pulmonary interventions

what is diaphragmatic breathing?

• helps to slow down the breathing and increases the tidal volume (this increases ventilation and oxygenation)

• can improve oxygen saturation and atelectasis

• eliminates accessory muscle activity

how do you diaphragmatic breath?

one hand on chest and one hand on belly, inhale and breath belly out, exhale and breath belly in

what does purse-lip breathing help with?

• decreases dyspnea

• improves activity tolerance

• improves gas exchange

what should you avoid with purse-lip breathing?

AVOID forceful exhalation!!!

what disease is pursed lip breathing often used in?

obstructive lung disease

what is segmental breathing used for?

it is used to encourage expansion of a specific part of the lung

• it improves aeration and oxygenation to that area

• good for post op patients (chest or abdominal surgery)

able to add a quick stretch to facilitate muscle contraction

what are the three types of segmental breathing?

• apical breathing

  • push more air into a segment, good for atelectasis

• lateral costal expansion

• posterior basal expansion

what is a way to strengthen using lateral costal breathing?

by using a belt to apply resistance during inspiration, and by assisting with pressure along the ribcage during expiration

can also use a TB

what are extremity and trunk exercises during breathing?

it is done with breathing to enhance chest mobility

EXHALE DURING FLEXION, INHALE DURING EXTENSION

EXHALE DURING ROTATION

what are indications for summed/stacked breathing?

• restricted chest movement

• decreased lung capacity due to muscle weakness

• inability to cough

what is summed/stacked breathing?

• series of deep breathing that are stacked on top of each other

  • shown to improve blood oxygenation, atelectasis and cough effectiveness

how do you do summed/stacked breathing?

• slowly breath in and stack one breath on top of the previous breatha s long as they can tolerate it

• at MAXIMAL volume, hold then exhale

what is paced breathing?

• coordination of breathing during an activity

  • breath slowly during an activity (rhythmic activities)

  • inhale at the beginning of the activity and exhale during the activity (non-rhythmic activities)

• helps to decrease dyspnea, fatigue and lower anxiety

• box breathing

what is incentive spirometer (IS)?

• it helps to prevent or decrease atelectasis

• may increase inspiratory capacity

how do you do incentive spirometry?

• take a slow, relaxed breath through the mouthpiece

• set a foal for the patient to reach

what is the manual diaphragm release technique?

• use of manual technique that stretches the diaphragmatic muscle fibers which helps to INCREASE CHEST WALL MOBILITY

• limited evidence BUT it may INCREASE chest expansion, and exercise capacity in people with mild/moderate COPD and post COVID

what are airway clearance techniques?

manual or mechanical procedures that facilitate mobilization of secretions from the airways

what are the types of airway clearance techniques?

• postural drainage

• percussion

• vibration

• cough techniques

• suctioning

• exercise

what are indications for airway clearance techniques?

• impaired mucocilliary transport

• excessive pulmonary secretions

• ineffective or absent cough

• Chronic bronchitis, CF, bronchiectasis, post surgical

what are tips for airway clearance techniques?

• perform > 30 minutes after a meal

• continuous tube feeding should be stopped for at least 30 minutes

• pain should be controlled

• inhaled bronchodilators should be given

• monitor vital signs during the treatment session

• always be able to see the patients face

what is postural drainage?q

• patient is placed in one or more body positions that allows gravity to assist with draining secretions from each lung segment towards a central bronchus where it can be cleared by coughing

• each position is maintained for 5-10 minutes or longer

• can be done exclusively or with another airway clearance technique

• “bad lung” up EXCEPT with a recent pneumonectomy and bronchopleural fistula

what are the 6 postural drainage positions that we need to know?

• anterior upper segment (upper lobes sitting up)

• posterior apical segment (leaning forward)

• right middle lobe (sidelying on left side, with legs in air)

• right lateral segment (full sidelying with feet raised in air)

• left lateral segment (right sidelying with feet raised in air)

• posterior segment (prone with feet raised in air)

what are precautions for postural drainage?

• pulmonary edema

• hemoptysis

• massive obesity

• large pleural effusion

• massive ascites

what are relative contraindications for postural drainage?

• increased intracranial pressure

• hemodynamically unstable

• recent esophageal anastomosis

• recent spinal fusion or injury

• recent head trauma

• diaphragmatic hernia

• recent eye surgery

what is percussion?

• aimed at loosening secretions from the airways so it can be expectorated

• can be manually done with hands, a percussor, or with a mechanical device

• perform 3-5 minutes over each area of the lung in a postural drainage position

• HANDS MUST BE CUPPED

what is vibration?

• gentle, high frequency force applied to the chest wall to move secretions towards larger airways

• instruct the patient to inhale

• apply high frequency vibration AS THE PATIENT EXHALES

• do 2-3 reps then have the patient cough

what is shaking?

• helps to move secretions to larger airways

• similar to vibration but it is a stronger bouncing maneuver

  • instruct the patient to inhale

  • apply high frequency shaking as the patient exhales

  • do 2-3 reps and then have the patient cough

what are precautions for percussion, vibration and shaking?

• uncontrolled bronchospasm

• osteoporosis

• rib fractures

• metastatic cancer to ribs

• tumor obstruction of airway

• anxiety

• coagulopathy

• conclusive or seizure disorder

• recent pacemaker placement

what are relative contraindications for percussion, vibration and shaking

• hemoptysis

• untreated tension pneumothorax

• PLT count below 20,000 per mm3

• unstable hemodynamic status

• open wounds, burns to the thoracic area

• pulmonary embolism

• subcutaneous emphysema

• recent skin graft or flap on thorax

what is high frequency chest wall oscillation?

• assists with mucus clearance

• inflatable vest that inflates/deflated to create gentle vibrations

what is high frequency chest wall oscillation used for?

• people with CF, bronchiectasis and other disorders to assist in mucus clearance

• can be used with kids as young as 2

• best results with patients sitting up

what is the purpose of active cycle of breathing?

loosen and clear mucus from the lungs and improve ventilation

what is breathing control in the active cycle of breathing?

diaphragmatic breathing at normal tidal volume

what is thoracic expansion exercises in the active cycle of breathing?

3-4 deep breaths with a brief hold and then a relaxed exhalation

what is forced expiratory technique in the active cycle of breathing?

1-2 huffs at mid to low lung volumes

what is the purpose of autogenic draining?

mobilize secretions in patients with large volumes of retained secretions (CF or chronic bronchitis)

what is autogenic drainage?

it involves using different depths and speeds of exhaled breath to move mucus up through the aiways

what are the 3 stages of autogenic drainage?

1. unsticking of mucous in smaller airways

2. collecting mucous in middle airways

3. evacuating mucous from large airways

what are positive expiratory pressure (PEP) devices?

• provides a resistance during exhalation which creates a back pressure which helps to hold the airways open during exhalation, increase collateral ventilation, prevents premature airway closure and gas trapping —> gets air behind mucus and moves it proximally

what are the 3 types of PEP devices we should know?

• theraPEP device

• acapella dvice

• flutter device

what are the stages of coughing?

• irritation

• adequate inspiration ( > 60% of predicted vital capacity)

• glottis (vocal cords) CLOSURE and active contractions of abs and intercostal muscles

• opening of glottis and forceful expulsion of air

what is huffing?

• alternative of coughing

• can be used with post op patients who are too painful to cough

• inhale, hold it and then quickly exhale without closing the glottis

what is costophrenic assist?

• place hands on patients costophrenic angle, then applies QUICK, manual compression inferiorly and medially during the exhalation phase of the cough

what is the abdominal thrust technique?

• place hand on the patient’s abdominal wall just above the navel

• instruct the patient to take a deep breath and hold it

• as the patient coughs the PT quickly pushes up and in under the diaphragm with the heel of the hand

what is anterior chest compression?

• V technique!!!!

• in supine

• place one forearm across the patient’s upper chest and the other arm across the abdomen

• during exhalation phase of the cough compression is given diagonally with both arms toward the middle of the chest (arm makes a V)

what is counter rotation assist?

• performed in side-lying

• stand behind the patients hips, place your proximal hand on the patient’s scapula while the distal hand is placed on the patients anterior iliac crest

• during inhalation, stretch the patients chest by pushing the thorax superiorly/anteriorly and away with the scapular hand while pulling the hip down and back with the distal hand

• slide the scapular hand forward onto the patients anterior upper chest while the distal hand slides back over the patients buttocks

• during the cough pull the upper chest down and back while pushing the buttocks up and forward

what is long sitting assisted cough?

• patient sits in long sitting with UE support

• patient extends their body backward while inhaling maximally and then as they cough they move their body into a flexed position

what is splinted cough?

use of a pillow/blanket over incision to decrease pain

how can aerobic exercise be used in airway secretions?

• hyperventilation has been shown to help mobilize secretions

• exercise improves ease of sputum clearance compared to rest (for patients with CF)

• exercise may have similar effects to traditional airway clearance techniques over the short term

• NEED TO BE CAREFUL in patients with HYPERACTIVE airways or those prone to desaturate with activity

what is respiratory muscle training?

• consists of training inspiratory and/or expiratory respiratory muscle

what are the types of RMT?

• inspiratory vs expiratory muscle training

• resistance vs endurance training

what are the potential benefits of RMT (mixed results)?

• improve resp muscle function (strength and endurance)

• increase exercise capacity

• reduce breathlessness (decrease WOB)

• reduce respiratory complications post op

• increase QoL

• improve swallowing or coughing

what are potential contraindications of respiratory muscle training?

• acute CVA

• untreated HTN

• acute delirium

• perforated tympanic membrane

• spontaneous pneumothorax

• hemodynamic instability

• rib fractures

• osteoporosis

• recent abdominal surgery

what are populations who may benefit from RMT?

• athletes

• post surgery

• patients on ventilator

• spinal cord injury and CVA

• neuromuscular disorders

• COPD

• CHF

• COVID

what is inspiratory muscle training?

• helps to improve inspiratory muscle strength and endurance

• inhale against a set resistance to strengthen the inspiratory muscles

what is the exercise prescription for inspiratory muscle training?

• freq: 1-2 sessions a day

• intensity: varies based on patient pop. (30-70% of PI max)

• time: 30 min a day

what is expiratory muscle training?

• exhale hard and fast against a set resistance

• exercise prescription is patient specific

what are the benefits of expiratory muscle training?

• increases strength of cough

• improves swallow ability

• increases phonation