Physical Therapy Chest Evaluation PDF

PHYSICAL THERAPY CHEST EVALUATION Prof.Dr. Mona Abd Elkhalek Dr. Ahmed Abd Elhalim  Respiratory Muscle Weakness inability of the respiratory muscles to maintain the force required to sustain minute ventilation in the presence of a mechanical load Causes of respiratory muscle weakness...

PHYSICAL THERAPY CHEST EVALUATION Prof.Dr. Mona Abd Elkhalek Dr. Ahmed Abd Elhalim  Respiratory Muscle Weakness inability of the respiratory muscles to maintain the force required to sustain minute ventilation in the presence of a mechanical load Causes of respiratory muscle weakness 1. The most important and common cause of respiratory muscle weakness was associated with chronic obstructive pulmonary disease 2. Chest wall deformity limit the ability of the thorax to expand and therefore pulmonary ventilation is compromised 3. Chest well deformity occur with Ankylosing Spondylitis, Kyphosis and scoliosis as well as chest wall trauma or burn. 4.. Cervical cord injuries interrupt spinal pathway to and from the chest wall, eliminating sensory input from the rib cage, intercostals and abdominal muscles Causes of respiratory muscle weakness 5. Paralysis or paresis of the respiratory muscles occurs with cervical cord injuries such as motor vehicle accident, athletic related event; falls and diving 6. Respiratory deterioration may appear many years after acute / old poliomyelitis 7. Motor neuron disease as multiple sclerosis (MS) 8. Progressive muscular diseases such as; muscular dystrophy, myasthenia, and amyotrophic lateral sclerosis (ALS). Causes of respiratory muscle weakness 9. Surgical procedures including anesthesia, loss of nerve or muscular integrity by incision 10. Obesity is known to induce respiratory mechanical impairment. 11. Phrenic nerve damage from radiotherapy. 12. Shoulder manipulation after interscalene block by anesthesia 13. After open heart surgery: axonal degeneration or demyelination of the nerve by cold injury which may occur in about by 40% of patients after cardiac surgery Chest Physical Therapy Evaluation: Steps  -History  -General Examination  -Local examination of chest:  Inspection  Palpation  Percussion  Auscultation A. Patient Interview Chief complaint Occupational history Past medical history Current medications Social habits (smoking) Family history The six cardinal symptoms of chest diseases The six cardinal symptoms of chest diseases 1- Dyspnea 2- Chest pain 3- Cough 4- sputum 5- Hemoptysis 6- Wheezes History of the present illness Dyspnea: (Difficulty in breathing) Grade Degree of dyspnea 0 No dyspnea except with strenuous exercise 1 Dyspnea when walking up an incline or hurrying on the level walks slower than most on the level, or stops after 15 minutes of walking 2 on the level 3 stops after a few minutes of walking on the level with minimal activity such as getting dressed, too dyspneic to leave the 4 house Dyspnea on Exertion Dyspnea on exertion is a common complaint of patients with cardiopulmonary dysfunction. Dyspnea during exercise or exertion usually precedes dyspnea at rest. It most often is a result of chronic pulmonary disease or CHF. Dyspnea on Exertion The basic defect that cardiac diseases produce during exertion is a limited cardiac output, primarily caused by a reduced stroke volume. To compensate for the relatively low stroke volume, the patient develops a rapid heart rate and a wide arteriovenous O2 difference (decreased capillary PO2) at an inappropriately low work rate. Therefore the exercising muscles (both skeletal and myocardial) have increased difficulty getting an adequate oxygen supply to perform the necessary work, which results in dyspnea, fatigue or pain. Dyspnea on Exertion Diseases that involve the lungs or thoracic cage generally prevent external respiration (ventilation) from keeping pace with internal respiration (in the cells). The primary symptom that limits exercise in pulmonary patients is dyspnea because of the difficulty they have eliminating CO2 produced by metabolism Hence, dyspnea on exertion in pulmonary patients is usually related to hypoxic or hypercapnic stimuli Orthopnea Orthopnea is dyspnea brought on in the recumbent position. The patient may state the need for two or three pillows under the head to rest at night. This symptom is commonly associated with CHF but may also be associated with severe chronic pulmonary disease. Paroxysmal Nocturnal Dyspnea This symptom has strong predictive value as a sign of CHF. The patient usually falls asleep in the recumbent position and 1 or 2 hours later, awakens from sleep with acute shortness of breath Classic PND cannot usually be eliminated by only elevating the trunk without lowering the legs. The patient must pool blood in the extravascular tissues of the legs to get adequate relief, which usually takes at least 30 minutes. This is why the patient must sit up or stand up, and ambulate Trepopnea Trepopnea refers to dyspnea in one lateral position but not the other. It is often produced by unilateral respiratory system pathology such as lung disease, pleural effusion, or airway obstruction. It also is commonly seen in patients with mitral stenosis Chest pain The onset. Site. Character. Radiation. What increases the pain what relieves or decreases it. Associated symptoms. Pleuritic chest pain originates from the parietal pleura or endothoracic fascia, but not the visceral pleura, which has no pain receptors. Pleuritic chest pain worsens sharply with inspiration as the inflamed parietal pleura is stretched with chest wall motion. Cough: Ask about the following: The frequency The severity Dry or productive Time of occurrence Relation to posture Sputum: Amount Color Character Odor Relation to posture What increases or decreases it Haemoptysis: The expectoration of blood or of blood stained sputum Wheeze Coarse, whistling sound produced in the respiratory airways during breathing. Wheezing may be intermittent as in asthma or persistent as in chronic bronchitis. When confirmed that the wheezing is because of heart disease, the patient is said to have cardiac asthma. Wheezing in cardiac patients is a manifestation of narrowed airways and thickened bronchial walls as a result of pulmonary edema. However, if patients have a history of episodes of wheezing and dyspnea since childhood, COPD, or asthma is the likely cause. Vital signs 1.Temperature: normal (afebrile) 98.6°F, (37°C). Core temperature increase indicates infection. 2.Heart rate (HR) normal adult from 60 to 100 bpm 3.Blood pressure. Vital signs 4.Respirations. - (1)Rate: in health is 12-20 breaths per minute. -Tachypnea is a rate greater than 20 br/min. -Apnea means no respirations. (2) Rhythm: regular or irregular. (3) Amplitude: shallow, deep Inspection Breathing Patterns Chest &spinal deformities Clubbing Inspection: Pattern of Breathing 1. Respiratory rate 2. Kussmaul 3. Pursed lip breathing 4. Use of Accessory muscles of breathing & increased work of breathing 1.Respiratory Rate Bradypnea: rate less than 12 per minute Tachypnea: rate greater than 20 per minute 2.Kussmaul Patients with acidosis from renal failure, diabetic,ketoacidosis and aspirin overdosage will have deep sighing (Kussmaul) respirations as they try to excrete carbon dioxide. 3.Pursed lip breathing Inspiration may be brief, even hurried, but expiration is a prolonged labored maneuver. These patients breathe out through pursed lips as if they were whistling; this mechanism maintains a higher airway pressure and keeps open the distal airways to allow fuller although longer expiration. Use of Accessory muscles of breathing & increased work of breathing Inspection: Chest &spinal deformities Barrel chest Pectus excavatum Kyphosis Scoliosis Barrel chest Barrel chest’ the chest wall is held in hyperinflation In normal people the anteroposterior diameter of the chest is less than the lateral diameter but in hyperinflation the anteroposterior diameter may be greater than the lateral. Barrel chest pectus excavatum pectus excavatum (‘funnel chest’) : The sternum is depressed: the condition is benign and needs no treatment but can produce unusual chest radiographic appearances Pectus excavatum  Kyphosis is forward curvature of the spine scoliosis is a lateral curvature of the spine Inspection: Clubbing Clubbing develops in five steps : 1. Fluctuation and softening of the nail bed 2. Loss of the normal< 165 °angle ("Lovibond angle") between the nailbed and the fold 3. Increased convexity of the nail fold 4. Thickening of the whole distal (end part) of the finger (resembling a drumstick) 5. Shiny aspect and striation of the nail and skin  Clubbing is associated with: Suppurativelung disease: lung abscess, empyema, bronchiectasis, cystic fibrosis  Palpation Tracheal Alignment Chest Excursion Vocal Fremitus Percussion Palpation: Tracheal Alignment Palpation: Tracheal Alignment Pneumothorax – shifts to unaffected side Pleural Effusion – shifts to unaffected side Fibrosis or Atelectasis – shifts towards affected side Pulmonary consolidation – no shift Palpation: Chest Excursion The examiner Places his hands on the patient's back with thumbs pointed towards the spine. the patient takes a deep breath so the hands should lift symmetrically outward. Palpation: Chest Expansion when Processes that lead to asymmetric lung expansion, as might occur when anything fills the pleural space (e.g. air or fluid), may then be detected as the hand on the affected side will move outward to a lesser degree. Palpation: Chest Excursion Palpation: Chest Excursion Palpation: Tactile Fremitus Normal lung transmits a palpable vibratory sensation to the chest wall. This is referred to as fremitus and can be detected by placing the ulnar aspects of both hands firmly against either side of the chest while the patient says the words "Ninety-Nine." The bony aspects of the hands are used as they are particularly sensitive for detecting these vibrations. Tactile Fremitus Percussion The middle finger of the left hand is placed on the chest and middle phalanx is struck with the tip of the middle finger of the right hand Compare the percussion note (resonant) with that of the corresponding area on the opposite side of the chest A resonant sound is produced during percussion The sound and feel of resonance over a healthy lung has to be learned by practice Percussion Proper technique Percussion of the Anterior chest wall 1- Stand to the right of the patient. 2- Ask the patient to lie supine. 3- Percuss both clavicles directly (over medial third) 4-Percuss the infraclavicular regions. Percussion of the Anterior chest wall 5- Percuss both parasternal lines right and left, from the second space to the sixth space with comparison. 6-Percuss both midclavicular lines right and left, from the second space to the sixth space with comparison. 7-Comment on dullness found. Percussion of the Anterior chest wall Normal Percussion Notes Anterior chest wall Resonance Dullness Most of lung 1- left anterior chest due to Heart 2- right lower chest due to liver Abnormal Percussion Notes Decreased or increased resonance is abnormal. Dullness – increased density Atelectasis, alveolar filling/consolidation, pleural effusion, fibrosis Hyperresonance – decreased density Hyperinflation (COPD), Pneumothorax Pulmonary hyperinflation is usually defined as an abnormal increase in functional residual capacity  In bronchieactasis percussion after a fit of coughing the cavity is emptied, and percussion at this time gives a high-pitched tympanitic note; when the cavity is full, the percussion note is dull. Deep-seated cavities are not easily detected by percussion. Diaphragmatic Expansion(excursion) Lower lung borders in expiration & inspiration 1st ask the patient to exhale & hold- percuss down the scapulae line until sound changes from resonant to dull. Mark with marker Diaphragmatic Expansion Now the patient takes deep breath & hold. Percuss from mark to dull sound and mark. Measure the difference. Should be + bilaterally 3-5cm in adult Note hold your own breath when conducting this test.  Inhale Exhale Auscultation Breath Sounds Normal breath sounds can be broken down into bronchial, bronchovesicular, and vesicular Bronchial sounds Bronchial sounds can be described as high pitched and are heard both in the inspiratory and expiratory phase. However the expiration phase is heard much stronger and louder than the inspiration This sound is also described as tracheal as its normal location is over the trachea. Broncho vesicular sounds these are also high-pitched and have equal inspiratory and expiratory cycles. However, a differentiating feature is the lack of a pause. Bronchovesicular sounds are heard well wherever the bronchi or central lung tissue is close to the surface. These include superior to the clavicles and suprascapular (apices), and parasternal and interscapular (bronchi). Vesicular breath sounds heard over the remaining peripheral lung fields. These sounds have primarily an inspiratory component with only the initial one third of the expiratory phase audible. Their intensity is also softer because of the dampening effect of the spongy lung tissue and the cumulative effect of the air entry from numerous terminal bronchioles. Thus as the therapist auscultates from top to bottom, the breath sounds are quieter at the bases than at the apices. Adventitious Breath Sounds crackles (rales), rhonchi, and wheezes Crackles Crackles (rales) are described as discontinuous, low- pitched sounds. They occur predominantly during inspiration. The sound of rubbing hair between the fingers or velcro popping simulates crackles. Crackles usually indicate obstructions in peripheral airway process Rhonchi Rhonchi are low pitched but continuous sounds. These occur both in inspiration and expiration. Snoring is a term used to describe its quality. Rhonchi are attributed to an obstructive process in the larger, more central airways. Wheezes Wheezes are continuous but high-pitched. A hissing or whistling quality is present. Wheezes predominantly occur during expiration and are an indication of bronchospasm (i.e., asthma). However, wheezes can also be caused by the movement of air through secretions, thus inspiratory wheezes can be described. Range of motion of the thoracic and cervical spines and shoulder girdle should be assessed, as limitations in these areas restrict thoracic expansion. Postural deviations and muscle group imbalances may result in decreased diaphragmatic excursion.  Vital capacity in both the sitting and the supine posture: A non specific insensitive measure, which only considerable on sever diaphragmatic weakness. Supine fall in vital capacity, a reduction value of >25% confirm diaphragmatic weakness.  Chest radiography: One of evaluation mean for the diaphragmatic excursion. While the subject took deep full inspiration, the right hemi diaphragm was out lined below the level of the nine rib. The right hemi diaphragm is usually higher than the left one by about 1-2 cm above the left..  Ultrasound: Allows observation of the thickness of the diaphragm during relaxation and maximum inspiratory efforts, consider an easy, noninvasive and accurate method  Ultrasound: A high resolution (7.5 MHz) ultrasound transducer is held perpendicular to the chest wall in the line of a right inter-costal space between the antero-axillary and mid axillary lines to observe the diaphragm ,0.5-2 cm below the costo-phrenic angle. The changes of thickness were observed while breath holding at total lung capacity and functional residual capacity.  Measurement of maximal inspiratory pressure: Is a simple, quick and noninvasive clinical procedure for determining inspiratorymuscle strength, with a solid –state pressure transducer.  Measurement of maximal inspiratory pressure: The maximum inspiratory effort was conducted by having the subject expire to a residual volume and then perform a maximum inspiratory maneuver. This pressure is normally lower in women than men, and also decrease with age in both genders.  Respiratory muscle endurance: Inspiratory work was then increased by the progressive addition of 25-100 gm at 2 min intervals. The pressure achieved with the heaviest load, tolerated for at least 60 second, is defined as the peak pressure, which reflect respiratory muscle endurance.  Electromyography: The response of the diaphragm to phrenic stimulation consider an objective and accurate method for assessment of diaphragmatic contractility. In normal adults phrenic nerve latency is 7.5 ms in average, with the extreme values ranging from 5.5-9.5 ms. The left latency time being longer.