Pulmonary System Review for Physical Therapist Assistants

Course Objectives and PTA Role in Pulmonary Management

• Management of Chronic Pulmonary Dysfunction: The Physical Therapist Assistant (PTA) must describe their role in managing patients with chronic conditions.

• Secretion Removal: Identify and explain the underlying principles of techniques used for secretion removal in pulmonary patients.

• Manual Techniques: Demonstrate competency in performing postural drainage and percussion.

• Exercises: Demonstrate competency in specific breathing and coughing exercises.

• Assessment and Analysis:

  • Analyze rib cage excursion.

  • Analyze breathing patterns.

  • Analyze cough and sputum characteristics.

• Monitoring: Recognize and monitor activities or position changes that affect vital signs, edema, dyspnea, pain, sensation, and integumentary integrity.

• Respiratory Distress: Detect signs and symptoms ($S\&S$) of respiratory distress.

• Clinical Execution: Competently assess and execute breathing exercises, coughing techniques, and secretion mobilization for patients with pulmonary disease according to laboratory rubrics and mock scenarios.

Anatomy and Physiology of the Respiratory System

• Thorax Components:

  • Sternum.

  • Ribs.

  • Thoracic Vertebrae.

• Upper Respiratory Tract (URT):

  • Nasal cavity.

  • Pharynx (divided into Nasopharynx, Oropharynx, and Laryngopharynx).

  • Larynx.

• Lower Respiratory Tract (LRT):

  • Extends from the Larynx down to the Alveoli.

  • Trachea.

• Lung Lobes and Segments:

  • Right Lung: Three lobes (superior, middle, lower).

  • Left Lung: Two lobes (upper, lower), including the lingula.

• Bronchopulmonary Segments:

  • Total of $10$ segments.

  • Right Main Bronchus branches into superior, middle, and inferior lobar bronchi.

  • Left Main Bronchus branches into superior and inferior lobar bronchi.

• Alveolar-Capillary Units: The site of gas exchange.

• Pleurae: Serous membranes surrounding the lungs.

Muscles of Respiration

• Inspiration:

  • Primary Muscles: Diaphragm and intercostals. The diaphragm flattens while intercostals elevate the ribs. Upper ribs increase the Anteroposterior ($AP$) diameter; lower ribs increase the transverse diameter of the chest.

  • Accessory Muscles: Sternocleidomastoid ($SCM$), scalenes, pectoralis major (sternal fibers), pectoralis minor, and serratus anterior.

• Expiration:

  • Quiet Breathing: Largely passive; involves the diaphragm, intercostals, and potentially the scalenes.

  • Forced Breathing: Rectus abdominis, external obliques, internal obliques, transverse abdominis, and potentially the quadratus lumborum.

Lung Volumes and Capacities

• Anatomic Dead Space Volume ($V_D$): The volume of air occupying non-respiratory conducting airways.

• Expiratory Reserve Volume ($ERV$): Maximal volume of air exhaled after normal tidal exhalation. Comprises approximately $15\%$ of total lung volume.

• Forced Expiratory Volume ($FEV$): Maximal volume exhaled in a specific period (usually $1$, $2$, or $3$ seconds) during a forced vital capacity maneuver.

• Forced Vital Capacity ($FVC$): Volume of air expired during forced maximal expiration after forced maximal inspiration.

• Functional Residual Capacity ($FRC$): Volume of air remaining in lungs after normal exhalation ($FRC = ERV + RV$). Comprises approximately $40\%$ of total lung volume.

• Inspiratory Capacity ($IC$): Maximal volume of air inspired after normal tidal exhalation ($IC = TV + IRV$). Comprises approximately $60\%$ of total lung volume.

• Inspiratory Reserve Volume ($IRV$): Maximal volume of air inspired after normal tidal volume inspiration. Comprises approximately $50\%$ of total lung volume.

• Minute Volume Ventilation ($V_E$): Volume of air expired in one minute ($V_E = TV \times \text{Respiratory Rate}$).

• Peak Expiratory Flow ($PEF$): Maximum flow of air at the start of a forced expiratory maneuver.

• Residual Volume ($RV$): Volume of gas remaining in lungs at the end of maximal expiration. Comprises approximately $25\%$ of total lung volume.

• Tidal Volume ($TV$): Total volume inspired/expired with each breath during quiet breathing. Comprises approximately $10\%$ of total lung volume.

• Total Lung Capacity ($TLC$): Volume of air in lungs after maximal inspiration; the sum of all volumes ($TLC = RV + VC$ or $TLC = FRC + IC$).

• Vital Capacity ($VC$): Volume change occurring between maximal inspiration and maximal expiration ($VC = TV + IRV + ERV$). Comprises approximately $75\%$ of total lung volume.

Pulmonary Changes and Aging

• Normal Pulmonary Age-Related Decreases:

  • Vital capacity and Tidal volume.

  • Respiratory muscle strength.

  • Number of cilia.

  • Lung expansion and elastic recoil.

  • Alveolar surface area and vascularity.

  • Maintained expansion of alveoli after expiration.

• Normal Pulmonary Age-Related Increases:

  • Stiffness of the chest wall.

  • Number of mucus-producing cells.

  • Residual volume (increased by $30-50\%$).

  • Functional residual capacity.

  • Respiratory rate.

• Clinical Implications of Aging:

  • Work of respiratory muscles can increase by up to $20\%$.

  • Ventilation/perfusion mismatch.

  • Decreased cough strength/force.

  • Increased risk of respiratory infections and shortness of breath ($SOB$).

  • Comorbidities such as Kyphoscoliosis.

Pulmonary Red Flags and Breathing Patterns

• Red Flags (May mimic musculoskeletal dysfunction):

  • Pneumonia, Pulmonary Embolism ($PE$), Pleurisy, Pneumothorax, Pulmonary arterial hypertension.

• Signs & Symptoms ($S\&S$): Cough, dyspnea, abnormal sputum, hemoptysis, cyanosis, digital clubbing, and altered breathing patterns.

• Chest Pain Types: Tracheobronchial, Pleural, Diaphragmatic.

• Specific Breathing Patterns and Associated Conditions:

  • Hyperventilation: Anxiety, acute head injury, hypoxemia, fever.

  • Kussmaul's: Strenuous exercise, metabolic acidosis.

  • Cheyne-Stokes: CHF, renal failure, meningitis, drug overdose, increased ICP. Normal in infants and older adults during sleep.

  • Hypoventilation: Fibromyalgia, muscle weakness, malnutrition, neuromuscular diseases (Guillain-Barr\u00e9, Myasthenia Gravis, Polio, ALS), Pickwickian syndrome, severe kyphoscoliosis.

  • Apneustic: Midpons lesion, basilar artery infarct.

  • Biot's Respiration (Ataxia): Exercise, shock, cerebral hypoxia, heat stroke, spinal meningitis, head injury, brain abscess.

  • Muscle Fatigue: Chronic fatigue syndrome, sleep disorders, encephalitis.

  • Hyperpnea: Increased rate and depth.

  • Hypopnea: Decreased rate and depth.

Pathology of Airways and Lungs

• Asthma:

  • $S\&S$: Mild (wheezing, chest tightness, slight $SOB$); Severe (dyspnea, flaring nostrils, anxiety, cyanosis, respiratory failure).

  • Tx: Anti-inflammatories, bronchodilators, airway clearance, breathing exercises.

• Bronchitis:

  • $S\&S$: Persistent cough, thick sputum, increased accessory muscle use, wheezing, cyanosis.

  • PT Tx: Lifestyle changes (smoking cessation), airway clearance, endurance training.

• COPD:

  • $S\&S$: Excessive mucus, chronic productive cough, fatigue, decreased exercise capacity.

  • Tx: Bronchodilators, inhaled steroids, supplemental oxygen, pulmonary rehab.

• Cystic Fibrosis ($CF$):

  • $S\&S$: Salty tasting skin, frequent lung infections, poor growth, greasy/bulky stools.

  • PT Tx: Airway clearance, assisted cough, ventilatory muscle training.

• Emphysema:

  • $S\&S$: Barrel chest, orthopnea, increased respiratory rate ($RR$), fatigue.

  • Tx: Lung volume reduction surgery, bullectomy, transplantation.

• Pneumonia:

  • $S\&S$: Fever, cough, shaking chills, chest pain fluctuating with breathing, muscle pain.

  • PT Tx: Rest and fluid intake.

• Pulmonary Edema:

  • $S\&S$: Feeling of suffocating/drowning, frothy blood-tinged sputum, rapid pulse.

  • Acute Emergency: Call $911$ if extreme $SOB$, profuse sweating, bubbly sounds, or cyanosis occurs.

• Pulmonary Embolism ($PE$):

  • $S\&S$: Sudden $SOB$, chest pain with deep breathing, coughing up blood, LE swelling.

  • Tx: Anticoagulants, thrombolytics, IVC filter.

• Restrictive Lung Dysfunction ($RLD$):

  • $S\&S$: Dyspnea on exertion, non-productive cough, hypoxemia, decreased vital capacity.

  • Tx: Mechanical ventilation, nutritional support.

Pharmacological Management

• Antihistamines (e.g., Benadryl, Allegra, Claritin): PTA should watch for orthostatic hypotension when moving from sitting to standing.

• Anti-inflammatory Agents (e.g., Pulmicort, AeroBid): Used for long-term control, not acute asthma. Rinse mouth after use to avoid irritation. Monitor for liver dysfunction (jaundice, lethargy).

• Bronchodilators (e.g., Atrovent, Ventolin, Serevent): Take before therapy. Notify PT of cardiac or vision abnormalities (toxicity).

• Expectorants (e.g., Mucinex): Perform airway clearance within $1$ hour. Take with water.

• Mucolytics (e.g., Pulmozyme, Mucomyst): Perform airway clearance within $1$ hour. Delivered via nebulizer.

Respiratory Assessment and Auscultation

• Respiratory Rate ($RR$) Norms:

  • Newborns: $33-45$ brpm.

  • $1$ year: $25-35$ brpm.

  • $10$ years: $15-20$ brpm.

  • Adult: $12-20$ brpm.

• Rhythm:

  • Normal Inspiration:Expiration ($I:E$) ratio is $1:2$.

  • COPD $I:E$ ratio is $1:3$ or $1:4$.

• Auscultation Procedure: Place stethoscope on unclothed chest; patient breathes in through nose and out through mouth. Compare sides.

• Normal Sounds: Tracheal, bronchial, vesicular.

• Adventitious Sounds: Crackles (rales), pleural friction rub, rhonchi, stridor, wheeze.

Airway Clearance Techniques

• Indications: Retained secretions, prophylaxis for post-op complications, atelectasis from mucus plugging.

• Active Cycle of Breathing ($ACB$): Includes breathing control, thoracic expansion, and forced expiratory technique (huff cough). Use splinting for post-op patients.

• Autogenic Drainage ($AD$):

  • Unsticking Phase: Nose breathing at low volume.

  • Collecting Phase: Breathing at tidal volume.

  • Evacuating Phase: Deep breath followed by huff.

• Directed Cough and Huffing:

  • Cough: Inhale, close glottis, contract expiratory muscles against closed glottis, cough $2-3\times$ through open mouth.

  • Huff: Contract abdominal muscles with glottis open (saying "ha, ha, ha").

• Postural Drainage ($PD$): Position for $2-3$ minutes over lung segment. Perform percussion/vibration.

Postural Drainage Contraindications and Precautions

• Contraindications (All Positions):

  • ICP > 20\,mmHg.

  • Unstabilized head/neck injury.

  • Active hemorrhage or hemoptysis.

  • Recent spinal surgery/injury.

  • Pulmonary edema from CHF.

  • Rib fracture, PE, or large pleural effusion.

• Trendelenburg Contraindications: Uncontrolled HTN, distended abdomen, esophageal surgery, risk for aspiration.

• Precautions: Osteoporosis, rib osteomyelitis, lung contusion, recent skin grafts on thorax, burns, subcutaneous emphysema.

Sputum Analysis

• Mucoid (White/Gray): COPD, asthma.

• Purulent (Yellow/Green): Bacterial infection, pneumonia, CF, bronchiectasis.

• Brown/Black: Smoking, coal inhalation (black lung).

• Pink/Bloody: Pulmonary edema, PE, TB, cancer.

• Rust: Pneumococcal pneumonia.

• Fetid: Bacterial infections, lung abscess.

• Thick/Tenacious: Asthma, CF.

• Frothy: Pulmonary edema.

Breathing Exercises

• Diaphragmatic Breathing ($DB$):

  • Procedure: Semi-fowler's; sniff to facilitate; hand on belly should rise while chest remains still; exhale via pursed lips.

  • Expected: Decreased $RR$, increased tidal volume, improved dyspnea.

• Paced Breathing: Synchronize with activity components (inhale during easy part, exhale during vigorous part). Do not hold breath.

• Pursed-Lip Breathing ($PLB$):

  • Inhale for $2$ counts through nose; pucker lips and exhale for $4$ counts. Do not blow with force.

  • Prevents airway collapse in emphysema.

• Incentive Spirometry ($SMI$):

  • Hold vertical, exhale, seal lips, inhale slowly to raise ball. Hold breath for $3$ seconds. Perform $5-10$ breaths per hour.

Clinical Guidelines and Positions

• Positions to Relieve Dyspnea:

  • Forward Leaning with Arm Support: Optimizes diaphragm length.

  • Reverse Trendelenburg: Reduces weight of abdominal contents on the diaphragm.

  • Semi-Fowler's: Supine with head of bed at $45^{\circ}$; used for cardiac/CHF patients.

• Oxygen Therapy Indications: SaO_2 < 90\%, hypotension (systolic $< 100$), low cardiac output (HCO_3 < 18), or respiratory distress (RR > 44 brpm).

• Post-Thoracic Surgery Precautions:

  • Monitor vitals constantly.

  • Limit shoulder flexion to $90^{\circ}$ on operated side while chest tubes are present.

  • Logroll patient; no percussion over incision; use splinting during coughing.