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Questions and Answers
Which condition is NOT a common cause of respiratory muscle weakness?
Which condition is NOT a common cause of respiratory muscle weakness?
Which of the following is a factor contributing to chest wall deformity that affects respiratory function?
Which of the following is a factor contributing to chest wall deformity that affects respiratory function?
What surgical intervention is associated with potential respiratory muscle weakness due to nerve damage?
What surgical intervention is associated with potential respiratory muscle weakness due to nerve damage?
Which progressive disease is linked to respiratory muscle weakness?
Which progressive disease is linked to respiratory muscle weakness?
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What is a mechanical factor that can impair respiratory function in obese individuals?
What is a mechanical factor that can impair respiratory function in obese individuals?
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What is the primary cause of trepopnea?
What is the primary cause of trepopnea?
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Which of the following best describes pleuritic chest pain?
Which of the following best describes pleuritic chest pain?
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In diagnosing wheezing related to heart disease, which term describes the condition where wheezing only occurs due to heart problems?
In diagnosing wheezing related to heart disease, which term describes the condition where wheezing only occurs due to heart problems?
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What breathing pattern is characterized by a rate greater than 20 breaths per minute?
What breathing pattern is characterized by a rate greater than 20 breaths per minute?
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Which vital sign change typically indicates the presence of an infection?
Which vital sign change typically indicates the presence of an infection?
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What does the presence of clubbing typically indicate in respiratory assessment?
What does the presence of clubbing typically indicate in respiratory assessment?
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What characteristic of sputum would NOT typically be evaluated when assessing a patient?
What characteristic of sputum would NOT typically be evaluated when assessing a patient?
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What is the minimum time it typically takes for a patient to achieve relief from classic paroxysmal nocturnal dyspnea after standing or ambulating?
What is the minimum time it typically takes for a patient to achieve relief from classic paroxysmal nocturnal dyspnea after standing or ambulating?
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Which of the following symptoms is NOT considered a cardinal symptom of chest diseases?
Which of the following symptoms is NOT considered a cardinal symptom of chest diseases?
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What is typically the underlying cause of dyspnea on exertion in patients with cardiopulmonary dysfunction?
What is typically the underlying cause of dyspnea on exertion in patients with cardiopulmonary dysfunction?
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How is orthopnea characterized in patients?
How is orthopnea characterized in patients?
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Which grade of dyspnea indicates that a patient only experiences symptoms with strenuous exercise?
Which grade of dyspnea indicates that a patient only experiences symptoms with strenuous exercise?
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What distinguishes paroxysmal nocturnal dyspnea from other types of dyspnea?
What distinguishes paroxysmal nocturnal dyspnea from other types of dyspnea?
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Which mechanism primarily leads to difficulty in providing adequate oxygen supply during exertion in cardiac diseases?
Which mechanism primarily leads to difficulty in providing adequate oxygen supply during exertion in cardiac diseases?
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The term 'dyspnea during exercise' typically refers to difficulty in breathing that arises due to:
The term 'dyspnea during exercise' typically refers to difficulty in breathing that arises due to:
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A patient complains of needing multiple pillows while sleeping due to breathing difficulty. This condition is likely indicative of:
A patient complains of needing multiple pillows while sleeping due to breathing difficulty. This condition is likely indicative of:
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What is the primary purpose of pursed lip breathing in patients with respiratory issues?
What is the primary purpose of pursed lip breathing in patients with respiratory issues?
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Which condition is associated with Kussmaul respirations?
Which condition is associated with Kussmaul respirations?
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In a patient with barrel chest, how does the anteroposterior diameter of the chest compare to the lateral diameter?
In a patient with barrel chest, how does the anteroposterior diameter of the chest compare to the lateral diameter?
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What is the first observable step in the development of clubbing?
What is the first observable step in the development of clubbing?
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When inspecting for deviations in tracheal alignment, where does the trachea shift in the presence of pneumothorax?
When inspecting for deviations in tracheal alignment, where does the trachea shift in the presence of pneumothorax?
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What type of curvature does kyphosis represent in spinal deformities?
What type of curvature does kyphosis represent in spinal deformities?
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Which of the following is an outcome of utilizing accessory muscles of breathing?
Which of the following is an outcome of utilizing accessory muscles of breathing?
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Which respiratory pattern is characterized by a rate exceeding 20 breaths per minute?
Which respiratory pattern is characterized by a rate exceeding 20 breaths per minute?
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What percussion note is typically heard after the cavity in bronchiectasis is emptied?
What percussion note is typically heard after the cavity in bronchiectasis is emptied?
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During the diaphragmatic expansion test, how much should the difference between marks measure in an adult?
During the diaphragmatic expansion test, how much should the difference between marks measure in an adult?
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Which breath sound is characterized by a stronger and louder expiration phase?
Which breath sound is characterized by a stronger and louder expiration phase?
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Where are bronchovesicular sounds normally best heard?
Where are bronchovesicular sounds normally best heard?
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Which condition typically results in a hyperresonant percussion note?
Which condition typically results in a hyperresonant percussion note?
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Which breath sounds are primarily inspiratory with a short expiring phase audible?
Which breath sounds are primarily inspiratory with a short expiring phase audible?
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What physical response is needed from the patient during the diaphragmatic expansion test?
What physical response is needed from the patient during the diaphragmatic expansion test?
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What characteristic of bronchovesicular breath sounds differentiates them from bronchial sounds?
What characteristic of bronchovesicular breath sounds differentiates them from bronchial sounds?
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What sound quality is associated with rhonchi?
What sound quality is associated with rhonchi?
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What might inspiratory wheezes indicate?
What might inspiratory wheezes indicate?
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Which method is used for evaluating the diaphragm's excursion on a chest X-ray?
Which method is used for evaluating the diaphragm's excursion on a chest X-ray?
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What is the primary indication of wheezes during a respiratory assessment?
What is the primary indication of wheezes during a respiratory assessment?
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What is the most significant change in vital capacity while in a supine position that indicates diaphragmatic weakness?
What is the most significant change in vital capacity while in a supine position that indicates diaphragmatic weakness?
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What kind of sounds describe crackles during respiration?
What kind of sounds describe crackles during respiration?
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What does a measurement of maximal inspiratory pressure assess?
What does a measurement of maximal inspiratory pressure assess?
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What is the proper positioning for observing diaphragm thickness using ultrasound?
What is the proper positioning for observing diaphragm thickness using ultrasound?
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Study Notes
Physical Therapy Chest Evaluation
- Respiratory Muscle Weakness: Inability of respiratory muscles to maintain force required for minute ventilation under mechanical load.
Causes of Respiratory Muscle Weakness
- Chronic Obstructive Pulmonary Disease (COPD): The most common cause of respiratory muscle weakness.
- Chest Wall Deformity: Limits thorax expansion, compromising pulmonary ventilation. Conditions include Ankylosing Spondylitis, Kyphosis, Scoliosis, and chest wall trauma/burns.
- Cervical Cord Injuries: Interrupt spinal pathways to chest wall, eliminating sensory input from rib cage, intercostals, and abdominal muscles.
- Paralysis/Paresis of Respiratory Muscles: Caused by cervical cord injuries (e.g., motor vehicle accidents, athletic events, falls, diving).
- Poliomyelitis: Respiratory deterioration can occur years after acute/old poliomyelitis.
- Multiple Sclerosis (MS): A motor neuron disease.
- Progressive Muscular Diseases: Include muscular dystrophy, myasthenia, and amyotrophic lateral sclerosis (ALS).
- Surgical Procedures (including anesthesia): Can cause loss of nerve/muscular integrity due to incision.
- Obesity: Induces respiratory mechanical impairment.
- Phrenic Nerve Damage from Radiotherapy: Damage to the phrenic nerve from radiation therapy.
- Shoulder Manipulation after Inter-scalene Block: Risk of complications can include further nerve damage.
- Open Heart Surgery: Risk of axonal degeneration or demyelination of the nerve due to cold injury (can occur in ~40% of patients).
Chest Physical Therapy Evaluation: Steps
- History: Includes patient details, chief complaint, occupational history, past medical history, current medications, social habits (smoking), family history and six cardinal symptoms of chest disease.
- General Examination: Assess overall patient status.
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Local Examination of Chest:
- Inspection: Observe breathing patterns, chest/spinal deformities, clubbing.
- Palpation: Assess tracheal alignment, chest excursion, vocal fremitus.
- Percussion: Evaluate resonant sounds.
- Auscultation: Listen for breath sounds.
Patient Interview
- Chief Complaint: Initial patient statement.
- Occupational History: Details of patient's work.
- Past Medical History: Previous health conditions.
- Current Medications: Prescribed medications.
- Social Habits: (smoking).
- Family History: Family history of relevant conditions.
- Six Cardinal Symptoms of Chest Diseases: Dyspnea, chest pain, cough, sputum, hemoptysis, and wheezes, history of present illness.
Dyspnea (Difficulty in Breathing)
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Grades of Dyspnea:
- Grade 0: No dyspnea except with strenuous exercise.
- Grade 1: Dyspnea when walking up an incline or hurrying on a level.
- Grade 2: Walks slower than most on the level or stops after 15 minutes of walking.
- Grade 3: Stops after a few minutes of walking.
- Grade 4: Dyspneic to leave the house.
- Dyspnea on Exertion: Common complaint of patients with cardiopulmonary dysfunction. Usually precedes dyspnea at rest. Often a result of chronic pulmonary disease or congestive heart failure (CHF).
- Mechanism in Cardiac Dyspnea on Exertion: Limited cardiac output (due to reduced stroke volume), compensatory rapid heart rate and wide arteriovenous O2 difference (decreased capillary PO2) at an inappropriately low work rate lead to insufficient oxygen supply to the exercising muscles (skeletal and myocardial) causing dyspnea, fatigue, and/or pain.
- Mechanism in Pulmonary Dyspnea on Exertion: Diseases affecting the lungs or thoracic cage prevent external respiration (ventilation) from keeping pace with internal respiration (within the cells), limiting exercise and causing dyspnea due to the difficulty in eliminating CO2 produced by metabolism (hypoxic or hypercapnic stimuli).
Orthopenea
- Dyspnea brought on by recumbent position.
- Patient may need two or three pillows for support while resting at night.
- Commonly associated with CHF, but also can occur with severe chronic pulmonary disease.
Paroxysmal Nocturnal Dyspnea (PND)
- Strong predictive value for CHF.
- Patient usually falls asleep in recumbent position and awakens from sleep with acute shortness of breath after 1-2 hours.
- Difficult to eliminate by only elevating the trunk; requires lowering the legs to pool blood in extravascular tissues of the legs to get adequate relief (which takes at least 30 minutes).
Trepopnea
- Dyspnea in one lateral position but not the other.
- Usually caused by unilateral respiratory pathology (lung disease, pleural effusion, airway obstruction).
- Commonly seen in patients with mitral stenosis.
Chest Pain
- Critical Elements in Assessing Chest Pain: Onset, site, character, radiation, factors increasing/decreasing pain, associated symptoms.
Pleuritic Chest Pain
- Originates from parietal pleura or endothoracic fascia (not visceral pleura).
- Worsens sharply with inspiration due to inflamed parietal pleura being stretched with chest wall motion.
Cough
- Evaluate frequency, severity, dryness/productiveness, time of occurrence, and relation to posture.
Sputum
- Assess amount, color, character, odor, relation to posture, and factors increasing/decreasing it.
Hemoptysis
- Expectoration of blood or blood-stained sputum.
Wheezes
- Coarse, whistling sound in respiratory airways during breathing.
- Intermittent (e.g., asthma) or persistent (e.g. chronic bronchitis).
- In heart disease-related wheezing (cardiac asthma), it's caused by narrowed airways and thickened bronchial walls due to pulmonary edema.
- Episodes of childhood wheezing and dyspnea often indicate COPD, asthma, or other respiratory conditions.
Vital Signs
- Temperature: Normal (afebrile) is 98.6°F (37°C); elevated temperature indicates infection.
- Heart Rate (HR): Normal adult range is 60-100 bpm.
- Blood Pressure: Measured.
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Respiration:
- Rate: Normal range is 12-20 breaths/minute; Tachypnea > 20 breaths/min; Apnea = no respiration.
- Rhythm: Regular or irregular.
- Amplitude: Shallow or deep.
Inspection
- Breathing Patterns: Observe for abnormalities in respiratory rate, Kussmaul, pursed lip breathing, and use of accessory muscles.
- Chest and Spinal Deformities: Assess for barrel chest, pectus excavatum, kyphosis, and scoliosis.
- Clubbing: Observe for physical characteristics—five steps in clubbing development.
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Specific Breathing Patterns
- Respiratory rate: Bradypnea (<12/min); Tachypnea (>20/min).
- Kussmaul: Deep, rapid breathing.
- Pursed lip breathing: Conscious exhalation technique used in COPD.
- Use of accessory muscles: Indication of increased work of breathing (retractions, nasal flaring, sitting upright, tripod position)
Palpation
Assess and compare tracheal shift, chest expansion (excursion), vocal fremitus and percussion.
- Tracheal Alignment: Assess the trachea's position to identify possible shifts associated with lung conditions such as pneumothorax or pleural effusion.
- Chest Excursion: Assess symmetric or asymmetric lung expansion with deep breathing manoeuvres.
- Vocal Fremitus: Palpable vibrations during vocalization. Differences may indicate a pathology.
- Percussion: Examine for sounds in different chest areas and comparing sides to identify abnormal changes- normal chest sounds.
Percussion
- Technique: Strike the middle finger with the middle finger.
- Resonance: Compare resonance on both chest sides. Resonant sound is normal.
- Dullness/Hyperresonance: Abnormal percussion note indicative of pathology (e.g., pneumonia, pleural effusion, hyperinflation).
Diaphragmatic Excursion/Expansion
- Technique: Percuss down the scapula line until sound changes from resonant to dull whilst patient holds exhale. Then measure and compare movement during inspiration.
Auscultation
- Breath Sounds: Evaluate bronchial, bronchovesicular, and vesicular breath sounds.
- Adventitious Sounds: Listen for abnormal sounds like crackles (rales), rhonchi, and wheezes (unusual sounds)
Assessment of Respiratory Muscle Power
- Range of Motion: Assess thoracic and cervical spine as well as shoulder girdle to identify restrictions.
- Postural Deviations/Muscle Imbalances: Can lead to decreased diaphragmatic excursion.
- Vital Capacity: Measures lung capacity in sitting and supine postures; a reduction of >25% while in the supine position often indicates diaphragmatic weakness.
- Maximum Inspiratory Pressure: Clinical procedure to measure inspiratory muscle strength.
- Respiratory Muscle Endurance: Progressive addition of increasing resistance to evaluate inspiratory muscle endurance to assess endurance, typically in 2-minute intervals.
- Electromyography (EMG): Measures diaphragm responses to phrenic stimulation; used for assessing diaphragmatic contractility.
- Ultrasound: Measures diaphragm thickness during relaxation or maximum inspiration.
- Other tests such as maximum expiratory pressure.
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Description
Test your knowledge on the causes and factors related to respiratory muscle weakness and respiratory function impairment. This quiz includes questions about common conditions, surgical interventions, and the effects of obesity on respiration. Assess your understanding of these critical topics in respiratory health.
