CardioPulm Lab - Pulmonary Interventions

position for postural drainage for right upper lobe posterior segment

bed flat, 1/4 from prone on left side, head and shoulders on pillow

what types of patients would benefit from airway clearance techniques?

patients with COPD, cystic fibrosis, post-surgery, bronchiectasis

how do you determine what lung segments need to be posturally drained?

during auscultation you heard sounds that felt like there was some build up

segments of right upper lobe

apical, anterior, posterior

segments of right lower lobe

superior, anterior basal, posterior basal, lateral basal

segments of left upper lobe

apical, anterior, posterior

segments of left lower lobe

superior, anterior basal, posterior basal, lateral basal

precautions for postural drainage

pulmonary edema, hemoptysis, massive obesity, large pleural effusion, massive ascites

postural drainage contraindications (positions are contraindications for:)

intracranial pressure >20mmHg, head and neck injury until stabilized, active hemorrhage with hemodynamic instability, recent spinal surgery, acute spinal injury, empyema, bronchopleural fistula, pulmonary embolism, confused or anxious patients who don't tolerate position changes, rib fracture, surgical wound or healing tissue, recent eye surgery

trendelenburg position contraindicated for

uncontrolled HTN, distended abdomen, esophageal surgery, recent gross hemoptysis related to lung carcinoma treated surgically or radiation therapy, uncontrolled airway at risk for aspiration

position for postural drainage for right and left anterior apical segments

patient seated and leaning back at 30-40 degree angle

position for postural drainage for right and left posterior apical segments

patient seated and leaning forward over folded pillow of knees at 30-40˚

position for postural drainage for left upper lobe posterior segment

HOB elevated to 45˚, 1/4 from prone on the right side, head and shoulders raised on pillow

position for postural drainage for right and left upper lobes anterior segments

supine, patient horizontal with pillow under knees

position for postural drainage for left lingula

foot of bed elevated 12 inches, 1/4 from supine on the right side

position for postural drainage for right middle lobe

foot of bed elevated 12 inches, 1/4 from supine on left side

position for postural drainage for left and right lower lobes superior segments

prone, bed horizontal, cupping at scapular inferior angle

position for postural drainage for right and left lower lobes anterior basal segments

supine, foot of bed elevated 18 inches

percussion

rhythmic clapping or striking of the thorax with a cupped hand or mechanical percussor direvtly over the lung segment being drained

vibration

the application of a fine, tremulous action on the chest wall over the lung segment being drained in the direction the ribs move during exhalation

when should vibration be performed?

during exhalation

precautions for percussion and vibration

uncontrolled bronchospasm, osteoporosis, rib fractures, metastatic cancer to the ribs, tumor obstruction of airway, anxiety, coagulopathy, convulsive or seizure disorder, reent pacemaker present

relative contraindications to percussion and vibration

hemoptysis, untreated tension pneumothorax, platelet count below 20,000 per mm3, unstable hemodynamic status, open wounds, burns in thoracic area, pulmonary embolism, subcutaneous emphysema, recent skin grafts or flaps on thorax

purpose of instructing patients on directed cough

trying to compensate for the patient's physical limitations to elicit a maximum forced exhalation

what type of patients would you instruct to perform a dirercted cough?

those who need to brace their abdomen, those who need to intentionally cough post-op

when would you perform an assisted cough?

when a patient's abdominal muscles cannot generate an effective cough (spinal cord injury)

when would you perform tracheal stimulation?

with patient who are unable to cough on command (infants, patients with brain injury or stroke)

why would you encourage patient to perform autogenic drainage?

to improve airflow in small airways to facilitate the movement of mucus without using postural drainage positions or coughing

phases of autogenic drainage

Unsticking phase, Collecting phase, Evacuation phase

good starting position for assisted diaphragmatic breathing

semi-fowler's position, but you will want to progress to upright sitting, stanidng, walking, and stair climbing

how can you re-educate the diaphragm?

initiating a quick stretch of the diaphragm before patient inhales to elicit stretch reflex of the diaphragm

paced breathing

strategy to decrease the work of breathing and prevent dyspnea during activity. allows anyone who has SOB to become less fearful of activity and exercise

pursed lip breathing

inhale slowly through nose for a 2 count, purse lips as you would whistle and slowly exhale while keeping your lips pursed for a 4 count

segmental breathing

facilitate inhalation by applying pressure during inhalation which improves ventilation to hypoventilated lung segments. increase to firm pressure just prior to inspiration. ask pt to breathe against resistance of PT's hands, reducing pressure to allow for full inhalation

how can patients be independent with segmental breathing?

have them use a towel to add self resistance to lateral and apical segments

what patients would benefit from inspiratory muscle training?

COPD, heart failure, acute spinal cord injury, Guillain-Barre syndrome, ALS, MS, muscular dystrophy, myasthenia gravis, ankylosing spondylitis, stable systolic heart failure, patients weaning from mechanical ventilator

precautions/contraindications for inspiratory muscle training

clinical signs of inspiratory muscle fatigue: tachypnea, reduced tidal volume, increased PaCO2, bradypnea an decreased minute ventilation

positive expiratory pressure (PEP devices)

external device that vibrates the airways on exhalation to improve airway clearance with intermittent positive expiratory pressure

what is the purpose of performing secretion clearing techniques?

to move the secretions from the periphery to the center for removal

purpose of postural drainage

positioning the patient in a way so gravity will help drain bronchial secretions from the specific lung segments toward the central airways so they can be removed by cough or mechanical aspiration

techniques for postural drainage?

2-3 minutes of percussion (tapopment) followed by 2-3 minutes of vibration every inspiration followed by coughing

position for postural drainage for right and left lower lobes posterior basal segments

prone, foot of bed elevated 18 inches

position for postural drainage for right and left lower lobes lateral basal segments

sidelying with affected side up, foot of bed elevated 18 inches

exhale with effort

breathing strategy employed during activity to prevent a patient from holding their breath

high frequency chest wall oscillation (HFCWO)

patient wears a vest that fills with air and then rapidly increases/decreases pressure. the pressure oscillation loosens secretions in the airway