unit 7

Restrictive Lung Disease and Pneumonia: Disorder Categories

Restrictive Lung Disease: Big Picture

  • Definition: Restrictive lung disease is characterized by the lungs being restricted from fully expanding with air, resulting in difficulty getting air into the lungs.

  • Variety of Causes: Multiple types of restrictive lung diseases exist, which can be classified into several categories:

    • Primary Lung Disease: Examples include:

    • Idiopathic Pulmonary Fibrosis (IPF): A condition where lung parenchyma becomes stiff and noncompliant.

    • Pleural Abnormalities: For example - pleural effusions.

    • Thoracic Abnormalities: Such as:

    • Kyphoscoliosis: A combination of kyphosis (curvature of the spine) and scoliosis (lateral spine curvature) that may restrict chest wall mobility.

    • Additional Factors: Other physiological factors that can limit lung expansion include:

    • Morbid Obesity: Excess body weight that might limit lung space.

    • Pregnancy: Expansion space for lungs is restricted as the abdomen grows.

Pneumonia (PNA) Defined

  • Definition: Pneumonia is described as an inflammatory response occurring in the bronchioles and alveolar spaces due to an infective agent.

  • Types of Infective Agents: The infections may be caused by:

    • Bacterial Agents

    • Fungal Agents

    • Viral Agents

Categories of Disorders in the Pulmonary System

  • Conducting Airway Problems: Obstruction that affects airflow.

  • Lung Tissue Problems: Pertaining to Diffusion of gases.

  • Compliance Issues: Referring to Ventilatory Pump Problems.

  • Respiratory Musculature Problems: Impairment of muscle function leading to respiratory difficulties.

  • Thoracic Cage/Posture Issues: Could restrict breathing due to physical stance.

  • Circulation Problems: Such as thrombus affecting blood flow and pressures involved in respiration.

  • Pleural Space Problems: Including air or fluid accumulation impacting lung expansion.

Mr. Noiren: Review of History and Physical

Patient Background

  • Name: Mr. Noiren

  • Age/Gender: 68-year-old male

Chief Complaint

  • Reported symptoms include:

    • Cough

    • Shortness of breath

History of Present Illness (HPI)

  • For the past four days:

    • Worsening shortness of breath.

    • Accompaniments include:

    • Fever

    • Shaking

    • Chills

    • Malaise

    • Productive cough

  • Pain developed in the right chest, intensifying with inspiration.

  • Current condition limits walking to 20 feet before needing to rest due to shortness of breath.

Past Medical History (PMHx)

  • Notes:

    • Hypertension

    • Appendicitis history

    • Left fibular fracture from a motorcycle accident in 1985

Past Surgical History (PSHx)

  • Appendectomy recorded.

Medications

  • Metoprolol, prescribed as a beta-blocker for managing blood pressure.

Review of Systems/Physical Examination

  • Vitals:

    • Fever: 102ºF

    • Blood Pressure: 152/90 mm Hg

    • Heart Rate: 112 bpm (sinus tachycardia)

    • Respiratory Rate: 24 (somewhat labored)

    • SpO2: 85% on room air

  • Physical Assessment Findings:

    • Neck: Large and tender lymph node in the right supraclavicular fossa

    • Heart Sounds: Normal S1, S2; absence of murmurs, rubs, or gallops

    • Lung Exam: Bilaterally diminished vesicular breath sounds; bronchial sounds and late inspiratory crackles in the right middle lobe

    • Abdominal Exam: Soft, non-tender, non-distended, with positive bowel sounds

    • Extremity Assessment: No clubbing, cyanosis, or edema noted

    • Neurologic Exam: Patient is alert and oriented x3.

Medical Diagnostic Tests for Mr. Noiren

  • Imaging Studies:

    • CXR (Chest X-Ray): Shows increased consolidation in the right middle lobe.

  • Lab Values from Complete Blood Count (CBC):

    • White Blood Cell (WBC): 17,000 cells/mcL (Normal range: 5000-10000 cells/mcL)

    • Red Blood Cell (RBC): 4.93 cells/uL (Normal range: 4.7 - 6.1 cells/uL)

    • Hemoglobin (Hgb): 14.2 g/dL (Normal range for males: 14.0 - 17.4 g/dL)

    • Hematocrit (Hct): 44.7% (Normal range for males: 42-52%)

    • Platelets: 196k cells/mcL (Normal range: 140-400k cells/mcL)

Physician Assessment/Plan for Mr. Noiren

  1. Diagnosis:

    • Right Middle Lobe (RML) pneumonia and associated symptoms (shortness of breath and cough).

  2. Management Plan:

    • Daily CXR monitoring.

    • Titration of supplemental oxygen to maintain SpO2 levels ≥ 92%.

    • Nebulizer treatments as necessary.

    • Sputum culture (cx) for microbial identification.

    • Blood cultures (cx) for infectious assessment.

  3. Management of Hypertension:

    • Continue metoprolol as prior.

  4. Routine Care Recommendations:

    • Diet: Regular diet is recommended.

    • PIV (Peripheral Intravenous line) for medication administration.

    • Rehabilitation therapy (PT/OT) as part of recovery.

Health Screening and Subjective Exam for Mr. Noiren

Indirect Patient History Review

  • Include:

    • Amount of supplemental oxygen support required.

    • Trends (improving or declining)?

    • Lab values, particularly WBC count (trending analysis).

    • Vital signs: Involves temperature, heart rate, respiratory rate, and SpO2 monitoring.

    • General overview: Is the patient improving or declining?

Key Subjective Exam Questions

  • Cough assessment?

  • Investigating sputum production: observe color and consistency.

  • Any presence of hemoptysis (coughing blood)?

  • Shortness of breath — relate to activities and functions (DASI questionnaire).

  • Supplemental oxygen needs assessment.

  • Chest pain presence?

  • Differential diagnosis considerations: SINS, aggravating and alleviating factors, prior health history.

  • Previous level of function prior to current illness.

Discharge Planning Considerations

  • Consider what the patient must achieve to ensure safe discharge home.

  • Equipment, social support, or other services available at home.

  • Includes evaluation for the need for home oxygen support.

  • Gathering clues from both direct and indirect histories can inform patient rehabilitation prognosis.

Patient Summary

  • Summary of Current Condition:

  • Mr. Noiren is a 68-year-old male who presents with acute pneumonia leading to increased shortness of breath, chest pain, and fatigue.

  • Symptoms restrict walking to less than 20 feet at a time, impacting his ability to function independently within the community.

Objective Examination

  • Commenced with an assessment of the patient's body position.

  • Body Position: Where is the patient, i.e., sitting in chair, bed position (HOB elevated or flat)?

  • Posture Assessment: Does the posture support relaxed breathing, or is there evidence of kyphosis or forward-shouldered posture affecting breath mechanics or inducing anxiety?

  • Environmental Clues: Can assess for suction tubing or tissues to indicate productive cough.

  • Sputum Observation: Evaluate color, with green/brown indicative of potential infection.

Objective Assessment: Key Impairments

Respiratory System

  • Reduced aerobic capacity due to:

    • Hypoventilation and reduced gas exchange at the alveolar level.

    • Difficulties with airway clearance noted.

Musculoskeletal System

  • Decreased lower extremity (LE) strength and power attributed to deconditioning over the past four days.

  • Impaired dynamic balance due to strength loss and deconditioning.

Objective Testing and Assessment Procedures: "Look"

  • Breathing Pattern Assessment:

    • Is the breathing labored versus relaxed?

    • Monitoring for accessory muscle usage.

    • Patient example: working hard to breathe on 4LNC, employing both diaphragm and upper chest.

  • Inspiratory Capacity Measurement: Using an incentive spirometer to assess treatment efficacy (measure pretest vs. posttest).

    • Patient example: patient achieves inspiratory capacity of 750 mL.

Objective Tests and Measures: "Listen"

  • Tests and Measures:

    • Pulmonary Auscultation:

    • Patient case example: Inspiratory crackles and bronchial sounds audible over the right middle lobe (RML).

    • Dynamic Airway Assessments:

    • Cough and Huff Mechanics: Patient shows difficulty mobilizing secretions but is able to expectorate thick, green/brown sputum following excessive coughing; demonstrates ability to huff effectively.

Objective Tests and Measures: "Listen" and "Feel"

  • Bronchophony Assessment:

    • Patient example: Normal sound in both lungs except for the RML, where there is increased sound production.

  • Mediate Percussion:

    • Patient example: Bilaterally resonant lungs to percussion, except RML which shows dullness.

  • Chest Wall Mobility Assessment:

    • Pump Handle vs. Bucket Handle Movement:

    • Patient's Status: Decreased bucket handle movement noted in middle and lower ribs on right side.

  • Tactile Fremitus Assessment:

    • Patient case example: Normal fremitus felt in both lungs; however, increased fremitus noted in the RML.

Objective Examination Analysis

  • Correlation of objective findings with CXR results.

    • Reviewed PA view, lateral view, and other necessary assessments.

Aerobic Capacity Assessment

  • Consider both prior and current function levels to propose appropriate challenges.

    • Patient case example: Supervised during bed mobility and transfers, currently walking to and from the bathroom as per nursing report.

    • Consider supplemental oxygen needs: Often orders to titrate oxygen to maintain SpO2 ≥ 92%, emphasizing safety protocols.

    • **Objective Measurement of Aerobic Capacity:
      ** | Rest (2L NC) | 1 Minute Walking | 2 Minutes Walking | 3 Minutes Walking
      | 96 bpm (NSR) | 110 bpm (sinus tachycardia) | 112 bpm (sinus tachycardia) | 129 bpm (sinus tachycardia)
      | SpO2: 93% | SpO2: 91% | SpO2: 91% | SpO2: 89%

    • Termination of the test requested by the patient after 3 minutes.

    • Recovery assessments indicate SpO2 levels improving after seated recovery.

Final Assessment of Mr. Noiren

  • Description of patient's current condition:

    • Presenting acute pneumonia infection contributing to shortness of breath, chest pain, and fatigue.

    • Faces difficulties in clearing secretions and maintaining SpO2 > 92% during ambulation of short distances.

    • Requires frequent rest breaks every 20-30 feet; impact on functional independence within community.

  • Conclusion:

    • Mr. Noiren will benefit from acute physical therapy services:

    • Focus on active airway clearance instructions for better secretion expectoration and improved ventilation.

    • Progressive gait training to combat aerobic deconditioning during acute illness.

    • Increased frequency of mobilization recommended for optimized safe independent mobility, preparing for home transition with home health services afterward.

Intervention Strategies for Mr. Noiren

Directing Toward Impairments

  • Respiratory System Interventions:

    • Aerobic Capacity Improvement:

    • Frequency: TID (three times a day), with a gradual reduction to once a day over time.

    • Intensity: Targeting 3–4/10 on modified Borg Scale, also titrating supplemental oxygen to maintain SpO2 ≥ 92%.

    • Time: Focus on duration rather than speed, accommodating for sitting/standing rest breaks as necessary based on exertion intensity.

    • Type: Incorporate an aerobic interval-based gait training approach.

  • Airway Clearance Techniques:

    • Effective Cough Mechanics:

    • Review inspiration phase mechanics.

    • Utilize incentive spirometer emphasizing the force and expulsion phase.

    • Controlled coughing strategies for R-sided chest pain.

    • Instruction in active airway clearance techniques as necessary.

Active Cycle of Breathing Technique

  • Components:

    • Breathing Control:

    • Gentle tidal breathing aimed at relaxing upper chest and shoulder muscles to prevent bronchospasm; duration of this phase is essential for effective relaxation.

    • Thoracic Expansion:

    • Focus on deep inspiration to loosen secretions; allows air to access behind secretions assisting with mobilization.

    • Incentive spirometer use encouraged in this phase.

    • Forced Expiratory Technique (FET):

    • Huffing technique used to transfer secretions from peripheral airways to more proximal airways to facilitate effective expectoration via coughing.

    • Targeting Specific Areas:

    • Long, quieter huff after a medium-sized inspiration to correct secretions in peripheral airways; short, louder huff after deep inspiration for clearance of proximal airways.

    • Integration of Art and Science:

    • Potential increase in time spent within phases of control, expansion, and FET based on patient needs (reactive airways, anxiety, atelectasis presence).

Treatment Efficacy Assessments

  • Implementation of Objective Measures (Pretest vs. Retest):

    • Pulmonary Auscultation Results: Changes observed from crackles to clear vesicular sounds.

    • Resting SpO2 Levels: Tracked improvement from 85% on room air in the emergency department to 96% on room air.

    • Incentive Spirometer Capacity: Measurement increased from 750 mL initially to 2,000 mL post-treatment.

    • Modified Borg Dyspnea Scale:

    • Resting measurements decreased from 3/10 to 0/10; activity scale dropped from 7/10 to 3/10.

    • 6MWT (6-Minute Walk Test) and Supplemental Oxygen Requirements:

    • Distance improvement: initially 100 feet to 800 feet post-rehabilitation.

    • Oxygen requirements transitioned from 2L NC at rest and 3L NC with activity to room air during all activities up to 3-4 MET.

Interstitial Lung Disease Assessment

Indirect History

  • Assessment considerations for interstitial lung disease include:

    • Activity levels pre-hospitalization and post-discharge.

    • Required durable medical equipment (DME) or assistive devices (AD).

    • Need for assistance at home.

    • Goals relating to breathlessness and fatigue.

    • Evaluation of supplemental oxygen utilization and nutritional status.

Objective Examination for Interstitial Lung Disease

  • Observational Assessments:

    • Look for breathing pattern changes, evaluate for accessory muscle use.

    • Presence of cyanosis or clubbing indicating advanced disease state conditions.

  • Sound Assessments:

    • Pulmonary auscultation revealing crackles associated with pulmonary fibrosis.

    • Potential diminished or absent lung sound due to airflow limitations or restricted expansion.

Interventions for Interstitial Lung Disease

Goals for Rehabilitation

  • Establish pulmonary rehabilitation parameters:

    • Help patients obtain increased air volume in lungs.

    • Address and reduce external restrictions (will include posture and soft tissue tightness).

    • Incorporate inspiratory muscle training aimed at enhancing resting respiratory function.

Other Considerations

  • Supplemental O2 Management:

  • Ensure proper recovery periods post-exertion and conduct re-training for breathing patterns at rest.

End of Notes