenic drainage phase 3

The patient then increases their tidal volume to moderate deep breaths for several breaths. After this phase is completed, the patient is instructed to cough

Autogenic drainage problems

This technique is difficult to teach the patient, and since it is to be taught for the patient to use independently, this has posed a problem.

Frequency of flutter vaulve

This technique should be repeated 5-10 times to help loosen secretions, followed by coughing to aid in the removal of the sputum. The treatment should last 5-15 minutes.

Mechanical Insufflation-Exsufflation purpose

This therapy is to assist or replace cough clearance in patients with respiratory muscle weakness or paralysis.

Autogenic drainage outcome

This type of breathing pattern helps loosen secretions, moving them into larger airways so they may be mobilized with an effective cough. This technique has shown some promise in patients with cystic fibrosis. It appears to mobilize secretions comparable to postural drainage and percussion without the degree of oxygen desaturation and is tolerated better by this type of patient.

Complications of chest physical therapy: Hypoxemia

a. Especially in COPD, cardiac or obese patients b. Modification of drainage position will make the therapy more tolerable for these patients c. May be minimized by the administration of a bronchodilator prior to CPT and the delivery of supplemental oxygen during the treatment

Positive expiratory pressure (PEP) therapy method

_____ is achieved by having the patient exhale through a mask or mouthpiece with a resistance valve. The valve creates back pressure into the patient's airway. Different size resistors or adjustable resistors are used to increase or decrease the amount of _____. Generally, ______ levels of 10-20 cm H2O are used.

EzPAP

a PEP device that also provides positive pressure during inspiration. The patient exhales against an adjustable spring-loaded valve resulting in positive expiratory pressure.Inspiratory pressure is generated from the high inspiratory flowrate that is 4 times the flowrate set on the flowmeter. The flowmeter is generally set at 5-10 L/min.

Autogenic Drainage definition

a modified coughing technique that has been shown in some studies to be comparable in secretion clearance to postural drainage and percussion techniques.

Steps in performing PEP mask therapy

a. Assemble equipment, select appropriate expiratory resistor (10-20 cm H2O) b. Position patient sitting up with elbows resting on table, with mask applied tightly (to prevent leaks) over the nose and mouth. c. Instruct patient to inhale a larger than normal volume, but not as deep as possible, then actively exhale, not forcefully, with expiration lasting 2-3 times longer than inspiration. d. The patient should perform 10-20 of these PEP breaths, then remove the mask and perform 2-3 "huff" coughs. This type of cough, also referred to as the forced expiratory technique (FET), requires forceful exhaling from a mid to low lung volume with an open glottis. This has been proven to be very effective for secretion clearance. e. Cough normally to mobilize secretions as needed. f. Repeat steps b-e four to six times per session.

Complications of chest physical therapy:Aspiration

a. Caused by vomiting during the treatment b. CPT should be performed no sooner than one hour following a meal

Complications of chest physical therapy: Rib fractures

a. Caused from too vigorous percussion b. Most common in neonates and elderly patients

Therapeutic effects of PEP

a. Improved distribution of inspired volume in the lung due to collateral air channels (pores of Kohn). b. Prevention of expiratory airway collapse. c. The ability to generate pressure on exhalation in an area distal to the site of mucus obstruction.

Complications of chest physical therapy:Decreased cardiac output

a. Often the result of positional hypotension b. Check heart rate periodically during the treatment

Complications of chest physical therapy: Increased airway resistance

a. Patient should be coughed periodically throughout the treatment b. Suction equipment should be readily available for patients having difficulty expectorating secretions

Complications of chest physical therapy: intracranial pressure (ICP)

a. Patients with head trauma should not be placed in the Trendelenburg (head down) position b. Increased ICP may result from prolonged coughing associated with CPT

Contraindications of PEP

a. acute sinusitis b. ear infection c. epitaxis (nose bleed) d. recent facial, oral or skull injury or surgery e. active hemoptysis

Percussion should not performed over the following areas:

a. spine b. sternum c. scapulae -3- d. clavicles e. surgical sites f. areas of trauma g. bare skin (although some advocate manually percussing over bare skin, it has been shown that the energy wave produced by the air trapped under the hand is not significantly reduced by light covering such as a hospital gown) h. female breasts

Expiratory pressure can be adjusted by increasing or decreasing the flowrate, with the PEP measured by a small plastic manometer provided with the device or by a separate larger manometer.

adjust Ezpap

The _________________ is a pipe-shaped device (see diagram) that the patient exhales through that produces a positive expiratory pressure (PEP) between 10 and 25 cm H2O. The effectiveness of the device is controversial, but some studies have shown improved secretion clearance in cystic fibrosis patients.

flutter valve

Positive expiratory pressure (PEP) definition

is a bronchial hygiene therapy used in the management of airway secretions and postoperative atelectasis. 2. It is becoming increasing popular as an alternative to chest physiotherapy and incentive spirometry especially in pediatric patients with cystic fibrosis and bronchiectasis. 3. It is also been found effective for preventing postoperative atelectasis by opening airways and improving gas exchange.

Chest physical therapy (CPT)

is a variety of therapies aimed at the mobilization of pulmonary secretions and promoting a greater use of the respiratory muscles, resulting in an increase in the distribution of ventilation.

which of the following statements involving chest physiotherapy is false?

lower lobes should be drained prior to draining the upper lobe

flutter vaulve cleaning maintanance

may be disassembled after each use and rinsed in tap water and dried before reassembly. In the home, the device should be cleaned every two days in a soap solution and disinfected at regular intervals by soaking in a solution containing 1 part vinegar and 3 parts water for 15 minutes, dried and reassembled for future use.

PEP therapy may also be combined with aerosolized bronchodilator therapy by attaching a nebulizer or an inhaler to the_________________________________ of the PEP device

one-way inspiratory valve

EzPAP indications

prevention or treatment of atelectasis for patients who don't meet the guidelines for IS, a VC of < 10 ml/kg of body weight.

Autogenic drainage, intrapulmonary percussive ventilation, high frequency chest wall oscillation, PEP therapy and flutter valve therapy

should all be considered as effective alternatives to chest percussion and postural drainage for patients with secretion management problems seen with cystic fibrosis and bronchiectasis.

Goals of incentive spirometry

treat atelectasis Improve the cough mechanism Maintenance of airway during preoperative period strengthens lung muscles prior to surgery improves the mobilization of secretions Prevention of postoperative atelectasis (This therapy is most effective in treating this condition.) Provide early detection of atelectasis or pneumonia by decreasing inspiratory capacity levels.