PTRS 826 - Check Off Diagnoses

Asthma

− Obstructive pulmonary disease characterized by episodic reversible airway narrowing

− Caused by airway inflammation, increased secretions, and smooth muscle bronchoconstriction

− Etiology: Unknown (genetics, environment, and infection are possible causes)

− Most common chronic childhood disease (affects 1/10 kids)

What is this diagnosis?

− Typically, a "trigger" for attack (i.e. allergen, exercise, etc.)

− Breath Sound: wheezes

− Shortness of breath, cough, chest tightness, can be induced by exercise,

tachycardia, rapid and labored breathing, cyanosis, expulsion of thick or sticky

mucus

− FEV1/FVC = 70% or lower

− Residual Volume Increases

− Possibly Increased Anxiety Levels

− Initially respiratory alkalosis initially due to hyperventilation, respiratory acidosis

due to decreased ventilation, metabolic acidosis later due to decrease in aerobic

metabolism (lactic acid buildup)

− Blood Gases: decreased PaO2 and Increased PaCO2

− Commonly affects children

Asthma

Asthma Subjective

− S/S are triggered after the start of increased activity

− S/S are not present during times of rest

− Cold and dry environments are triggering environments; bad air quality and

allergens also have an effect

Asthma Objective

- Decreased FEV1/FVC value

- Shortness of breath

- Wheezing during exercise (during auscultation)

- Reduced expiration especially during or after exercise (increased residual volume

Tests & Measures for Asthma

- Spirometry (Lung Function)

- Allergy testing

- Auscultation (Heart and Lung Sounds)

o Wheezinglungsoundsduringanasthmaattack;wouldneedtoprovokes/s to hear wheezing sounds

- Vitals (Pulse, O2, BP)

PT / Mobility Intervention for Asthma

- Posture exercises

- core strengthening exercises to address weakness to maintain prolonged posture

- thoracic mobility

- aerobic conditioning: maintain aerobic level

- preferred environment = warm and moist rooms

- longer gradual increased warm-up period

Breathing Techniques / Interventions for Asthma

o Active Cycle of breathing -combo of deep breathing, controlled breathing,

and forced expiration

o Postural Drainage and Percussion/Vibration

o Diaphragmatic Controlled Breathing

- Pursed- lip breathing

- postural drainage and percussion for severe attacks

Posture for Asthma

- Upright head/neck/trunk positioning

- Increase thoracic mobility

Bronchiectasis

- Dilation of the bronchial

- Irreversible with chronic inflammation and infection

- Thickening of airways

- High amounts of very smelly sputum

What is this diagnosis?

- Cough w/ LOTS of smelly sputum

- History of recurrent or chronic lung infections

- Blood in sputum

- Dyspnea and tiredness

Bronchiectasis

Objective Findings with Bronchiectasis

- FEV: < 70%

+ Objective tests =

+ Productive cough

+ Signet ring sign on CT

+ Abnormal blood gases

Assessments for Bronchiectasis

- Auscultation

- Vitals

- Cough

- Secretion clearing: percussion/vibration, postural drainage

- Thoracic ROM

- Measure of diaphragmatic mobility: excursion, etc.

- MMTS: quadriceps

Breathing Interventions for Bronchiectasis

- ACTB: helps patient emphasize independence in secretion clearance and thoracic expansion

- Controlled breathing techniques coordinated with activity

- Pursed lips and diaphragmatic breathing techniques

- Inspiratory muscle training to improve strength and endurance of accessory muscles

Functional Interventions for Bronchiectasis

- (Functional and breathing intervention paired) Sit to stands focused on LEs pushing through the floor to rise (minimizing use of thorax flexing forward) and pairing breathing with it (inspiration facilitated through extension, expiration through flexion)

- Postural drainage & percussion

- Endurance exercises - walking on treadmill coordinating breathing while exercising

Chronic Bronchitis

A long-term inflammation of the bronchi that leads to persistent cough and mucus production

What is this diagnosis?

- Presence of chronic productive cough for 3 months in each of 2

successive years

- Hypersecretion of mucus

- Shortness of breath, coughing, dyspnea, excess of bodily fluid

- CYANOSIS (late sign)...think blue bloaters

Chronic Bronchitis

Physical Exam Findings for Chronic Bronchitis

- Auscultation of lungs shows prolonged expiratory phase

- Patient may assume tripoding position

- Chest x-ray changes noted in late disease progression

- Wheezing

Objective for Chronic Bronchitis

- FEV1/FVC < 70%

- Sputum analysis

- Arterial blood gas determination (continue to monitor for signs of respiratory acidosis)

- Spirometry

- Oximeters: measurement of O2 saturation in blood

- Exercise testing for functional deficits (6 min walk, etc)

Interventions for Chronic Bronchitis

-Secretion clearance techniques

- Controlled breathing techniques (pursed lips and paced breathing) at rest

- Controlled breathing techniques and breathing retraining coordinated with position changes,

ambulation, and stair climbing

- Ambulation with rolling walker

- Instruction in the use of recovery from shortness of breath positions

- Self-management

- Endurance exercise training

- Optimal use of oxygen with activity

- Strength and weight training

- Thoracic stretching exercises

- Postural reeducation to avoid round-shouldered postures

Congestive Heart Failure

A complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood.

What is this diagnosis?

Sinus tachycardia

quick shallow breaths (dyspnea)

peripheral edema

jugular vein distension

decreased exercise tolerance

decreased quality of life

paroxysmal nocturnal dyspnea and orthopnea

crackles/rales

cold/cyanotic extremities

fluid retention

Congestive Heart Failure

Subjective for Congestive Heart Failure

- sudden SOB upon waking from sleep

- feels better when they sit up

- prefer to sleep with pillows/HOB propped up or in chair

- swelling in legs and ankles

- decreased exercise tolerance

- weight loss/gain

- GI distress, abdominal swelling

- cough with frothy sputum

Objective of Congestive Heart Failure

- Chest x-ray: cardiac silhouette, fluid in lungs

- Cold/Cyanotic extremities

- S3 Heart Sounds - Hallmark Sign

- Auscultation (rales/crackles during inspiration)

- SPO2

- BP

- Palpation

- Swelling in feet and ankles

- Abdominal ascites

- Ventilatory muscle weakness/limited diaphragmatic descent

tests and measures for CHF

- EF < 30%

- ECG

- Blood gas levels

- Auscultation

- 6 minute walk test

- Questionnaires

- Physical appearance

- Respiratory rate (increased)

- Breathing problems

Strength Training Interventions for CHF

- 10 repetitions for 2-4 months or 60-80% of max voluntary contraction

- Progress slowly with weight training

- Exercises:

Sit to stands

Standing/seated marches

UE ADL training (can utilize resistance bands)

- Unilateral exercises may be better than 2-legged exercises

Aerobic Interventions for CHF

- walking plans

- Work on increasing endurance

- Add breaks as needed

- Use RPE

Breathing Exercises for CHF

Inspiratory muscle training using incentive muscle spirometer

Emphysema

condition of the lung characterized by destruction of alveolar walls and enlargement of airspaces distal to terminal bronchioles.

What diagnosis is this?

- FEV1/FVC <70%

- No secretion production

- Often has acute exacerbations of symptoms, but is not cyclical or seasonal in

nature

- Could have pelvic floor dysfunction or urinary incontinence

- Increased anxiety

- Shortness of breath

- Compensation with respiratory muscles

- Barreled chest

- Productive cough

Emphysema

Subjective for Emphysema

- Older

- Environmental causes

History of smoking (most common cause)

Prolonged exposure to airborne irritants, such as chemicals, vapors, and

dusts (another common cause)

- Genetic/ Family History of Emphysema

- Dry, non-productive cough

- Fatigue

- Shortness of breath (especially upon exertion)

Objective for Emphysema

- Wheezes during expiration upon auscultation

- Increased residual volume

- Prolonged expiratory phase

- Forced expiration instead of passive

- Observation of compensations for breathing (i.e. tripod position, accessory

muscle use)

- X-ray changes seen later in disease progression

Possible tests for emphysema

palpation of upper lobe motion and right, middle, and left lingula

lobe motion, palpation of lower lobe motion, palpation of activity of scalene

muscles, palpation of diaphragmatic motion

Measures for emphysema

- Incentive spirometry

- FVC/ FEV1 below 70%

- PaO2 and PaCO2 values

- pH and PaO2 will decrease, PaCO2 will increase, this will result in respiratory acidosis

- O2 sat = usually between 88%-92%

Interventions for Emphysema

- active cycle of breathing

- therapeutic positioning techniques and ventilatory movement to facilitate expiration

- pursed-lip breathing

- paced breathing

- diaphragmatic controlled breathing

- positions for dyspnea relief

- walking

- posture

- thoracic stretching and mobilization

Idiopathic Pulmonary Fibrosis

Chronic, progressive, irreversible, and usually lethal interstitial lung disease

What is the diagnosis?

- Affects older adults; unknown cause

- Environmental factors - cigarette smoking; metal and wood dust

- Cough, nocturnal cough, hypoexemia

- Several comorbid conditions: obesity, diabetes, GERD, pulmonary HTN, OSA, CAD, &

emphysema

- Recent decline in forced vital capacity

- Reoccurrence is common, often fatal

Idiopathic Pulmonary Fibrosis

Subjective of Idiopathic Pulmonary Fibrosis

Shortness of breath

Dry cough

Fatigue

Unable to catch their breath

Feeling limited in ADLs

Unintentional weight loss

Finger clubbing

Objective for Idiopathic Pulmonary Fibrosis

- AQ-IPF Questionnaire

- Auscultation- bibasilar inspiratory crackles are heard on chest

- FEV1/FVC >70% (will look normal)

- Finger clubbing (not enough O2 to periphery)

- Pain Rating

- Chest wall mobility assessments

- Assess breathing: chest, diaphragmatic, shoulder

- St. George's Respiratory Questionnaire: provide valuable information about a patient's

perceived symptoms and quality of life.

Tests / Measures of Idiopathic Pulmonary Fibrosis

- Spirometry

- 6-min walk test: assesses exercise capacity

- Vitals

Interventions for Idiopathic Pulmonary Fibrosis

- Inspiratory Muscle Training

o 2 sets of 30 breaths (example)

- Pursed Lip Breathing/Diaphragmatic Breathing

- Mechanical ventilation (AIRVO)

- Aerobic training (walking, biking)

- Resistance training

- Flexibility training

- Nutrition education

- Psychological coping mechanisms

- Medication management education

Pneumonia

- Restrictive lung disease

- Inflammatory process of the lung parenchyma

- Begins with an infection in the lower respiratory tract

- Caused by causative agents: Bacteria, viruses, fungi, etc

What is the diagnosis?

- High Fever

- Cough with yellow or green mucus

- Fatigue

- Rapid breathing/HR

- SOB

- Bluish skin, lips, or nails

- Nausea, vomiting or diarrhea

- Sweating

- Shaking/chills

65 years and older:

- Confusion or changes in mental awareness

- Lower than normal body temperature

Pneumonia

Subjective for Pneumonia

- Patient will describe feeling SOB and rapid, shallow breathing (hard to breathe in)

- Had a recent hospitalization

- Smokes frequently

- Weakened immune system from other chronic conditions

- Feels tired/fatigued

- Not able to sleep

- Constantly coughing and has mucus they are coughing up

- Not physically active prior to getting sick

- Had a fever

- Loss of appetite/not eating much

- Stays in bed most of the day

- I have difficulty walking around the house or performing activities at home

Objective for Pneumonia

Vital Signs:

- Tachypnea (RR > 20 breaths per minute)

- Tachycardia (Pulse Rate > 100 beats per minute)

- Fever (> 100.4 F/38 C or greater)

Respiratory Status:

- Palpation: increased tactile fremitus and chest expansion decreased on involved

side

- Percussion: dullness over the affected area

- Auscultation: decreased breath sounds or rales, crackles, rhonchi, or wheezes

Sputum Characteristics:

- Bacterial Pneumonia: purulent or blood-tinged sputum

- Viral Pneumonia: mucopurulent sputum Use of accessory muscles for breathing, indicating respiratory distress

Interventions for Pneumonia

Breathing techniques: focus is efficiency with breath

- Paired breathing!

- Diaphragmatic breathing

- Incentive spirometer

- Airway clearance techniques (can be done in conjunction with postural drainage)

Clearance Techniques: Postural drainage, percussion, vibration

Positioning: Trendelenburg position

Functional Activities for Pneumonia

- Transfer Supine to EOB

- Timed Standing while maintaining good vitals

- Walk to the bathroom and back

Pulmonary Edema

- Increase in amount of fluid within the lung

- Cardiogenic PE is an increase in the pulmonary capillary hydrostatic pressure, often

secondary to left ventricular failure

- Noncardiogenic PE has many causes including increased capillary permeability and

lymphatic insufficiency

- Adequate treatment of fluid buildup is critical

- Treatment is aimed at decreasing cardiac preload and maintaining oxygenation of the

tissues

What is the diagnosis?

- Crackles/Rales heard at lung base

- Productive Cough (often pink or blood

tinged frothy sputum)

- Dyspnea

- Abdominal Ascites

- Paroxysmal Nocturnal Dyspnea

- Tachypnea

- Cyanosis

Pulmonary Edema

Subjective for Pulmonary Edema

- Shortness of breath

- Feeling like you're "drowning"

- Anxiety

- Chest tightness

- Coughing up blood/mucus

- Difficulty breathing when lying down

- Sense of panic or impending doom

Objective assessments for pulmonary edema

- Auscultation, listen for abnormal lung sounds (wheeze, rasp, crackles, rales)

- Auscultation, listen to the heart

What will patients with pulmonary edema have difficulties with?

- Shortness of breath

- Impaired Gas Exchange

- Reduced Cardiac Function

- Increased Risk of Infection

- Increased Risk of Complications including Acute Respiratory Failure/Organ Dysfunction

- Prolonged Hospitalization

- Activity intolerance

- Fall risk

Interventions for Pulmonary Edema

- Postural Drainage with Percussion

- Diaphragmatic or Pursed Lipped breathing, general deep breathing exercises

- Active Cycle of Breathing

- Functional: low-impact exercises such as walking or sit to stands. Can incorporate

breathing techniques into exercises (inhale during eccentric, exhale during exertion).

Pulmonary Effusion

- restrictive lung condition

- abnormal amount of fluid within the pleural space

Pulmonary Function Test results with pulmonary effusion

decreased lung volumes: TLC, VC, and FRC

S&S of Pulmonary Effusion

- Dyspnea and pleuritic chest pain

- Diminished breath sounds over affected area

- Decreased chest wall movement on affected side

- Possible tracheal deviation (if large effusion)

Subjective of Pulmonary Effusion

- Progressive shortness of breath

- Pleuritic chest pain, worse with deep breathing

- Cough (nonproductive)

- Acute Onset

Objective of Pulmonary Effusion

- Dullness to percussion

- Decreased breath sounds

- Decreased fremitus

(vibrations when speaking)

- Localized fluid

- Tests: Chest X-ray - Blunted

costophrenic angles, fluidvisible; Ultrasound - Detects fluid and guides thoracentesis; Thoracentesis - Diagnostic fluid analysis (transudate vs. exudate)

Interventions for Pulmonary Effusion

- Thoracentesis for relief

- Treat underlying cause (e.g., infection, CHF, malignancy)

- Oxygen therapy

- Diaphragmatic breathing

- Postural Drainage

- Thoracic Mobilization techniques

- Spirometer exercises