Common Acute Pulmonary Conditions

For every condition you should ask:

1. What is the problem?

2. What happens to lung function?

3. What would I expect on IPPA?

4. What might I see on CXR?

5. What can PT do?

Lung Function

Refers to how well the lungs can:

• Move air: (ventilation) bring in O₂ and remove CO₂

• Expand: lung volumes (less) and compliance (decreased)

• Exchange gases: oxygen into blood, carbon dioxide out

• V/Q matching: match ventilation and perfusion

What is the end goal we are concerned with?

Maintain adequate oxygenation and ventilation to meet the body’s metabolic needs

What the lungs are doing physiologically

Lung function

Assessment findings

How we observe and measure that function (tactile fremitus, SOB, increased breathing)

What can we ask that will help us understand many acute respiratory disorders?

What is preventing oxygen from getting into the blood?

Problems preventing oxygen from getting into the blood

Collapse, fluid/cells in the alveoli, or something in the pleural space

Example of collapse

Atelectasis (collapsed alveoli)

Example of fluid/cells in the alveoli

Pneumonia (fluid filled cells)

Examples of something in the pleural space

Pleural effusion (fluid), pneumothorax (air), or hemothorax (blood)

What may be involved during atelectasis?

Lung segment, lung lobe, or the entire lung

Atelectasis

Collapse of alveoli

In atelectasis, what is preventing the oxygen from getting into the blood?

Collapsed alveoli not receiving air

What are common causes of atelectasis?

Obstruction, shallow breathing, or compression

Atelectasis (caused by obstruction)

Air can’t reach alveoli → trapped air is absorbed into the blood →alveoli lose volume and collapse → atelectasis

Example of atelectasis caused by obstruction

Mucus plug (although, can exchange gas until they run out of fresh air)

Atelectasis (caused by shallow breathing)

Alveoli aren’t fully expanded →alveolar volume decreases →alveoli can collapse →atelectasis

Examples of atelectasis caused by shallow breathing

Pain, sedation, post-op, drug overdose

Atelectasis (caused by compression)

Alveoli are squeezed closed → air is displaced →alveoli lose volume and collapse → atelectasis

Examples of atelectasis caused by compression

Pleural effusion, mass, prolonged positioning during surgery, prolonged positioning in general

Why do PTs care about atelectasis?

It is very common in acute care, especially post operatively (~90%). Contributing factors:

• general anesthesia and mechanical ventilation

• prolonged supine positioning

• pain

• shallow breathing

• reduced mobility/immobility

• secretions or obstructions

How does atelectasis affect lung function?

It decreases lung volumes, compliance, and gas exchange. It can reduce ventilation in affected areas, which worsen V/Q matching (blood may flow past collapsed or poorly ventilated alveoli). If obstruction or secretions contribute to the collapse, air way resistance may increase.

For inspection, what might we see with atelectasis?

Tachypnea, accessory muscle use, increased WOB (because there is a reduced ventilated lung volume and increased respiratory effort)

For palpation, what might we see with atelectasis?

Decreased chest wall expansion over affected area, possible tracheal shift toward (more common with significant collapse), these occur because with volume loss there is less expansion and if significant volume loss it may pull the trachea towards the affected side

For percussion, what might we see with atelectasis?

Dull sound over the affected area (because there is less air in the collapsed region, there is increased tissue density)

For auscultation, what might we hear with atelectasis?

Decreased or absent breath sounds with FIC over affected area (because decreased airflow causes diminished/absent sounds; collapsed small airways/alveoli may reopen during inspiration →FIC)

How might atelectasis present on a CXR?

• Opacity: white area that indicates increased density

• elevated hemidiaphragm if large

• volume loss

  • which can result in a shift towards the affected side (if larger volume loss)

Medical management of atelectasis

• treat cause: obstruction, pain, compression, hypoventilation

• oxygen if hypoxemic

• suction if secretions or plugging are present

• bronchodilators if airway narrowing is present

• pain control to support breathing

How can PTs manage atelectasis?

• positioning

• deep breathing with/without SMI

• mobilization

• splinted cough

• airway clearance if secretions are present

• education

Mobilization

Increases respiratory rate and depth of breathing (Vt) →increases ventilation and lung expansion →helps recruit under-expanded alveoli and mobilize secretions (if present and contributing to atelectasis)

Sustained Maximal Inspiration

SMI

Deep Breathing

Deep inspiration →increases transpulmonary pressure →expands/recruits collapsed or under-expanded alveoli →increases lung volume and improves ventilation

SMI

A brief inspiratory hold is important because it gives air time to reach slow-filling or poorly ventilated alveoli via collateral ventilation (not used under normal tidal volume breathing), helping alveolar recruitment

What is the problem occurring with pneumonia?

Acute inflammation of the lung that usually affects the alveoli or bronchioles

What are some of the more common causes of pneumonia?

Bacterial, viral, aspiration, fungal, and chemical

Community Acquired Pneumonia (CAP)

Starts outside the hospital, the most common type

Hospital Acquired Pneumonia (HAP)

Starts more than 48 hours after admission (did not come there with pneumonia), they are medically harder to treat as they are more resistant organisms

Aspiration Pneumonia

Common in RML, inhaled oral/gastric contents, swallowing or neuro risk

Ventilator Acquired Pneumonia (VAP)

Tubing bypasses normal defenses of the lung (HAP in intubated patients), linked to ventilation

Opportunistic Pneumonia

In immunocompromised patients (unusual/fungal/viral organisms)

In pneumonia what is preventing oxygen from getting into the blood?

Inflammation causes protein-rich fluid and inflammatory cells (instead of air) to leak into and fill the alveoli, causing consolidation

Exudate

Protein-rich inflammatory fluid and cells that accumulate in the alveoli

Consolidation

In pneumonia occurs when alveoli are filled with inflammatory exudate (fluid proteins and inflammatory cells), the alveoli remain expanded but are no longer air-filled

What is the difference between consolidation and atelectasis?

Alveoli are filled versus alveoli are collapsed

How does pneumonia affect lung function?

Compliance and gas exchange will be decreased, airway resistance may increase if airways are inflamed or secretions are present (not present in all types of pneumonia), ventilation may be reduced in affected areas, V/Q matching worsens (blood flows past poorly ventilated alveoli), and lung volumes often maintained early (may decrease with shallow breathing or pain)

In pneumonia, why are lung volumes often maintained early?

The lungs are still filled, it is just that they are filled with fluid instead of air

For inspection, what might we see with pneumonia?

Tachypnea, accessory muscle use, and increased WOB (due to impaired gas exchange and increased effort)

For palpation, what might we see with pneumonia?

Decreased chest expansion over the affected areas (reduced movement), increased tactile/vocal fremitus over the affected areas (consolidation=increased density), rhonchal fremitus (if large airway secretion in large airways)

For percussion, what might we see with pneumonia?

Dullness over the affected area (consolidation replacing air=increased density)

For auscultation, what might we see with pneumonia?

Bronchial breath sounds over the affected area (consolidated lungs=increased density), fine inspiratory crackles (small airways reopen during inspiration often due to fluid/exudate or shallow breathing), coarse crackles (large airway secretions), or wheeze (airway narrowing due to inflammation or secretions)

How might pneumonia present on a CXR?

Opacity (what we see), consolidation is not what we would call it but moreso a possible interpretation based on clinical findings

Air Bronchograms

Air filled bronchi visible through consolidated lung (within an opacity)

What are the key characteristics of consolidation?

Alveoli are filled with fluid/pus/cells=exudate, lung volume is usually maintained, often seen with pneumonia (CXR=opacity without major volume loss)

What are the key characteristics of atelectasis?

Alveoli are collapsed, lung volume is lost, often seen with post-op or with obstruction/compression (CXR=opacity with volume loss)

How do secretions differ from consolidation?

Secretions: located in the airways, caused by accumulation/retention of airway secretions, auscultate: hear coarse crackles/wheeze

Consolidation: located in the alveoli, caused by alveoli filled with inflammatory exudate/fluid, auscultate: hear bronchial breath sounds

What can be cleared using PT techniques?

Secretions, NOT consolidation (this resolves as the underlying diseased is treated)

Pleural Space Disorders

Occur when air, fluid, or blood accumulates in the pleural space (NOT IN THE LUNG), this disrupts normal pleural mechanics and can compress or separate the lung from the chest wall, limiting lung expansion

What is pleural effusion?

Fluid in the pleural space

What is pneumothorax?

Air in the pleural space

What is hemothorax?

Blood in the pleural space

In pleural space disorders, what is preventing oxygen from getting into the blood?

The lung cannot fully expand because air, fluid, or blood is in the pleural space

What is the problem when looking at pleural effusion?

Abnormal fluid in the pleural space, fluid outside the lung compresses lung tissue and limits expansion

What are the common causes of pleural effusion?

Heart failure, pneumonia, malignancy (due to cancer), and inflammation/infection

Transudative Pleural Effusion

Mostly fluid; low protein, few cells →systematic pressure/fluid problem (ex. heart failure)

Exudative Pleural Effusion

Fluid and lots of protein and inflammatory cells →ex inflammation/infection/malignancy

Memory tip for exudate

EXtra stuff (proteins and cells)

How does pleural effusion affect lung function?

Ventilation is reduced in affected region (compressed lung receives less air), lung volume(fluid limits expansion and may cause compression atelectasis) and compliance(lung/chest is harder to expand) is decreased, gas exchange (may decrease if less lung is ventilated), V/Q matching worsens (blood may flow past compressed or poorly ventilated lung

For inspection, what might we see with pleural effusion?

Tachypnea, increased WOB, (reduced expansion and impaired oxygenation),may prefer to sit upright/semi fowler

For palpation, what might we see with pleural effusion?

Decreased expansion, decreased tactile/vocal fremitus over effected area (we are not in the lung blocks transmission from lungs through pleura), fluid in pleural space dampens vibration transmission

For percussion, what might we see with pleural effusion?

Dullness over affected area (fluid replaces air in the pleural space)

For auscultation, what might we see with pleural effusion?

decreased or absent breath sounds over fluid; possible FIC above fluid level (less air entry; compressed alveoli may reopen above fluid)

What may be seen in CXR when someone has pleural effusion? (in upright)

Opacity at lung base, blunted costophrenic angles, meniscus sign (gravity pulls the fluid to curve to the center)

How may pleural effusion present in a CXR of someone who is supine?

Pleural fluid spreads behind the lung, so there may be no clear opacity or meniscus; instead, the lung may look “diffusely hazy”

Medical management of pleural effusion

Monitor if small/asymptomatic, treat underlying cause, oxygen if hypoxemic, and thoracentesis or chest tube if large/symptomatic

PT management of pleural effusion

Positioning for comfort and oxygenation, deep breathing→ increases lung expansion → helps recruit/expand compressed alveoli and improve ventilation in the affected lung (important it does not remove the pleural fluid itself), mobility, and splinted cough (if pleuritic pain, the parietal pleura is pain sensitive)

What position might be best for patient comfort with a pleural effusion?

Upright; allows pleural fluid to settle at the base, promotes lung expansion, and often improves breathing comfort (it is difficult and painful to lie supine)

Which position might be best for oxygenation with pleural effusion?

Effusion side UP and good lung DOWN, perfusion increases to the dependent good lung, the good lung is also better ventilated than the compressed effusion side, promotes better V/Q matching and oxygenation

What do we do to reassess the patient’s response to positioning?

SpO2, RR, WOB, and comfort

What is the problem in a pneumothorax?

There is air in the pleural space, that disrupts the negative pressure that normally helps keep the lung expanded (as a result the lung partially or completely collapses)

Why do pneumothorax occur?

Spontaneous (occurs without trauma), traumatic (caused by chest injury), and iatrogenic (caused by a medical procedure)

What is the main difference between atelectasis and pneumothorax?

Alveoli lose volume and collapse, whereas air enters the pleural space resulting in a loss of negative pleural pressure and the lung then recoils or collapses

What causes pneumothorax?

Ruptured bleb, trauma, medical procedures

How does pneumothorax effect lung function?

Ventilation is reduced on the affected side (lung cannot fully expand), lung volumes (on the affected side) and compliance (collapsed lung is harder to expand) decrease, gas exchange may decrease because less lung is ventilated, and V/Q matching worsens (perfusion may continue to poorly ventilate lung)

For inspection, what might we see with pneumothorax?

Tachypnea, increased WOB, pleuritic pain (lung cannot fully expand; reduced ventilation and splinting if pain)

For palpation, what might we see with pneumothorax?

Decrease expansion on affected side, decreased tactile/vocal fremitus; possible tracheal shift away if large (air pressure limits expansion; air in pleural space separates lung from chest wall; increased pressure may push trachea away)

For percussion, what might we see with pneumothorax?

Hyperresonance (extra air in pleural space)

For auscultation, what might we see with pneumothorax?

Decreased/absent breath sounds (compressed/collapsed lung=decreased/no airy entry)

What might we see on a CXR for pneumothorax?

• increased blackness (air in the pleural space appears black)

• visible pleural line (thin white line marking the edge of collapsed lung)

• no lung markings beyond the pleural line (area contains pleural air, not inflated lung tissue)

• collapsed lung may appear smaller

• if the incidence is large: trachea/mediastinum may shift away from the affected side

What happens to the trachea in atelectasis vs pneumothorax (both being serve cases)?

Pulls it towards the affected side versus pushes it away from the affected side

Medical Management of Pneumothorax

Monitor if small/stable, oxygen if hypoxemic, needle decompression if unstable/tension pneumothorax, and chest tube if needed

As PTs, what can we do for pneumothorax?

Monitor symptoms (SpO2, RR, HR), position for comfort and oxygenation, mobility once medically stable, deep breathing if appropriate (especially with chest tube/medical clearance) and watch for sudden worsening (increased SOB, chest pain, desaturation, or distress)

Hemothorax

Blood in the pleural space, which can compress the lung, reduce ventilation and impair oxygenation

What is hemothorax often linked with?

Chest trauma, rib fractures, surgery/procedures, pneumothorax can lead to hemopneumothorax

Clinical findings may look similar to what?

Pleural effusion since they both share decreased expansion, dull percussion, decreased/absent breath sounds, and opacity on CXR

What is the medical management for hemothorax?

Often chest tube drainage

Why do we use chest tubes?

They remove air, blood, or fluid from the pleural space

What are chest tubes used for?

Pneumothorax, pleural effusion, hemothorax, and post-thoracic surgery or trauma

PT question for patients with a chest tube?

Can the patient breathe, cough, reposition, and mobilize safely?

Chest tube basics for PT

• enters the chest wall into the pleural space

• they enter around the 4th-5th intercostal space on the lateral chest wall

• connects to a drainage system

• allows air, fluid, or blood to leave the pleural space

Parts of the drainage system

Collection chamber, water seal chamber, air leak monitor, and suction control