Transcript Physiology II-4 - Hogeschool van Amsterdam

Cardio-respiratory II-4
Pulmonary Assessment
Cardio and pulmonary rehabilitation
Pulmonary Rehabilitation
In Hospital
Pulmonary assesment
• History (past, present, social, occupational) > Medical
notes
• Observation > general appearance, colour, hands,
oedema, jugular venous pressure, chest shape,
respiratory rate, breathing pattern, sputum, sputum
specimen & sputum induction
• Risk factors
Medical notes
Necessary details from doctor’s note include:
• Past & present relevant history
• Social history
• Other disorders requiring physiotherapy
• Relevant investigations i.e. X-rays
• Response to medical treatment
• Recent cardiopulmonary resuscitation
• Possibility of bony metastasis
• Long-standing steroid therapy > risk of osteoporosis
• History of radiotherapy over the chest
= Contraindication for percussion / vibration over the ribs
Chest pain
•
Lung parenchyma (functional part of an organ; in this case: alevoli,
respiratory bronchiole, alveolar duct, terminal bronchiole) doesn’t contain
pain fibers but important chest pain are:
•
Pleuritic pain > denotes nature of pain, rather than pathology > sharp,
stabbing, worse on deep breathing, coughing, hiccuping, talking &
being handled; Causes > pleurisy, pneumonias, pneumo-thorax, fractured
ribs or pulmonary embolism
•
Angina pectoris > paroxysmal suffocating pain, greater with exertion,
stress; substernal or left anterior, sometimes radiating to left arm/jaw;
Cause > myocardial ischemia
•
Musculoskeletal pain > i.e. costovertebral tenderness due to hyperinflation
•
Raw central chest pain > worse on coughing; Cause > tracheitis &
associated with upper respiratory tract infection or excessive coughing
Observation: Clubbing
Clubbing, recognized by loss of angle
between nail & nail bed; in later stages by
bulbous ends to fingers.
Causes are: pulmonary (75%), cardiac
(10%), liver/gut (10%), other (5%)
Palpation
•
•
•
•
Abdomen
Respiratory Excursion
Tactile Fremitus
Diaphragm level
ESP slide 6
Abdomen
Patient position
•Relaxed abdominal muscles
•Lying supine, arms relaxed at side
•Palpate all 4 quadrants using both light
and deep palpation
•Begin palpation away from any area of
pain (as identified from the history), and do
the painful area last.
RUQ = Right Upper Quadrant
RLQ = Right Lower Quadrant etc.
Dermatomes:
T 6 > epigastric area
T10 > umbilical area
T12 > suprapubic area
Assessment of Respiratory Excursion
•Place your thumbs about the level of and
parallel to the 10th rib, your hands
grasping the lateral rib cage.
•As you position your hands, slide them
medially in order to raise loose skin folds
between your thumbs and the patient's
spine.
•Feel for range of symmetry of respiratory
movement.
Anterior palpation
•Place your thumbs along each costal
margin with your hands along the lateral rib
cage.
•As you position your hands, slide them
medially a bit to raise a between the thumbs.
•Ask the patient to inhale deeply. Watch for
your thumbs to separate as the thorax
expands.
•Feel for the range and symmetry of
respiratory movement.
Palpate Chest for Tactile Fremitus
•Fremitus refers to the palpable vibrations transmitted through
the lungs to the chest wall when the patient speaks.
•Have the patient say "ninety-nine" or "one-one-one" and you will
feel vibrations.
•Vibrations are more difficult to feel over bone.
•NOTE: Patients with a heavy layer of fat may need to speak
more loudly for you to feel the vibrations.
Follow this Procedure to Palpate Properly
•Use the ball of the hand (the palm of the hand at the base of the
fingers), palpate and compare like areas of the lungs.
•To be more accurate, use only one hand rather than both hands.
Do not let your fingers touch the patient's chest.
•Have the patient repeat a sound that will make full and rich
sounds such as "ninety-nine" or "one-one-one."
•Symmetrically move your hand over the patient's chest. You
should feel vibrations of equal intensity on either side of the
patient's chest.
•Normally, you will feel fremitus on the upper chest, close to the
bronchi. Also, normally, you should feel little or no fremitus in the
lower chest. Compare like (symmetrical) areas of the lungs.
Diaphragm level
The level of the diaphragm can be estimated roughly by
noting where fremitus stops upon the downward palpation
of the chest. It is normal to find that the right side of the
diaphragm is slightly higher than the left side.
Chest Percussion
•To perform a percussion examination, strike the surface of the body.
•When this is done, various sounds can be heard. The sounds are different depending on the
underlying structure of the body.
•There are two reasons to use percussion as an examination technique.:
First, percussion results in setting the chest wall and underlying tissues in motion. This produces
sounds that can be heard.
Second, percussion sounds can be divided into four recognizable notes. Train your ear to recognize
the pitch and duration of these notes. The sound can indicate whether the underlying tissues are
filled with air, filled with fluid, or solid.
NOTE: Percussion will set tissues in motion only about five to seven centimeters into the chest, so
the percussion examination technique is not a way to detect lesions that are very deep.
Technique
In order to perform the percussion examination technique, strike the stationary finger of one
hand with a flexed finger of the other hand.
Firmly rest the first joint of the
middle finger of one hand on
the patient's chest, but don't let
the rest of the hand touch the
chest
Keep the fingers of the
other hand flexed and the
wrist loose
With the tip of the middle finger of
the flexed hand, strike the first joint
of the middle finger of the hand
that is on the patient's chest .Have
the motion come from the wrist.
Withdraw the striking finger immediately to avoid damping the vibration.
Strike once or twice, then move your hands symmetrically to another part of the chest.
Areas of percussion
The patient should lie in the supine position (lying on the back, face upward) for percussion on the front of the chest.
The patient should be sitting up for percussion on the back.
If the patient is ill and unable to sit up, examine with the patient lying on the right or left side.
Percuss the patient's anterior
chest . In a healthy patient, the
entire upper chest is resonant
except for the area of cardiac
dullness. Percuss across the top
of the body and work downward,
symmetrically.
Measure the diaphragmatic
excursion (movement of
the diaphragm from a
position of rest) by noting
the difference between the
levels of dullness when the
person inhales fully and
exhales fully. The
difference is normally about
5 or 6 cm.
Measure the diaphragmatic
excursion (movement of
the diaphragm from a
position of rest) by noting
the difference between the
levels of dullness when the
person inhales fully and
exhales fully. The
difference is normally
about 5 or 6 cm.
Chest Auscultation
Auscultation (listening with a stethoscope) of the lungs is useful in estimating the airflow through
the tracheobronchial tree, detecting an obstruction, and assessing the condition of the
surrounding lungs and the pleural space.
Position the patient. Have the patient sitting or in a supine position. When the patient is lying
down, examine his back by turning the patient from side to side.
Show the patient how you want him to breath through the mouth, deeper and more forcefully
than usual.
Listen with the stethoscope.
Start at the top of the back and work downward, comparing the right and the left sides.
Then, start at the top of the chest and work downward, comparing symmetric points sequentially.
Listen to one full breath in each location. Be alert for patient discomfort--light-headedness,
faintness--that signals hyperventilation.
Technique
Auscultate vesicular breath
sounds. These sounds are
normally heard over the
entire lung surface, except
beneath the manubrium
sterni and in the
interscapular region. The
sounds are long when the
patient inhales and short
when the patient exhales.
Auscultate bronchial (tubular) breath sounds. These sounds
result from consolidation or compression of the pulmonary
tissue that assists in the transmission of sound from the
bronchial tree. Bronchial breath sounds do not occur in the
normal lung except directly over the trachea. These sounds are
short when the person breathes in and long when the person
breathes out. The sounds are usually louder than vesicular
breath sounds.
In Hospital Rehabilitation
•
•
•
•
Pulmonary Assesment
Pulmonary Therapy
In Hospital Training
Case
Pulmonary assesment
Analysis:
• Medication
• Temp, HR, RR, spO2
• Arterial bloodgasses
• Spirometry
• Gold classification or Bode index
Arterial bloodgasses
•
•
•
•
Ph
;
Pa CO2;
Pa O2 ;
Sa O2 ;
7,35 – 7,45
35- 45 mmHg
80- 100 mmHg
> 96%
Spirometry
• FEV1; forced expiratory volume in 1
second
• FEV1/ FRC; functional residual capacity
• VC; Vital Capacity
• Pi max; inspiratory mouth pressure
• Pe max; experitary mouth pressure
Spirometry
Gold classification or Bode index
• Stadium 0; chronic symptoms
(coughing with mucus), normal
spirometry
• Stadium 1; chronic symptoms,
FEV1> 80% predicted.
• Stadium 2; most of the time
chronic symptoms,
30%<FEV1> 80% predicted.
• Stadium 3; most of the time
chronic symptoms. FEV1
<30% pred. or FEV1 < 50%
with respiratory insuf. or right
heart failure.
• The Body-Mass Index (BMI)
• Airflow Obstruction (FEV1 %)
• Dyspnea (MMRC dyspnea
scale)
• Exercise Capacity Index ( 6
min. Walking test)
ESP slide 22
Pulmonary assesment
Assesment (subjective):
• Symptoms (how long, frequency, beter or worse)
• Pain
• Breathlessness
• Cough
• Sputum/ mucus
• Functional limitations
Pulmonary assesment
Observation (1):
• Chest shape
• Work of breathing
• Breathing pattern (abdominal paradox, inspiratory;
expiratory ratio: 1;2, a-symmetric breathing pattern,
pursed lipp breathing etc.)
• Sputum
Pulmonary assesment
Observation (2)
• Hoover sign
• Periferal colour and oedema
• Pink Puffer or Blue Bloater
• Drains or other machinery in order
Pink Puffer
• Near normal bloodgasses
• Weight los
• Breathlessness ↑
Blue Bloater
• Less breathless
• Abandons the fight of
normaal blood gases,
poor gasexchange
• Periferal oedema
• Double the mortality of
Pink Puffer patient
Pulmonary assesment
Palpation
• Chest expansion
• Percussion Note
• Abdomen
• Tactile vocal fremitus
• Sputum localisation
Pulmonary assesment
Exercise tolerance
• Functional exercise tolerance (ADL)
Pulmonary Therapy
•
•
•
•
Breathing techniques
Postural drainage
Manual techniques
Other important things
Breathing techniques
• Active Cycle of Breathing Techniques(ACBT)
• Forced Experiation Techniques (FET)
• Reducing breathlessness
Active Cycle of Breathing
Techniques(ACBT)
• Relaxed abdominal breathing to facilitate relaxatio
• 3-4 deep breaths to reverse aiway closure and open
collateraal chanels
• 1-2 huffs to mobilize secretions
• (1 cough)
Forced Experiation Techniques
(FET)
• Relaxed abdominal
breating
• Forced Expiration with
open mouth
Postural drainage
• Assist drainage of
secretions
• 30 – 40 min.
Manual techniques
• Chest compression
• Cough facilitation
• Percussion (clapping) ->
no evidence!
Reducing breathlessness
• Purshed lip breathing
• Positioning in bed
Other important things
• Out of bed
• CPaP and pharyngeal suction
In Hospital Training
• Peripheral muscle strength training ( 60- 70% 1 RM,3 x 8
repetitions)
• When possible start cycle training (interval)
• Treshold Loader when:
FEV1 < 30% predicted, much dyspnea and weak
respiratory musceles. PaCO2 > 50 mm Hg and Pi max <
50 -60% pred. weak respiratory musceles.
Case 1
Mrs. Q; 04-10-1941
In hospital:
• Exacerbation COPD ( emphysema) and pneumonia left lung.
Medical history:
• Depression
• COPD with frequent exacerbations
• ’05 Pneumonia middle lobus
Arterial blood gases:
• pH: 7.43; pCO2; 37 mmHg; pO2: 59 mmHg; spO2: 91%
• Oxygen suppletion: 1L/m
Medicine:
• Furosemide, DAF, Ipramol, Fluimicil, Budesonidem, diazepam and Augementin
Respiratory function test:
• FEV1: 1.59 L ( 65 % predicted); VC: 1,9 L.
Probems:
• Exercise limitation, breathlessness and sputum retention
Case 2
Mrs. M; 17-06-1951
• In hospital:
• Exacerbation COPD ( emphysema), breathless and lots of white mucus.
• Medical history:
• COPD with frequent exacerbations
• Smoking, 42 packyear
• ‘ 04 Pulmonary embolism
• Arterial blood gases:
• pH: 7.44; pCO2; 37.7 mmHg; pO2: 112 mmHg; spO2: 96%
• Oxygen suppletion: • Medicine:
• Antibiotics, symbicort, DAF and diazepam
• Respiratory function test:
• FEV1: 1.17 L (51 % predicted); VC: 2,6 L.
• Problems:
• Mucus retention, exercise limitation and still smoking (in hospital)
References
• http://207.5.42.159/sweethaven/MedTech/
RespDisease/lessonMain.asp?mode=1&i
Num=0202
• Hough “Physiotherapy in Respiratory
Care”