Pulmonary 2023 Handout PDF

Outline of Topics Brief Review of Pathology & Dx. Tests PT Associated with: Airway clearance dysfunction Ventilatory pump dysfunction & failure Respiratory Failure Examination – common to both Pulmonary & Cardiac dx. History Medical tests/procedures: O2 therapy, Ventilators, lines/tubes, EKG, Lab te...

Outline of Topics Brief Review of Pathology & Dx. Tests PT Associated with: Airway clearance dysfunction Ventilatory pump dysfunction & failure Respiratory Failure Examination – common to both Pulmonary & Cardiac dx. History Medical tests/procedures: O2 therapy, Ventilators, lines/tubes, EKG, Lab tests , enzymes, CBC, ABG Appearance Dyspnea Systems Review Chest Exam – common to all CP dx Exercise Tolerance/function – some covered in cardiac material Interventions Breathing exercises Airway clearance techniques Inspiratory Muscle Training Functional Exercise Respiratory Medical Equipment/Treatment O2 delivery systems Miscellaneous Mechanical Ventilation Lab Wear lab clothes – exposure to back & chest Pillows Stethoscope Textbook – images – CPT positions EKG –review homework Review Do Poll on Pulmonary Pathology Review Gather info about present c/o & PMH Risk factors- common risks cardiac & pulmonary Medical record review if available/appropriate Symptoms Dyspnea, cough, pain, secretions, if chest pain what are characteristics when does it occur Understanding of disease Patient Interview Patient goals What/how are they limited How far can they walk, how do they walk? Self report 6MWT – part of exam Difficulty with phonation Smoking history Pack years - # packs smoke/day x # years Risk Factors for Pulmonary Disease Smoking/second-hand smoke > 70 pack years ≈ emphysema Occupational exposure to irritants/allergens Air pollution (urban settings) Premature birth Recurrent lung infections PMH chemotherapy/radiation Heart Failure Neuromuscular disorders CVA, SCI, GBS, MD Musculoskeletal disorders Scoliosis, AS, pectus excavatum/carnavatum Trauma/surgery/scarring CABG Integumentary: burns to thorax/neck, scleroderma Autoimmune disease Vascular dysfunction Medical Record Review Dx, date, event Symptoms: prior to & since admission PMH, PSH Current meds Social Hx Diagnostic tests, vital signs, hospital course ABG: oxygen status CBC, cytological tests CXR Pulmonary Function tests Environmental assessment lucency or whiteness means there's something solid Chest X-ray Obs disease - more lucency, less dome in diaphragm Restrictive disease - What do you expect to see on a normal chest X-ray? What would you expect to see in obstructive disease? What would you expect to see in restrictive disease? Pneumonia Pleural effusion Normal Heart size = 1/3 if we see a big heart it suggests HF If ribs fat, it might indicate barrel chests from COPD Normal XR should look like trachea midline, ribs downward angle, nice angle at costo-phrenic angle, dome-shaped diaphragms normal http://www.ctsnet.org/sites/default/files/graphics/experts/Thoracic /venuta_giant_bullous/venuta06.jpg COPD R Middle lobe Pneumonia Pulmonary fibrosis speckled dots throughout whiteness in 1 lobe www.radiopedia.com www.paternatherapeutics.com acute respiratory distress syndrome = restrictive disorder Acid Base Balance Arterial Blood Gas (ABG) pH pH describes the balance between blood acids and blood bases. indicates concentration of H+ ions in the blood Acids give up H+ ions and bases accept them Two types of acids which are regulated by the lungs and the kidneys: Volatile Nonvolatile acids, ketoacids - regulated by kidneys pH Normal pH = 7.4 (7.35-7.45 normal range for this class) pH < 7.4 = acidemia process causing it called acidosis pH > 7.4 = alkalemia process causing it called alkalosis Acidosis pH Normal Alkalosis  7.4 7.35 – 7.45 →→→→→→→ H+ + HCO-3 ↔ H2CO3 ↔ (Bicarbonate) (Carbonic Acid) H2O + CO2 Four Primary Acid-Base Disorders Low HCO3: Metabolic acidosis High PaCO2: Respiratory acidosis High HCO3: Metabolic alkalosis pH high, CO2 low Low PaCO2: Respiratory alkalosis low levels of CO2 Inverse relationship with CO2 and pH Respiratory Acidosis PaCO2 > 45 mmHg pH < 7.35 Causes: Sedatives COPD cant get co2 out; use other systems to regulate pH levels down to norms Hypoventilation Metabolic Acidosis HCO3 < 22 pH < 7.35 Causes: Acidemia 2o to diabetes, starvation, diarrhea, renal failure, exercise Respiratory Alkalosis PaCO2 < 35 pH > 7.45 Causes: Hyperventilation due to… airway obstruction metabolism anxiety pain Metabolic Alkalosis HCO3 > 27 pH > 7.45 Causes: Loss of HCl (stomach), K+ loss, diuretics, alkaline infusion Star this!!!!! Normal Values pH 7.35 – 7.45 PaCO2 35 – 45 mmHg PaO2 80 – 100 mmHg HCO3 22 – 26 mEq/L bicarbonate represents metabolic bc it occurs in the kidneys BE +2 O2 sat 90 – 100 % 4 Steps in Analyzing Blood Gas 1. Determine acid base balance pH > 7.45 = alkalosis pH < 7.35 = acidosis 2. Check PaCO2. This indicates how lungs are functioning. Increased PaCO2 = respiratory acidosis Decreased PaCO2 = respiratory alkalosis 3. Check bicarbonate (HCO3) Increased HCO3 = metabolic alkalosis Decreased HCO3 = metabolic acidosis 4 Look for compensation or correction. Compensation: pH is normalized by altering the component not primarily affected. Correction: pH is normalized by altering the component primarily responsible. https://accessphysiotherapy-mhmedical-com.rdasproxy.mercy.edu/content.aspx?sectionid=176350331&bookid=2270#176350475 ABG: Practice & Review Refer to Practice Handout Reference to chapter 9 in text Examination Patient appearance SOB/Dyspnea Pain – Pain scale Systems Review Musculoskeletal: ROM, MMT, Postural deformities, ability to move functionally (change positions/ walk) Integumentary: Scars, wounds, surgical sites Neuromuscular: Gross screen of sensation, coordination, balance (impaired in pulmonary disease), function Cardiopulmonary –Do this first with exception of exercise capacity Vital signs HR, BP, RR, temp, peripheral pulses Oxygenation: Pulse oximetry Chest exam Cough effectiveness Exercise capacity – 2m or 6m walk, exercise test if appropriate Patient Appearance General Appearance : Body type cachexia Color Clubbing Overall state of consciousness Posture Appearance of distress Difficulty breathing/speaking, accessory muscles, facial expression/pain Medical devices: IV, lines, tubes, supplemental oxygen/delivery method, ventilator Evaluation of Dyspnea Should be done at rest and with activity Modified Borg Dyspnea Scale Quantifies dyspnea Borg Rate of Perceived Exertion Scale 6-20 scale 0-10 scale Quantifies perception of exertion Medical Research Council (MRC) Breathlessness Scale Does not quantify dyspnea Measures degree dyspnea interferes with functional activities Quality of Life Measures – Outcome Measures SF 36 St. George’s Respiratory Questionnaire – Disease specific quality of life tool Modified Borg Dyspnoea Scale 0 Nothing at all 0.5 Very, very slight (just noticeable) 1 Very slight 2 Slight 3 Moderate 4 Somewhat severe 5 Severe Exercise Training Zone 6 7 Very severe 8 9 10 Very, very severe (almost maximal) Maximal Patient Instructions for Borg Dyspnea Scale: “This is a scale that asks you to rate the difficulty of your breathing. It starts at number 0 where your breathing is causing you no difficulty at all and progresses through to number 10 where your breathing difficulty is maximal. How much difficulty is your breathing causing you right now?” http://www.docstoc.com 4 Components of Chest Examination Inspection Palpation Percussion Auscultation Cough/cough effectiveness Inspection General appearance Level of consciousness Color Clubbing Facial expressions Respiratory effort Body type Cachexia: wasting ©Mayo Foundation for Medical Education and Research www.merck.com www.coalitionforpf.org Inspection Overall condition cachexia Posture/positioning Chest abnormalities Assymetry Scoliosis/kyphoscoliosis Pectus carinatum Pectus excavatum Barrel chest Pectus Carinatum Pectus Excavatum Barrel Chest Inspection Evaluation of neck accessory muscles tracheal position jugular vein distension Inspection (continued) Respiratory pattern evaluation of chest resting & dynamic rib angles, symmetry, transverse & AP diameter, scars moving chest rate, pattern, I:E ration, paradoxical breathing pattern Try to observe without client noticing (a good time is when taking pulse) Phonation, cough & cough production (observe for spontaneous cough) Breathing Pattern Description Apnea Absence of breathing Eupnea Normal rate, depth and regular rhythm Bradypnea Slow rate, shallow/normal depth, regular rhythm Dyspnea Rapid rate, shallow depth, regular rhythm, Tachypnea Fast rate, shallow depth, regular rhythm Hyperpnea Normal rate, increased depth, regular rhythm Cheyne-Stokes Increasing and decreasing depth, periods of apnea, regular rhythm Biot’s (CNS) Slow rate, shallow depth, periods of apnea, irregular rhythm. Apneustic Slow rate, deep inspiration followed by apnea, irregular rhythm, brainstem disorders Doorstop Normal rate & rhythm with abrupt cessation of inspiration with restriction Orthopnea Difficulty breathing in postures other than upright Palpation Tracheal position are A-P movements the same? They should be. Chest motion – breathing patterns Anterior: lower chest wall (near abdomen) & Upper chest wall (mid-sternal) Posterior: base of lung, between scapulae, shoulders/upper trap area Check for asymmetry. Chest excursion with tape measure – not too reliable Evaluation of Fremitus Vocal fremitus-normally felt when speaking Rhonchal fremitus-felt during quiet breathing; indicates build up of secretions Muscle Activity Pain Percussion Evaluate lung density Diaphragmatic excursion Percussion Technique Tap DIP joint of L middle finger with tip of R Middle finger Percuss between scapula and vertebral column Diaphragmatic excursion Mediate Percussion Lung tissue - may produce 3 sounds: Resonance - normal Dullness Tympanic/Hyper-resonance Resonance Normally heard in healthy lung Anteriorly from clavicle to 6th rib Laterally to 8th rib Posteriorly to 10th rib Moderate to loud intensity Hollow Intensity Dull Sound Soft intensity Dull thud-like quality Produced with percussion over liver Abnormally heard in lung tissue with consolidation (fluid/solid), atelectasis, pleural effusion, or tumor Tympanic or Hyper-resonance Loud lengthy and low pitched Hollow quality Percussion over empty stomach Abnormal in periphery of lung Indicates increased air in lung: emphysema Auscultation of Lungs Breath Sounds Are generated by vibration and turbulence of airflow into and out of the airways and lung tissue during inspiration and expiration. Performing the Exam Instruct patient to lean slightly forward Expose anterior chest to evaluate upper and middle lobe. Patient breaths in and out through mouth. Evaluate at least one breath/segment. Compare intensity, pitch, quality of each segment between R and L Cranio-caudally, symmetrical Repeat posteriorly Anterior Chest http://medicine.ucsd.edu/clinicalmed/index.htm Auscultation: Posterior Chest http://medicine.ucsd.edu/clinicalmed/index.htm Lateral Chest http://medicine.ucsd.edu/clinicalmed/index.htm Normal Breath Sounds: Tracheal Bronchial Bronchovesicular Vesicular Tracheal Breath Sounds Normally heard only over the trachea. Loud Harsh, high pitched Absence of sound between inspiration and expiration – expiration slightly longer than inspiration Like wind blowing through pipe. Bronchial Breath Sounds Normally heard adjacent to the sternum around major airways. Loud, high pitched, hollow sounds Expiration longer and louder than inspiration Pause between inspiration and expiration. “Tubular sounds” Bronchovesicular Breath Sounds Normally heard adjacent to the sternum/manubrium 1st & 2nd intercostal space at costo-sternal border, and posteriorly between scapula – over larger airways Softer sound than bronchial – medium pitch Inspiration and expiration are equal in length and loudness and are continuous-no pause Abnormal: If heard in other areas indicates consolidation. Diminished if decrease in lung tissue or shallow breaths. Vesicular Breath Sounds Soft, Low pitched, muffled Breezy quality Inspiration is louder, longer and higher pitched than expiration. Pause between inspiration & expiration Normally heard over periphery of lung Abnormal if diminished or absent https://www.youtube.com/watch?v=JFWMJGtmG5E Voice Sounds Reflect the ability of the lung tissue to transmit spoken or whispered sound to the thoracic wall to be heard through the stethoscope. Should be evaluated as decreased, normal or increased. Voice Sounds Bronchophony Egophony Pectoriloquy Whispered Pectoriloquy Patient asked to whisper 1, 2, 3. Usually not heard clearly. Heard clearly in airless lung. Bronchophony Ask patient to to repeat the word 99, 99 etc. Normally sound will be muffled If heard distinctly indicates underlying tissue is relatively airless. Egophony Patient asked to say EEEE which is auscultated on chest as AAAA. Related to sound transmission through airless lung – mass/consolidation allow better sound transmission than through air Egophony https://www.youtube.com/watch?v=5RqrBf242mk Adventitious Breath Sounds 2 Common Categories: Crackles: Previously called rales, non-musical sounds (usually heard on inspiration) Fine (dry) Coarse (wet) Wheezes: What was previously called rhonchi is put in this category musical quality Crackles Commonly heard throughout inspiration or end inspiration. Often heard at base of lungs. May represent sudden opening of previously closed airways. May result from movement of secretions during inspiration or expiration When might you hear this? pneumonia, atelectasis, CHF, pulmonary edema Wheezes Continuous adventitious sounds with constant pitch. Most frequently heard on exhalation and associated with airway obstruction. Found in airway constriction as in bronchospasm or when secretions are narrowing the airway. What conditions would you hear these in? asthma, bronchitis Adventitious Sounds Other Adventitious Sounds Stridor Rubs Crunches Cough Effective, weak/ ineffective, unable Dry/moist/productive Sputum Color Consistency: thin, moderately thick, thick Smell – don’t sniff, but does it have an odor Laboratory analysis/cytological tests Change in breath sounds after cough? Normal Heart Sounds First Heart Sound (S1) Due to closure of the mitral (M1) and tricuspid (T1) valves. High frequency sound “lub” Second heart sound (S2) Due to closure of aortic (A1) and pulmonic (P2) valves. High frequency sound “dub” Auscultation of the Heart Sounds Methods: Use a systematic approach Different areas of the chest are used to examine different anatomical structures of the heart Identify a reference point in cardiac cycle Listen for time interval between S1 and S2 (shorter duration) and between S2 and S1 (longer duration Palpate pulse: sound heard closest to palpable pulse is S2 ECG: sound heard at time of R wave is S1 Auscultation areas Aortic area: 2nd ICS, R sternal border, S2 best heard Pulmonic area: 2nd ICS, L sternal border, pulmonic valve closure (P2) of the second heart sound is best heard Tricuspid area: 5th intercostal space L sternal border. Tricuspid valve closure (T1) of the 1st heart sound is best heard in this area. Mitral area: 5th ICS midclavicular line near left nipple, mitral valve closure (M1) of the first heart sound is heard best here http://medicine.ucsd.edu/clinicalmed/index.htm Abnormal Heart Sounds Third heart sound (S3): low frequency sound heard in diastole “lubdub-dub” Normal in children Associated with heart failure in adults Due to poor ventricular compliance Fourth heart sound (S4): low frequency sound heard in late diastole. Associated with MI and hypertension “dub-lub-dub” Due to exaggerated atrial contraction and turbulence Abnormal Heart Sounds Murmurs: Swishing sounds heard during systole, diastole or both. Due to rapid or forceful blood flow past area of stenosis or regurgitation Systolic click: single/multiple clicking sound in heard in systole Mitral or tricuspid valve prolapse Pericardial friction rub: squeeky or leathery sound heard usually heard during diastole Pericardial effusion Other Tests Handheld Spirometry: FVC, VC Peek flow used with asthmatics Mouth Pressures-Indirect measurement of respiratory muscle strength prediction equation for age and gender (55-80) MIP: M =120-(age x 0.25) F = 122 – (age x 0.79) MEP M =353- (age x 2.33) F = 158 – (age x 0.18) Respiratory Pressure Meter Functional Activity Assessment Bed mobility ADL Ambulation Response to exercise 6-minute walk O2 saturation: rest, activity, recovery Vital signs, pre-activity, position changes, peek activity, recovery Oxygen Saturation www.nuh.nhs.uk/qmc/MESU/images/Nellcor550.jpg Oxygen Saturation intensivecare.hsnet.nsw.gov.au/.../oximeter.jpg www.wingsandwheels.com/images/SPO003_Blanks1.jpg Please Review Pulmonary Function Tests Chest X-rays Mouth Pressures Blood Gases Pulmonary Interventions Interventions Patient Education Positioning Airway Clearance Techniques Relaxation Exercise Flexibility Exercise Aerobic Exercise Strengthening Exercise Breathing Exercise/breathing retraining Inspiratory Training (resistive) Functional Training Balance if appropriate Oxygen Patient Education Pre-operative Teaching General education relating to disease Prevention of complications Respiratory complications Surgical complications Exercise Principles of exercise Safety/precautions Energy conservation Post operative Positioning comfort may improve respiration surgical: head elevated 20, legs slightly flexed, keeps scar slack and does not impair diaphragm excursion Relaxation Visual imagery Jacobson’s relaxation Pain Relief Incentive Spirometer Cough: splinted Secretion removal - postural drainage More on Positioning Dependent areas of lungs will have less ventilation and prone to atelectasis Lower posterior lobes have highest perfusion V/Q mismatch in supine position Prone positioning in ARDS Avoid supine exercise in CHF due to increased cardiac preload Breathing Exercises Incentive Spirometry – Deep Breathing Diaphragmatic Breathing Pursed lip breathing Segmental breathing (localized expansion) Breath stacking Coordinated breathing with functional activities PNF activities Inspiratory Muscle Training (IMT) Incentive Spirometer Diaphragmatic Breathing Claims Strengthens diaphragm ? Decreases work of breathing ? Decreases O2 demand Uses less energy to breath Decreases sympathetic tone Improved stability of core Plays role in pain management Decreased Cortisol levels Pressure in lungs decreases Inspiration Diaphragmatic Breathing Expiration https://my.clevelandclinic.org/health/articles/9445-diaphragmatic-breathing Evidence: Breathing Exercise Pursed lip breathing (PLB), Diaphragmatic breathing (DB) Although these have been a long-time staple in the interventions used in COPD the evidence is conflicting. PLB: slows respiratory rate, decreases airway narrowing in expiration DB: been shown to increase work of breathing and dyspnea in some patients with poor diaphragmatic movement and hyperinflation Positive effects related to decrease in RR Patient’s who may benefit from DB are those with shallow rapid respiratory rates and who demonstrate increased tidal volume while using this technique (Cahalin, 2011) May not be helpful in patients who have paradoxical motion of diaphragm Evidence supports PLB but little support of DB Diaphragmatic Breathing - EBP DB in 29 patients with mod-severe COPD resulted in significant increase in TV and decrease in RR leading to improved ventilation, increased O2 sat and reduction in dead space ventilation. 10 patients with asynchronous abdominal diaphragmatic motion showed worsening dyspnea (Fernandez, et.al., 2011) DB and combination of DB+PLB were studied in patients with COPD both DB and DB+ PLB resulted in a significant increase in chest wall TV and decreased RR. No change in dyspnea or end expiratory volume were observed (Mendez, et. al., 2019) Pursed Lip Breathing (PLB) Slows respiratory rate Prevents breath stacking - explain Prevents small airway closure by maintaining consistent pressure in airways Prevents air trapping Slows RR by prolonging expiration Helps relieve SOB Promotes relaxation Instruction: breath in through nose and exhale slowly through pursed lips Pursed Lip Breathing PLB in participants with COPD showed increased in O2 saturation mean increase of 2.5%, decrease in RR (mean 0.65) and decrease in HR (mean 1.6b/min). (Sakhaei, S.,2018) PLB, ventilatory feedback plus exercise, DBE, combined BEs, and singing could be used to improve ventilation and QOL based on low to mod level evidence in a meta-analysis (Ubolnuar, N, 2019) In a different Meta-analysis, moderate quality evidence demonstrated that PLB increases O2sat, and TV, decreases RR and reduces time taken to recover to pre-exercise breathlessness levels. (Roberts, 2009) Exercises to Increase Expansion Used to help prevent or treat atelectasis Prophylactically post op Improved expansion in pneumonia and pleural effusion Deep breathing Encourage use of diaphragm – all components not just anterior Incentive spirometry Segmental breathing Breath stacking –Stacked breathing - neurologic Segmental Breathing https://www.exerciseprolive.com/ https://slidetodoc.com/pulmonary-rehabilitation-in-rheumaticdiseases-by-sally-saber/ EBP: Other Breathing Techniques Study concludes that the segmental breathing exercises have better effect on chest expansion and pulmonary function than deep breathing exercises in pleural effusion. Gunjal, S.B , 2015 A preoperative breathing intervention on patients undergoing cardiac surgery may help improve respiratory performance after surgery, reduce postoperative pulmonary complications and hospital length of stay. However, more trials are needed to support and strengthen the evidence. (Rodrigues, SN.,, et. al , 2021) Breath Stacking A way to improve lung volume when a patient cannot take a deep breath on their own Helps improve inspiratory volume Prevent atelectasis Help move secretions Person takes as deep of a breath as they can, then PT manually adds more inflation with ambu bag Can be done by having person take a deep breath, hold then attempt to take in more-repeat. Used in post COVID Breath Stacking Breathe out fully. Take a full breath in. Hold your breath for a few seconds, then try to take another breath on top of the previous one. Repeat step 3 until you feel you have taken as deep a breath as you are able too. This may take between 2 and 5 repetitions Try to hold your breath for 3-5 seconds then slowly breathe out. Rest between each breath stacking attempt for at least 30 seconds. Then repeat steps up to 5 times in a session. If there are secretions try to cough or huff. Rest between cycles, to avoid getting light-headed. Intervention: Inspiratory Muscle Training Inspiratory Resistive Exercise Rationale: Impairment in respiratory muscle function contributes to poor exercise tolerance in COPD if muscle function can be improved so will exercise tolerance Inspiratory Muscle Training Evidence: Inspiratory Muscle Training Evidence is varied Training intensity must be sufficient to increase maximal inspiratory pressure to see improved exercise performance At least 30% PI max 15-30 minutes/day 5 days/week Although the evidence is inconclusive, IMT is safe, non-invasive and can be performed at home with a relatively inexpensive device. Inspiratory Muscle Training Meta-Analysis of 13 randomized controlled trials of use of IMT in patients, post-cardio-thoracic surgery totaling 784 patients found that IMT group exhibited significantly decreased postoperative pulmonary complications compared to standard care (Xiaoqing G, 2018) Inspiratory muscle training is beneficial for improving respiratory muscle strength, functional capacity, and dyspnea in patients with stable heart failure and respiratory muscle weakness. (Lin et. al., 2012) In COPD addition of IMT to regular exercise program improved MIP and functional capacity. (Gosselink, R., 2011) Airway Clearance Techniques (ACT) A variety of different techniques used to eliminate excess secretions Goal is to reduce airway obstruction caused by secretions occupying the airway prevent respiratory tract infections re-expand the collapsed areas of the lung improve gas exchange What technique is best? It depends…. Patient diagnosis Cognitive status/learning ability Patient preference and buy in Airway Clearance Techniques Postural drainage Cough Controlled cough Assisted cough Self assisted cough Forced expiratory technique (huffing) Active cycle of breathing Autogenic Drainage Endotracheal/Nasotracheal suctioning Mechanical Devices Postural Drainage A passive technique in which the patient is placed in positions to enable gravity to assist in the flow of secretions from the airways. Often performed in conjunction with manual techniques such as: percussion, vibration or rib shaking. Although frequently performed together each technique has its own indications and contra-indications Postural Drainage Indications Mechanical ventilation Prolonged bed rest Increased sputum production Splinting from pain hypoventilation Atelectasis Pneumonia Pre/post-op secretion control Obtunded/coma patient CNS/general weakness Weak cough Artificial airways Contraindications to PD I.C.P. > 20 mmHg Unstable head/spine injury Active Hemorrhage with hemodynamic instability Recent spinal surgery Active hemoptysis Empyema Pulmonary edema (CHF) Large pleural effusion Pulmonary embolism Rib Fx/flail chest Aged, confused or anxious patients Not immediately after meal/feeding tube must be closed at least 20 min prior Contraindications to chest manipulation Subcutaneous emphysema Coughing up blood Recent epidural/spinal anesthesia Recent skin graphs, burns, open wounds, skin infections Recently placed pacemaker Lung contusion Bronchospasm Osteomyelitis of ribs Osteoporosis, bone metastasis Coagulopathy Platelet count