Pulmonary PT Study Guide PDF

PT 820: Pulmonary PT: STUDY GUIDE BREATH SOUNDS BREATH SOUND INDICATES WHAT IN LUNG? OFTEN HEARD WITH WHAT? OTHER (nl, abnl, disease/pathology) Tracheal Normal air movement th...

PT 820: Pulmonary PT: STUDY GUIDE BREATH SOUNDS BREATH SOUND INDICATES WHAT IN LUNG? OFTEN HEARD WITH WHAT? OTHER (nl, abnl, disease/pathology) Tracheal Normal air movement through the Normal physiology; heard directly over the Loud and high pitched with trachea trachea equal inspiratory/expiratory phases (1:1) Discontinuous Bronchial Air moving through large airways Abnormal if heard in peripheral lung fields High pitched, hollow, louder (indicates consolidation, e.g. pneumonia expiration than inspiration (1:2) Discontinuous Bronchovesicular Air movement in mid-sized airways Normal in the upper sternum and between Moderate pitch and intensity; the scapulae equal inspiration/expiration Abnormal in peripheral areas (consolidation) phases (1:1) Continuous Vesicular Air moving through small airways Normal in peripheral lung fields Soft, low pitched longer inspiration than expiration (3:1) Continuous Crackles/Rales Fluid or alveolar popping Abnormal: pneumonia, heart failure, Discontinuous, fine (sudden Represents wetness in the airways pulmonary fibrosis, atelectasis opening of closed airways) or coarse (fluid/secretions) heard during inspiration Bubbles popping Wheezes/Rhonchi Airflow obstruction Abnormal: asthma, COPD, bronchitis Continuous, high pitched Usually heard during exhalation (rhonchi may clear with cough if due to musical sound (wheezes) (bronchoconstriction/secretions) secretions) Rhonchi lower pitched snoring sound (clears with cough) Stridor Airflow obstruction at upper airway Abnormal: epiglottis, foreign body, laryngeal Continuous, high pitched edema wheeze during inspiration/exhalation Pleural Rub Visceral and parietal pleura rubbing Abnormal: pleuritis, pleural effusion Creaking or grating sound, heard together both during inspiration and exhalation Vocal Changes: Egophany- Consolidation or fluid in the lung Abnormal: pneumonia, lung abscess Egophony: “E” sounds like “A” Bronchophony-Whispered enhancing sound transmission Bronchophony: clear/loud Pectoriloquy whispers, repeat “99” Whispered Pectoriloquy: extreme bronchophony, say “1, 2, 3” MEDIATE PERCUSSION SOUNDS MEANING Resonant Loud/low pitched Heard over air filled organs (lungs) Hyper Resonant Very low pitched Heard over tissue with decreased density (diseased lungs, emphysema, inflated lungs) Tympanic High pitched Hear over hollow organs (stomach/gas bubbles in the stomach) Dull Low amplitude medium to high pitched Increased tissue density or lungs with decreased air Heard over solid organs Flat Very dull sound/high pitch Very dense tissues Heard over muscle mass LUNG DISEASES/PATHOLOGY LUNG Obstructive/ Problem in Lung Auscultation Other Test Results (PFT, Other DISEASE/PATHO Restrictive Results xray, excursion, etc) LOGY Bronchitis Obstructive Airway disease Adventitious breath PFT: decreased VC and Barrel Chest (Blue Bloater) Inflammation of sounds increased TLC and RV Faster/Shallower breaths bronchi Decreased breath Decreased Vibration due to Obstruction of airway sounds hyperinflation Alveolar wall Crackling/Wheezing Increased vibration over mucosal areas destruction Egophony over Dull sounds over mucosal area mucosal areas Morning cough Emphysema Obstructive Abnormal/irreversible Adventitious breath PFT: decreased VC and Pursed lips (Pink Puffer) enlargement of airways sounds increased TLC and RV Using more accessory muscles distal to the terminal Decreased breath CXR: overinflated (hypertrophy) bronchioles sounds lungs/horizontal Barrel Chest Crackles/Wheezing ribs/increased subcostal Short/Faster Breath sounds Muffled sounds angle Flat Diaphragm Signs of right heart failure Less Fremitus More air in lungs Hyper resonant sounds Irreversible Asthma Obstructive Chronic inflammation Wheezing → CXR: hyperinflation Increased mucosal edema of the airways exhalation > Possible small areas of Dyspnea Reversible obstruction inhalation atelectasis Unproductive cough to airflow Decreased breath Tightness in chest Bronchospasm sounds Inability to expel air Increased RR Increased accessory muscle use Usually episodic Bronchiectasis Obstructive Abnormal permanent Crackles/Wheezing PFT: with advanced disease Frequent infections → muscopurulent dilation of Decreased breath may see decreased FEV1 and sputum bronchi/bronchioles sounds increased RV Chronic cough with purulent sputum Chronic Pleural rub Dyspnea inflammation/infection Clubbing Destruction of elastic Irreversible and muscular  bronchiole walls Bronchiole artery enlargement Destruction of mucociliary elevator which leads to problems with pulmonary hygiene Cystic Fibrosis Obstructive Thick, excessive Inspiratory CXR: hyperinflation and Pancreatic enzyme deficiency (GI issue) secretions and poor crackles/wheezes flattening of the diaphragm Increased sweat production ciliary function Decreased breath PFT: obstructive pattern (Integumentary issue) Obstruction of small sounds Chronic productive cough with possible airways stress incontinence Affects bronchial Dyspnea hygiene More accessory muscle use Genetic influence Clubbing Frequent infections Bronchopulmon Obstructive Underdeveloped lungs Decreased breath N/A Developmental delays ary Dysplasia Inflammation and sounds, crackles, Mechanical ventilation may contribute (BPD) scarring of the lungs wheezing, stridor to development of BPD MOST COMMON in (rare) children Pulmonary Restrictive Inflammation of Sharp crackles Breathing Pattern: Idiopathic or immune response or Fibrosis alveolar wall Diminished breath rapid/shallow breaths genetic or occupational hazards Scarring sounds Hypoxemia Stiffness and decreased Progressive onset of breathlessness and compliance non-productive cough Clubbing Pleuritic chest pain with exertion Low grade fever or malaise or weight loss Irreversible Pneumonia Restrictive Inflammation of the Crackles and low- N/A Diagnosed with sputum culture lung beginning with pitched wheezing Increased RR lower respiratory tract Bronchial breath Increased work of breathing infection sounds over area of Hypoxemia consolidation Fever Productive cough Decreased lung volumes/compliance/gas exchange Bronchial Breathing where it is supposed to be vesicular Acute Restrictive Sudden respiratory Diffuse crackles N/A Shortness of breath Respiratory failure due to fluid Wet breath sounds Can lead to fibrosis Distress accumulating in alveoli Decreased breath Labored/rapid breathing pattern Syndrome sounds Cough (ARDS) Pink frothy secretions Decreased lung compliance HYPOtension Confusion Extreme fatigue Fever Hypoxemia Hypoxia Respiratory distress Lung Carcinoma Restrictive Malignant tumor in the Diminished breath N/A Dyspnea lung sounds Persistent non-productive coughing up Crackles/Wheezing blood Hemoptysis Dull and aching chest pain Pleural Effusion Restrictive Fluid in the pleural Decreased breath N/A Dyspnea space sounds Pleuritic chest pain Pleural Rub Dry non-productive cough Decreased chest expansion Dullness on percussion Atelectasis Restrictive Partial or total collapse Diminished or absent N/A Tachypnea of the alveoli or lung breath sounds over Fever segments/lobes involved areas Decreased chest movement Decreased aeration to the area Results from either secretion retention or compression of the lung Pneumothorax Restrictive Presence of air in the Absent or diminished N/A Acute dyspnea pleural cavity breath sounds Pleuritic chest pain Hemothorax: blood in Hyperresonance on percussion the pleural cavity Decreased tactile fremitus Tuberculosis Honorable Infection of the lungs Crackles CXR: abnormal with fluffy Mode of transportation through Mention Bronchial breath shadows/atelectasis/enlarge inhalation droplets that become sounds over area of lymph airborne consolidation nodes/cavitations/scarring Unproductive cough Fever Night Sweats Weight loss Dyspnea COVID-19 Honorable Hypoxemic disease N/A N/A Fever and chills Mention Can progress to ARDS Shortness of breath Restrictive Scarring in the lungs Cough and difficulty breathing Fatigue Body/Muscle aches and headaches Loss of taste/smell Sore throat/congestion Runny nose Nausea/vomiting/diarrhea Mult-organ failure DIAGNOSITC TESTING: PFT - Used for diagnosing and monitoring respiratory symptoms/disease - Measure the volume and flow of air during inspiration and exhalation - Interpretation o Obstruction present? ▪ FEV1 and FEV1/FVC: decreased ▪ RV: increased ▪ TLC: normal or increased o Is obstruction reversible? ▪ Look for improvement in FEV1 or FVC by at least 12% o Is restrictive disease present? ▪ TLC: decreased ▪ RV: decreased ▪ VC: decreased ▪ FRC: decreased ▪ FEV1/FVC: within normal limits o Combined disorder? ▪ Combination of decreased TLC with associated decrease in flow (FEV1 and FEV1/FVC) o Isolated Gas Exchange Abnormality? ▪ Normal PFT with decreased DLCO  ▪ Could be an early sign of interstitial lung disease/vasculitis/PE/anemia ABG - Normal Values o pH = 7.35-7.45 o PCO2 = 35-45 o PO2 = 80-100 o HCO3 = 22-28 o Hgb = 12-16 - Alveolar Ventilation o PaCO2 < 35 = Alveolar HYPERventilation o PaCO2 > 45 = Alveolar HYPOventilation o PaCO2 > 50 = Respiratory failure - Acid-Base Balance o Acidosis = pH < 7.4 ▪ Metabolic = decreased HCO3 ▪ Respiratory = Increased HCO3 Alveolar HYPOventilation and HYPERcapnia ▪ Acidemia = pH < 7.35 o Alkalosis = pH > 7.4 ▪ Metabolic = Increased HCO3 ▪ Respiratory = Decreased HCO3 Alveolar HYPERventilation and HYPOcapnia ▪ Alkalemia = pH > 7.45 o In terms of pH and PaCO2 ▪ Respiratory = INVERSE relationship ▪ Metabolic = DIRECT relationship o Acid-Base Primary Respiratory ▪ If HCO3 is increased and pH is acidic = respiratory acidosis ▪ If HCO3 is decreased and pH is alkalotic = respiratory alkalosis ▪ Look at differences between PaCO2 and pH Acute: change in PaCO2 of 10 mmHg + pH shift of 0.08 Chronic: change in PaCO2 of 10 mmHg + pH shift of 0.03 - Compensated or Uncompensated?  o Uncompensated ▪ pH is outside of normal range ▪ PaCO2 is within normal range o Partially Compensated ▪ BOTH pH and PaCO2 are outside of normal range o Compensated ▪ pH is within normal range ▪ PaCO2 is outside normal range - Oxygenation Status o Normal PaO2 = 80-100 o Mild Hypoxemia = 60-80 o Moderate Hypoxemia = 40-60 o Severe Hypoxemia = < 40 o Oximetry: measure of oxyhemoglobin saturation ▪ Normal = 95% ▪ Mild Hypoxemia = 90-95% ▪ Moderate Hypoxemia = 75-90% ▪ Severe = < 75% IMAGING - Radiographs (X-Rays) o Radiolucent = dark o Radiopaque = light o Air = dark o Fat = dark gray o Muscle = light gray o Bone = white - Chest X-Ray (CXR) o Standard for looking at the anatomy of the chest - Tomography (CT scans) o With contrast to show tissues with increased density proportionally to their vascularity o Used to look for pulmonary nodules (Chest CT) - MRI o Used primarily for soft tissue and lymph nodes  o Better view of soft tissues compares to a CT scan BUT ▪ More expensive ▪ Takes longer - Pulmonary Angiogram o Catheter inserted and carefully fed into and through the right side of the heart to the pulmonary artery (leads to lungs) o Dye injected into the catheter o X-Ray images are taken to see how the dye moves through the lungs’ arteries o The dye helps detect blockages to blood flow - Bronchoscopy o Direct visualization of the bronchial tree through a scope o Use for diagnostic and therapeutic purposes - Radionuclide V/Q Scan o Ventilation and perfusion should match o Poor Ventilation = possible airway obstruction o Poor Perfusion = possible PE LUNG VOLUMES/CAPACITIES - Volumes o Tidal Volume = 500 mL +/- 100 mL o IRV = 3000 mL o ERV = 1000 mL o RV = 1200 mL - Capacities o Vital Capacity = 4000-5000 mL o IC = 3000-4000 mL o TLC = 6000 mL o FRC = 2400 mL QUIZ 3 CONTENT STARTS HERE MEDICAL/SURGICAL INTERVENTIONS: - Surgical Procedures  o Wedge Resection ▪ Remove section of lung tissue (usually triangle shaped) o Bullectomy ▪ Removal of 1 or more bullae o Lobectomy ▪ Excision of lobe o Pneumonectomy ▪ Removal of the entire lung o Lung Volume Reduction (LVRS) ▪ Reduce the size of the lungs by removing percentage of diseased lung tissue - Lung Transplant o Candidacy ▪ Advanced stage pulmonary disease ▪ Absolute and relative criteria ▪ Absolute and relative contraindications o Single vs Bilateral Lung Transplant ▪ Donor criteria o Complications ▪ Primary graft dysfunction ▪ Airway complications ▪ Infection ▪ Acute rejection ▪ Chronic allograft dysfunction - Surgical Approaches o What would be the causes of restrictive lung “disease” with/due to surgery? ▪ Pain ▪ Incision ▪ Spine surgery ▪ Fear o PT Implications ▪ As PTs, we mobilize these patients’ post-op and need to also focus on coughing/deep breathing/thoracic expansion ▪ Watch the tubing/pleur-evac etc ▪ Look at breathing pattern and what you can do to improve it ▪ Important to get these patients moving, why?  Early mobilization Breathing exercises - Oxygen Therapy o Indications ▪ Hypoxemia ▪ Increased work of breathing ▪ Increased myocardial work ▪ Decreased exercise/activity tolerance for patients who desaturate with exercise/activity ▪ Also consider hyperoxia → oxygen toxicity - Artificial Airways o Reasons for Intubation ▪ Airway obstruction ▪ Inability to protect the lower airway from aspiration ▪ Inability to clear secretions from the lower airways ▪ Need for positive pressure ventilation (apnea or ventilatory failure) o Endotracheal Tube ▪ Oral → mouth to trachea ▪ Nasal → nose to trachea (nasotracheal tube) o Tracheostomy Tube ▪ Directly to trachea via tracheostomy just below the vocal cords - Mechanical Ventilation o Positive Pressure Ventilator delivers POSITIVE pressure ▪ Airway pressure is applied at patient’s airway through endotracheal or tracheostomy tube Gas/air flows into lung until ventilator breath ends Still gets passive recoil for exhale when pressure drops ▪ Positive Pressure Ventilation (PPV) Modes Controlled Modes o Ventilator delivers all breaths at a preset frequency and flow rate o Can control with a set volume and/or pressure Assist/Control (AC)/Continuous Mandatory Ventilation (CMV) o Volume controlled/pressure controlled o If patient does not initiate the breath, the machine will supply a breath o ALL breaths are machine delivered Synchronized Intermittent Mandatory Ventilation (SIMV)  o Mechanical and spontaneous breaths Pressure Support (PS) o Constant pressure, but the volume needed to reach the pressure may vary depending on: ▪ lung compliance ▪ resistance ▪ patient effort o Patient determines rate of breathing and volume o Machine will NOT deliver a breath without a patient trigger ▪ Positive Airway Pressure Terms o Recruitment → opening of previously collapsed airway (alveoli) o Derecruitment → collapsing of previously opened alveoli Positive End Expiratory Pressure (PEEP) o Maintains set pressure at the end of expiration to prevent airway collapse Continuous Positive Airway Pressure (CPAP) o Spontaneous breathing with an elevated baseline airway pressure → helps keep airway open (prevents derecruitment) o Indicated for oxygenation o Negative Pressure Ventilator ▪ Iron lung ▪ Vacuum pump created negative pressure chamber that led to expansion of patient’s chest → DECREASED intrapulmonary pressure lets air flow into lungs When negative pressure dropped to “0” → elastic recoil allowed for passive exhale o Non-Invasive Ventilation (NIV) ▪ NIPPV→ noninvasive positive pressure ventilation (CPAP, BiPAP) CPAP → delivers predetermined pressure throughout respiratory cycle BiPAP o Indicated for ventilation (helps blow off CO2) o Can set inspiratory/expiratory pressures o Can set FiO2 and PEEP ▪ May mobilize patients on CPAP/BiPAP Source of O2 may limit distance → have RT around when mobilizing ▪ Both require tight fitting mask ▪ Some patients are NOT indicated for positive pressure intervention  Thoracic patients Esophagectomy patients o Ventilator ▪ Look at screen to see Type of Breath o C = control o S = spontaneous Respiratory Rate o If we don’t see a set rate, that means the patient is breathing on their own and is most likely on CPAP ▪ ALARMS High Pressure o Check for secretions or airflow obstruction o May need suction or use Ambu bag Low Pressure o May be a leak in the circuitry or poor connection to patient Apnea → no breath o Patient did not trigger the machine to deliver a breath Disconnection o Usually a low-pressure alarm Volume o If not maintaining minute ventilation, patient may be fatiguing ▪ Worst Case Scenario If the vent is not working properly → DISCONNECT the patient from the ventilator and START Ambu bagging the patient while calling for help o Suctioning ▪ Need to maintain sterile field ▪ Low vacuum setting → below 120 mmHg ▪ Insert catheter gently until cough is stimulated by contact with the carina ▪ Apply suction while REMOVING catheter from airway DO NOT suction while inserting catheter ▪ Only 5-15 seconds ▪ May suction orally/via trach/nasally - Pulmonary Medications o Smoking Cessation Medications  ▪ Nicotine replacement ▪ Bupropion (zyban) ▪ Varenincline (Chantix) o Medications to Manage Secretions ▪ Antitussives ▪ Antihistamines ▪ Decongestants ▪ Mucolytics and Expectorants o Bronchodilators ▪ Beta2 agonists (beta-adrenergic agonist) ▪ Theophylline (xanthine derivatives) ▪ Anticholinergics o Anti-Inflammatory Medications ▪ Corticosteroids—glucocorticoids ▪ Leukotriene modifiers/inhibitors ▪ Cromones o Important Reminders ▪ Therapist should be aware of patients with exercise induced asthma (pre-medicate if appropriate) Bring short acting bronchodilator to PT session, in case an asthmatic attack occurs ▪ Be aware of the side effects of cardiac effects of theophylline and beta-agonists as well as corticosteroid induced thinning of the skin and weakening of bones, potential steroid myopathy EXERCISE PHYSIOLOGY/TESTING: - Oxygen Transport o Convective O2 Transport ▪ Movement of O2 in air or blood o Diffusive O2 Transport ▪ Passive movement of O2 down concentration gradient across tissue barriers (alveolar-capillary membrane) o Variables ▪ Oxygen Demand → the amount of O2 required by cells for aerobic metabolism Least at rest Increases with activity ▪ Oxygen Delivery (DO2) to tissues Volume of oxygen delivered to systemic vascular bed per minute  Product of cardiac output and arterial oxygen content o Cardiac output (Q) → Q = SV x HR Stroke Volume is affected by o Pre-load o Myocardial distensibility o Myocardial contractility o Afterload ▪ Oxygen Consumption (VO2) by tissues Amount of oxygen that diffuses from capillaries to mitochondria Amount of oxygen a person requires Measure by using OPEN CIRCUIT SPIROMETRY ▪ Oxygen Extraction Ratio (OER) Tissue oxygenation is adequate when tissues receive sufficient oxygen to meet their metabolic needs - Basal Metabolic Rate o Rate of metabolism for an individual in a completely rested state ▪ Work of breathing ▪ Heart/renal/brain function ▪ Thermal regulation → often looking at RESTING METABOLIC RATE (RMR) o MET (Metabolic Equivalent) = close approximation of RMR ▪ Amount of oxygen consumed while sitting at rest ▪ 1 MET = 3.5 mL 02/kg/min ▪ Energy cost of an activity → MET level = VO2/3.5 - Maximum Oxygen Consumption o VO2 (mL/kg/min) ▪ Often use maximal and peak VO2 interchangeably ▪ Maximal True max of what the body could do if exercising all muscles at once ▪ Peak When the body has “had enough” ▪ The more muscle groups working at once → the more closely VO2peak approximates VO2max - DO2 vs VO2 o How does exercise affect both? ▪ Rest → 4x amount of O2 needed is delivered to tissue (excess O2) DO2 → 3-4x greater than oxygen demand VO2 → not going to be dependent on oxygen delivery  ▪ Exercise (in a healthy person) DO2 → increases to meet demands VO2 → demands can increase up to 20x in response to muscle metabolism needs o CO can increase 5x to meet needs o Increased blood flow and capillary recruitment o Increased venous return to heart o Increase in SV and HR If DO2 declines, what happens to VO2? o Typically, does not affect VO2 → but if someone is critically ill, might not meet VO2 demands even at rest ▪ Develop lactic acidosis and decreased pH - Oxygen Debt o O2 Debt or Deficit → difference between O2 body required and what it was able to wake in during activity ▪ Example → sudden sprint o PEOC → once stop activity and begin to recover, need more O2 to recover than body has available o After Strenuous Exercise there are 4 tasks needed to be completed: ▪ Replenish ATP ▪ Replenish myoglobin with oxygen ▪ Replenish glycogen ▪ Remove lactic acid - Factors that Perturb Oxygen Transport o Temperature and ingestion o Disease Factors o Gravitational Stress o Emotional Stress o Exercise Stress ▪ Greatest perturbation to homeostasis and oxygen transport in human ▪ CO, Ventilation, HR, SV are all increased ▪ Oxygen extraction is enhanced ▪ Left Ventricle output is increased by increased HR/SV/contractile pressure → increases systolic pressure and force of ejection LV output = LV input ▪ - Important Equations and Values o Younger/Healthy Individuals ▪ HRMax = 208 – 0.7(age) o 6 Minute Walk Test ▪ VO2Max = (distance ft x 0.012) – 0.732 → 6-minute walk test o % HRR (Karvonen)  ▪ Target HR = (exercise intensity %) x (max – rest) + (rest) o % VO2 Reserve ▪ Target VO2 = (exercise intensity %) x (max – rest) + (rest) o MET Level ▪ VO2/3.5 o VO2 ▪ (MET level) x (3.5) Lab Content - Postural Drainage o Use of gravity to remove secretions from involved lung segment ▪ Maintain for 5-10 minute for each involved segment If done in conjunction with percussion and vibration, then do 3-5 minutes in each position - Percussion (P) o Loosen retained secretions from the airways so they can be removed by expectoration (coughing) or suctioning o Should be rhythmic horse hooves  o Do not perform over bony prominences - Vibration o Move secretions from lung periphery → larger airways where they may be suctioned or expectorated o Gentle, high frequency force o Shaking ▪ More vigorous, similar to vibration ▪ Hands follow movement of the chest wall as air is exhaled - Cough Maneuvers o 4 Phases of an Effective, Controlled Cough ▪ 1st: Inspiratory Phase → inspiration > tidal volume ▪ 2nd: Hold Phase → glottal closure (momentary hold for 2-3 seconds) to increase intrathoracic pressure ▪ 3rd: Force Phase → contract abdominal and intercostal muscles (further increases intrathoracic pressure) ▪ 4th: Expulsion Phase → sudden opening of the glottis with forceful expulsion of inspired air (sharp cough 2-3 times through open mouth while moving into trunk flexion) o Splinted Cough ▪ Use towel/pillow over incisions or painful areas by applying pressure during exhalation o Huff Cough ▪ Forced exhalation maneuver with glottis open ▪ Less airway velocity than cough BUT decreased potential airway collapse ▪ Kids: fog mirror; Adults: use a tissue ▪ Have patient say “ha ha ha” during rapid exhale o Breath Stacking ▪ Breath in, a little more, a little more (like sneezing) - Manual Assisted Cough o Anterior Chest Compression → compress anterior and lower chest o Costophrenic Assist (supine or side lying) ▪ Apply down and in - Self-Assisted Cough o Short Sitting ▪ Wrap arms around abdomen below the ribs ▪ Cough and “throw” body forward o Long Sitting ▪ Can have hands behind head ▪ Throw self forward with cough with head flexion o Prone on Elbows ▪ Extend head/neck, then use head flexion o Quadruped/Hands-Knees Rocking ▪ Extend head/neck, then flex head when push back onto heels while coughing - Active Cycles of Breathing (ACB) o 3 Main Steps ▪ 1- Breathing Control Diaphragmatic breathing for 5-10 seconds at normal tidal volume ▪ 2- Thoracic Expansion Exercises AKA → segmental breathing Increase regional ventilation Do 3-5 reps, may include 2-4 second breath hold ▪ 3- Forced Expiratory Technique Recommend using huff cough Quiet tidal breathing before a med-lg inhale followed by huff cough - Autogenic Drainage (AD) o Use of controlled breathing to mobilize secretions by varying expiratory airflow without PD ▪ Phase 1: Unsticking Breathes at tidal volume inhalation, go into expiratory reserve o “unstick” mucus in smaller airways by breathing at low lung volumes ▪ Phase 2: Collection Breathes slightly above tidal volume and into expiratory reserve o “Collect” mucus in middle airways by breathing at low to mid lung levels (increasing inspiration and exhalation) o Moving breathing from lower to higher lung area and moving mucus with it ▪ Phase 3: Evacuation Breaths into inspiratory reserve and just to end of tidal volume o “Evacuate” secretions from central airways by breathing at mid to high lung levels (breathing at higher lung volumes) ▪ Continue for 3-4 cycles and encourage patient not to cough until complete OR if they hear a “mucus rattle” - Suctioning o Open Technique ▪ Catheter only foes to level of carina so need to use other techniques to get secretions from the peripheral airways first o Closed Technique ▪ Through ventilator tubing o Deep inspiration may be difficult for intubated patients, so AMBU can help inflate o Apply suction while REMOVING catheter - Therapeutic Positioning and Ventilatory Movement Strategies o Normal Inspiration ▪ Paired with UE flexion, ABduction, ER with upward eye gaze o Normal Exhalation ▪ Paired with UE extension, ADduction, IR with downward eye gaze o Pelvic Position  ▪ PPT → facilitates diaphragmatic breathing ▪ APT → facilitates upper chest breathing - Paced Breathing – pair with Breathing and Activity o Inhalation ▪ Paired with trunk extension, moving against gravity, eyes up o Exhalation ▪ Paired with trunk flexion, coming back to gravity, eyes down - Inspiratory Muscle Training o Goal is to increase ventilatory capacity and decrease dyspnea o Must be specific to the muscle you are training o Flow resistive breathing; threshold breathing o Diaphragm ▪ Resisted inhalation (for pts with VT > 500) Can give resistance manually or with weights on the abdomen ▪ Inspiratory mm trainers Up to 30% max inspiratory pressure helpful with vent weaning ▪ If VT < 500, active inspiration without resistance is best o Abdominals ▪ Forward lean test is good indication for abdominal strengthening - Inspiratory Muscle Training: Endurance o Overload → low load over long period of time o Resisted UE concentric ABduction and eccentric ADduction with phonation