Respiratory Therapy Exam Notes

Lung Expansion Therapy

• Indicated for conditions like pneumonia and atelectasis.

• Aims to expand lungs and clear secretions.

• Incentive spirometry is an initial step.

• Chest physiotherapy can loosen secretions.

• Postural drainage is another option.

• Assessment of lung sounds is important in determining the correct route.

Lung Sounds

• Atelectasis: Deflated alveoli.

  • Expect diminished breath sounds.

  • Possible crackles upon airway re-inflation.

• Stridor: Indicates upper airway edema.

• Wheezing: Associated with COPD, asthma, and narrowed airways, caused by inflammation.

• Crackles: Can be present in atelectasis due to lack of air movement.

• Diminished Breath Sounds: Associated with lack of air movement.

Atelectasis Assessment

• Expected Findings:

  • Diminished breath sounds.

  • Possible crackles during airway inflation.

  • Low oxygen saturation (SaO2) due to ventilation-perfusion mismatch.

  • Increased breath rate.

  • Dull sound upon chest percussion due to lack of air.

• Diagnostics:

  • Chest X-ray to confirm atelectasis.

Lung Expansion Therapy Interventions

• Incentive spirometry.

• Positive airway pressure (PAP).

• Continuous Positive Airway Pressure (CPAP) - not primary.

Incentive Spirometry

• Switch to other therapies if patient doesn't meet goals.

• Goal is proportional to patient's height and ideal body weight.

• Should be 10 mL per kilogram of ideal body weight.

Positive Airway Pressure (PAP)

• Consider if incentive spirometry fails.

• If PEP and PAP fail, and oxygen demand increases, consider IPPB (Intermittent Positive Pressure Breathing).

• IPPB is rarely used due to limited availability of the machine

Wheezing

• Causes:

  • Narrowed airways.

  • Bronchospasm.

  • Inflammation.

  • Secretions.

• Inflammatory Response:

  • Cytokine type two cells cause inflammation.

  • IgG and eosinophils increase.

• Muscle Contraction:

  • Involves eskinetic receptor.

Unilateral Wheezing

• Wheezing louder on one side than the other.

• Bilateral Wheezing:

  • Examples include COPD and asthma.

  • Involves systemic inflammation of lungs and airways.

• Unilateral Wheezing:

  • Caused by narrowing in one airway.

  • Foreign body aspiration (e.g., a child swallowing a penny).

  • Tumor growth.

Foreign Body Aspiration

• Can cause unilateral wheezing.

• May cause high heart rate and altered oxygen saturation.

• Louder wheeze indicates more air movement.

• Higher pitch indicates smaller opening.

• Complete obstruction leads to diminished breath sounds.

Unilateral Wheezing: Adult Causes

• Food aspiration due to dysphagia.

• Tumor growth.

Tumor-Related Wheezing

• Persistent coughing with unilateral wheezing is concerning.

• Robotic bronchoscopy may be used for diagnosis and treatment.

• Robotic bronchoscopy is capable of reaching smaller segments of the airways

Review of Respiratory Diseases

• Common conditions include atelectasis, pneumonia, COPD, and cystic fibrosis.

Intubation

• Not expected to be on the final lab assessment.

• Indication is severe respiratory acidosis.

• Hypoxia is treated with oxygen, not necessarily intubation.

Crackles

• Indicate fluid in the airways or collapsed alveoli.

• Types: fine, medium, and coarse.

Types of Crackles

• Fine Crackles:

  • Alveolar level.

  • Interstitial fluid or atelectasis.

  • Sound of alveoli popping open.

• Coarse Crackles (Rails):

  • Larger airways.

• Medium Crackles:

  • In between fine and coarse.

  • May require postural drainage and chest physiotherapy.

Airway Clearance Therapy

• Start with least invasive methods.

• Order:

  • Directed cough.

  • Acapella.

  • Suctioning (most invasive).

Role of Coughing

• Before and after any intervention, ask the patient to cough.

• Helps clear airways.

Auscultation Flowchart

• Assess lung sounds, perform intervention, reassess lung sounds.

• If sounds change, adjust therapy accordingly.

Atelectasis Therapy Matching

• Atelectasis = Lung expansion therapy.

• Pneumonia consolidation or coarse to medium crackles = Airway clearance therapy.

Pneumonia

• Clinical presentation includes diminished lung sounds and crackles.

• Interstitial edema and localized inflammatory response.

Interstitial vs. Pulmonary Edema

• Interstitial Edema: Inflammatory response, such as infection on finger.

• Pulmonary Edema: Fine crackles due to congestion.

Pneumonia Treatment

• Airway clearance therapy.

  • Chest physiotherapy.

  • Postural drainage.

  • Vest.

  • Acapella.

  • Directed cough techniques.

  • Cough assist (if patient cannot cough effectively).

  • Suctioning (most invasive).

Suctioning Techniques

• Nasotracheal Suctioning:

  • Catheter goes through the nose to the trachea.

  • Performed with a sterile catheter.

Pneumonia Confirmation

• Elevated temperature.

• Increased respiratory rate.

• Increased heart rate.

Lab Findings for Pneumonia

• Elevated leukocytes (white blood cells).

• Consolidation on chest X-ray.

• Increased vascular markings.

• Elevated segs and bands (in severe infection).

COPD Pharmacological Approach

• Short-acting bronchodilators (SABAs) like albuterol.

• Short-acting muscarinic antagonists (SAMAs) like ipratropium bromide to block bronchoconstriction.

COPD Maintenance Therapy

• Long-acting beta-agonists (LABAs).

• Long-acting muscarinic antagonists (LAMAs).

COPD Flare-Ups

• If eosinophils are over 300, add inhaled corticosteroids (ICS) to reduce airway remodeling.

Asthma Treatment

• SABAs

• If not controlled, add ICS.

ABGs

• Oxygenation assessed by PaO2 and saturation.

• Ventilation assessed by PaCO2.

• Base excess indicates how much base is needed to normalize pH.

Oxygenation vs. Ventilation

• High PaO2 with low saturation indicates poor oxygen utilization/transport.

• High PaCO2 indicates need for ventilation.

Henderson-Hasselbalch Equation

• $pH = pKa + log \frac{bicarbonate}{carbon \ dioxide}$

• $pH = pKa + log \frac{base}{acid}$

• Used to manipulate and determine desired CO2 and bicarbonate levels to balance pH.