Cardio Pulmonary Master Document Google Docs

Cardio Pulmonary Master Document
Cardiac
Cases
MYOCARDIAL INFARCTION
Case 1
Mr M is a 49 year old man who suffered a myocardial infarction 10 days ago. He
has been referred to a cardiac rehabilitation program to assist his recovery. Mr M
is a single father and has two teenage children. He works as a manager and has a
history of cardiac arrhythmia. As part of the regular monitoring of Mr M’s
rehabilitation program, he is asked to assess level of exertion using the Borg Rating of
Perceived Exertion Scale (RPE) after each period of activity. The patient rates the level of
exertion as 9 on the 6 ‐ 20 scale.

Q1 What does a rating of 9 mean?

a. very light
b. somewhat hard
c. hard
d. very hard

ANS: A
Reference P n P Pg 500.
The 15‐grade borg scale is used and this starts from 6‐20.
6 = No exertion at all
7‐8 = extremely light
9 = very light

On the 10 point scale the very light rating is equivalent to 1.

Q. In sending Mr M for rehabilitation, the cardiologist indicates that Mr M’s exercise
program should not exceed 7 metabolic equivalents (METs). Given this requirement,

Q 2 which of the following activities is CONTRAINDICATED?

a. riding a sta倀onary bike at approximately 8 km/hr‐
b. descending a ﬂight of stairs independently
c. ascending a ﬂight of stairs with assistance
d. ambula倀ng independently at 8 –10 km/hr

ANS: D
UPTO 5mph is allowed in 7MET
Reference ‐ O’Sullivan 558.
D ‐ upto 8 km/hr falls within 7 MET. But anything more than that is greater than 7 MET.
Most possible it will be 7.5 or 8 MET. Hence this is the ANS

POE
8 km/hr is approximately 5mph
A ‐ Upto 7 MET is 11 mph of cycling. So this is within range.
B and C ‐ light recreational activities fall within 7 MET. Such as light jogging, friendly
match of badminton and tennis. Hence stairs too will be within limits.

Case 2
A home health physical therapist is treating an elderly patient. On this day he is
confused with shortness of breath and generalized weakness. Given his history of
hypertension and hyperlipidemia, the therapist suspects:

a. his mental changes are indica倀ve of early Alzheimer's disease.
b. he may be experiencing unstable angina.
c. he forgot to take his hypertension medica倀on.
d. he may be presen倀ng with early signs of myocardial infarc倀on.

ANS: D
MI can ave more severe pain than angina. But it is also possible to have a silent MI.

POE
A and C are out because of logic.
B The patient doesnt have any chest pain. So this option is out.
Angina is partial blockage of coronary arteries
D This seems most appropriate right now.
MI complete obstruction of coronary arteries.

Myocardial infarction
1. phase 1 ,stage one what exercise
a. sit at the edge, and walk to bathroom is it is near
b. walk for 2 min etc

2.what type of muscle fibres get affected
a.endurance fibres etc

Case 3
Case: 40 something year old man. Myocardial Infarction

1. Immediate physio intervention

a. Walk twice a day for 5 min s
b. Walk 5 min s for 3‐times/ day.
c. 15 to 30 min s on ‫ﻐ‬lat surface.
d. Walking for 15‐30 minutes on elevated surface.

ANS – B.
Reference P n P. Pg 505.
Phase 1 rehabilitation is in hospital. Its advisable to do short periods of activities
frequently.
F ‐ 2‐3x/day
I ‐ RHR + 20 bpm post MI
RHR + 30 bpm post CABG
RPE keep below 11 (light) or symptom limited.
T ‐ anywere between 5‐20 mins. intermittent bouts.
T ‐ sitting, standing, functional activities, walking etc.

2. What will physio implement on cardiac rehab ( something related to discharge)

a. Walking 15 min s on inclined
b. walking 30 min s on ‫ﻐ‬lat surface
c. 1 to 2 ‫ﻐ‬light of stairs with physio or nurse
d. walking 2 ‫ﻐ‬lights of stairs 4 times a day independently

ANS ‐ B (best option). Ideally duration should be increased ‫ﻐ‬irst then followed by the
intensity(resistance, speed or duration

Acc to P n P pg 506‐ In phase II 30 min walk once or twice daily.

POE:
A ‐ Inclined surface is too much for this patient at this stage. It will be in phase 2 rehab.
Over a period of 6 weeks.
C ‐ 1‐2 ‫ﻐ‬lights will come later. Walking can be done ‫ﻐ‬irst.
D ‐ This is more intensive than option C and I will keep this on the side.

3. Non complicated MI exercise intensity

a. 60 – 75 %of max heart rate for exercise testing for 1st 4 weeks.

b. Very light intensity exercises for 4 weeks
c. very light intensity exercises for 2 weeks and progress to moderate intensity.

ANs – c
This is the recommended dosage. I agree with this option as it has speci‫ﻐ‬ic values.

My ans: 6070% of intensity starts at Phase III i.e. around 3 4 weeks post event to 612
weeks
C clearly answers the Q acc to P n P pg 510 as mod intensity workload reduces risk of
arrhythmias since the case is of uncomplicated MI
Phase 1 57 days <11 Borg scale
Phase 2 26 weeks

4. Which is the most appropriate pathway for heart electric conduction from SA node?

1. From SA node through internodal pathways to AV node and then to Bundle of His.
2. From SA node to AV node to internodal pathways and connecting to Bundle of
His.
3. From SA node through Bundle of His to AV node and then to ventricles via
internodal pathways.
4. From SA node through internal pathways to Bundle of His and then to AV node.

ANS – A( google)

5. Which of the following cannot be done if he has been advised for exercise intensity <7
METS, not sure about options

A: Walk twice a day for 5 min s
b. Walk 5 min s for 3‐times/ day.
c. walk on treadmill at 8km/hr.
d

ANS ‐ C
Reason ‐ 8km/hr (= 5mph) is 7 MET. This is the most intensive option given in all 3
options. And if he walks at 8 km/hr he is working out 7 METs. Hence this is the correct
answer.

Case 4

ANS:A
Unstable angina chest pain not responding to rest or nitroglycerin

Case 5

ANS: B since pain is going away with rest stable angina
Absence of oedema means NO CHFcongestive heart failure.

Case 6

ANS: B
No c/c of oedema
Symptoms of heart failure start to happen when your heart can't pump enough
blood to the rest of your body. In the early stages, you may:
● Feel tired easily.
● Be short of breath when you exert yourself.
● Feel like your heart is poundingor racing (p
alpitations ).
● Feel weak or dizzy.
As heart failure gets worse, fluid starts to build up in your l ungs and other
parts of your body. This may cause you to:
● Feel short of breath even at rest.
● Have swelling ( edema ), especially in your legs, a
nkles , and feet.
● Gain w
eight . This may happen over just a day or two, or more slowly.
● Cough or wheeze, especially when you lie down.
● Need to urinate more at night.
● Feel bloated or sick to your s
tomach .

Case 7
&q69= A patient is four weeks post myocardial infarction. Resistive training using
weights to improve muscular strength and endurance is appropriate:
69a= if exercise intensities are kept below 85%25 maximal voluntary contraction.
69b= if exercise capacity is greater than 5 METs with no anginal symptoms/ST segment
depression.
69c= during all phases of rehabilitation if judicious monitoring of HR is used.
69d= only during post‐acute phase 3 cardiac rehabilitation.

ANS: B
Resistive training contraindicated if METS<<<<6
ST depression means‐ mycardial ischemia
ST elevation means‐myocardial infarction
http://lifeinthefastlane.com/ecg‐library/st‐segment/

A‐ no relation between max vol contraction with resisitive training in cardiac rehab
D‐resistive training can be used in Phase 4

Case 8
&q86= A patient is recovering at home from a myocardial infarction and
percutaneous transluminal coronary angioplasty. The physical therapist decides to use
pulse oximetry to monitor his responses to exercise and activity. An acceptable oxygen
saturation rate (SaO2) to maintain throughout the exercise period is:
86a= 82%25.
86b= 75%25.
86c= 92%25.
86d= 85%25.

ANS: C

Case 9
&q133= A patient is ‫ﻐ‬ive days post‐MI and is referred for inpatient cardiac
rehabilitation. Appropriate criteria for determining the initial intensity of exercise
include:
133a= systolic BP less than 240 mmHg or diastolic BP less than 110 mg Hg.
133b= HR less than 120 beats/min and RPE less than 13.
133c= HR resting + 30 beats/min and RPE less than 14.
133d= greater than 1 mm ST‐segment depression, horizontal or downsloping.

ANS: B

A‐ situation contraindicate ex in Phase 1 in post‐MI
C‐ Resting HR+30 bpm = for post CABG not post MI ( Resting HR+20 bpm)
D‐ It means myocardial ischemia n elevation means myocardial infarction

Case 10
ANS:
Surgeries
CABG
Case 1
Mr A is a 80 YO, almost retired man of a farm, who helps his family
with the family business. He has had CABG X 2 in 1994 and 2007. He
lives 300km from the rehab centre. Over the past 4 months he has
been feeling breathless over small activities. He can walk 200m on
ᣠat ground but he is very breathless on slope or incline and while
climbing stairs. His wife is concerned that he might do too much.

Q: What is the best management plan for this patient?

1: Arrange an outpatient service for his cardiac rehab
2: Arrange a 4 weeks inpatient stay and then outpatient rehab twice a week
3: Provide a home program with written exercises and review him on intervals
4: Review every 6 weeks

ANS: C
This is the most appropriate. As we have told the patient what to do
and then we are FU on him after certain periods.

POE
A - Outpatient service will still be difឈcult for this patient as he is 400
km away from the rehab centre.
B - Inpatinet stay is for only 5-7 days. Hence this long term inpatient
stay is out too.
D - reviewing every 6 weeks is do-able. But this alone is not enough as
there is no action plan.

Q1 he's too far for OPs at 300k+ per visit. He seems too good 200m amb for a 4 week IP stay. And I'd want to
do something about him now, not review every 6 weeks. So I'd go C. HEP and review on intervals.

Q2 prior return to sport seek cardiologist review. So A.

Q3: levels of Exertion as we use in cardiac rehab. It will be what he is familiar with. So B.

Q: How can his wife be a part of his rehab?

1: Ask her to check he is doing his exercises correctly
2: Ask her to report to the physio his progress regularly
3: She can encourage him to keep his rehab going
4: She can implement emergency treatment

ANS: C

POE
B - No need to report as patient is coming for review sessions.
D - She is not supposed to implement emergency Rx.

Between A and C. Between checking and encouraging, encouraging
the patient will be better as this includes checking too that he is doing
his job well.
Pat do need + supportive environment.

Q. Mr A now feels better. He is able to walk 500m and feels much less
breathless on slope.
He asks you if he can play golf now, help more with the farm and do
some lifting.

Q: What is the most appropriate answer that you would give as his
treating physio?

1: Ask him to call his cardiologist and check with him
2: Tell him to go back to work and play golf and stop his rehab
3: Tell him he’ll be able to go back to work and play golf but later
4: Tell him he won‘t be able to do such activities anymore

ANS: A

Best answer - refer him back to the Dr.

POE
B - We cannot stop rehab for CR patients. Maintainence is
recommended which is still upto 4-5x/week.
C - This doesn’t sound so very appropriate as this is not giving a speciឈc
direction as to when and what time lines.
D - This is discouraging the patient and it will kill his motivation.

Q: How can Mr A self-monitor his exercise intensity?

1: Based on pain in his legs
2: Based on level of exertion
3: Measuring his blood pressure
4. Measuring his respiratory rate

ANS: B

Reference P n P ‐ Pg 499 ‐ 500.
Either patient will measure HR or RPE. Since HR is not given as an option, the next best
is RPE. The 15 point scale or CR10 either one is effective and can be used.

CROP ‫ﻐ‬ile: pg 104
Walking at low to moderate intensity is considered the best initial exercise. Patients are
instructed to start on ‫ﻐ‬lat ground and walk at a comfortable pace using the self
monitoring (e.g. Borg scale, talk test).
Once they can achieve this for 30 minutes they can consider adding inclines. Progression
is usually achieved in 5 minute increments if they are sign and symptom free at their
current level.

Diff Q from FB:

Q how to self monitor his exercise intensity ?
1 leg pain
2 level of exertion
3 b orgs scale
4 respiratory rate

Case 2
Cardiac prevention clinic –A 50 y.o male has come for regular health assessment. All
vitals look normal. He has a BMI of 30

Q: What does a BMI of 30 mean? The patient is:

1. Overweight
2. Normal
3. Obese
4. Underweight

ANS – C god has answered it

http://l.facebook.com/l.php?u=http%3A%2F%2Fwww.health.gov.au%2Finternet%2Fh
ealthyactive%2Fpublishing.nsf%2FContent%2Fhealthy‐weight&h=2AQF_aKEp

Q: How often should he exercise during his rehab program?

1. 4‐5 times a week
2. 3‐4 times / week
3. 1‐2 times / week
4. Every day

ANS ‐1
http://www.heartonline.org.au/articles/exercise/exercise‐program‐set‐up‐and‐design
#maintenance‐exercise‐programs

Cardiac rehab (according to PnP) should include 12 supervised sessions and 2 home based exercise
sessions. Thats i choose 34 times a week for q1. Whats your reasoning for q1? (Ive got PnP fourth edition
maybe its outdated?)
Others days at home: walk or leisure activities.

Also this is very very similar to plmonary rehab toolkit.
http://www.pulmonaryrehab.com.au/index.asp?page=57
Options for maintenance exercise programs:
Continue to exercise 3 to 5 days per week by either:
● once a week, supervised exercise program in a health facility, community or hospital
outpatient setting plus unsupervised exercise on 2 to 4 other days per week.
or

● unsupervised home exercise program with regular review (e.g. every 3 to 6 months) at the
pulmonary rehabilitation program

Q: What is the role of a physio in a cardiac prevention clinic?

1. Assessment and management of pain
2. Weight reduction program
3. Assessment & appropriate management of cardiac risk factors
4. Assess risk factors of cardiac problems

ANS – C
Reference Tidy’s 15th ed. pg 147 (top left)‐ The role of PT is in exercise prescription,
training and education of patient in stages 1‐3 of the rehab.

POE
A ‐ Not necessarily managing JUST pain here. It can be part of the entire Rx.
B ‐ Same reasoning as A.
D ‐ Yes. Ax is good. But Ax and Mx will be even better. As is done in C.

Case 3
Cardiac rehabilitation, CABG 2yrs ago, lives in farm
Ques abt assessment

a. Troponin level, QOL
b. Resp rate, auscultn, sputum
c. Oswestry disability questionnaire

ANS: A
Recall looks poor to me. But some critical thinking.

POE:
A ‐ Enzyme levels in blood work help determine the presence of an MI. CK‐MB are the
most sensitive in diagnosing the problem if within the ‫ﻐ‬ist 10 hours. After 10 hours
troponin levels are reliable.

High cardiac enzymes ‐ greater risk of complications and and future cardiac events

B ‐ RR, Auscultation (this can be helpful with S1 and S2 sounds. But it will be more
bene‫ﻐ‬icial for the valvular problems.). Sputum is not a big issue if the person is suffering
a MI. Most important is diagnosis.
C ‐ Oswestry disability questionnaire is used for LBP patients. So this option s out.

Out of the 3 the best options still standing is A.
Case 4
48‐year‐old male. Running information technology ‫ﻐ‬irm. He enjoys bike riding but does
not do regular exercises. His BMI is 31. Had blood pressure reading at rest of 136/88
mmHg. Achieved a maximal heart rate of 170 beats per minute and was noted to have
above average ‫ﻐ‬itness for his age.
He has been referred to a multidisciplinary team including physiotherapy for
preventative management

Q : 1 What does BMI indicate?

‐ obese
‐ overwight
‐ Slightly overweight
‐ normal

ANS: A

Reference:
● A BMI below 18.5 (shown in white) is considered underweight.
● A BMI of 18.5 to 24.9 (green) is considered healthy.
● A BMI of 25 to 29.9 (yellow) is considered overweight.
● A BMI of 30 or higher (red) is considered obese.

Q : 2 Mr R asks the physiotherapist what is the target blood pressure for people at risk of
coronary heart disease. What should the physiotherapist tell him?

‐ < 180/110mmHg
‐ < 160/100mmHg
‐ < 130/80mmHg
‐ ≤ 120/60mmHg

ANS: C
Yes C is most appropriate. Its important to maintain SBP less than 130 and diastolic less
than 100.

Q : 3 What percentage of maximal heart rate should the physiotherapist recommend Mr
R maintain while exercising?

‐50‐60%
‐ 6070%
‐ 70‐80%
‐ 80‐90%

ANS: B
www.heartfoundation.org.au

reference for these questions.
Ans : B. ‐ 60‐75% of maximal heart rate(HRmax)
475‐ 4ed‐. P n P

In the INTENSITY prescription, the most critical things to do is to maintain a target HR.
This can be done in various ways.
1. Symptom limited HR
2. Age‐adjusted HR ‐ 220 bpm ‐ age in years
3. HRR(heart rate reserve‐ maximal HR ‐ resting HR

In all the 3 options the target to be maintained is between 60‐75% of the calculated
value.
Except for 1st one (symptom limited). Where the target HR needs to be 10‐20 beats
below the symptom.

Age adjusted and training HR set at 60‐75% of maximal HR===40 ‐65% of VO2 max

60‐75% HHR===60‐75% VO2 max

Q : 4 Mr R is confused about the roles of the various health professionals in the
multidisciplinary team. What should the physiotherapist tell Mr R is the role of the
physiotherapist in the cardiac clinic?

‐ Assessment and management of patient’s physical needs.
‐ Behavioural management and counselling.
‐ Design and implementation of weight loss programs.
‐ Monitoring of coronary heart disease risk factors.

ANS: A‐ APC answer
Reference Tidy’s 15th ed. pg 147 (top left)‐ The role of PT is in exercise prescription,
training and education of patient in stages 1‐3 of the rehab.

Case 5
Cardiac prevention clinic –A 50 yr. male has come for regular health assessment. All
vitals look normal.

Q1: According to current evidence, how long the rehab programme should run for
achieving maximum bene‫ﻐ‬it.

1. 2‐3 weeks
2. 4‐6 weeks
3. 6‐8 weeks
4. 8‐12 weeks

ANS: D acc to FB

Q2: Patient is asked not to work for more than 7MET. What should he not do during this
period?

1. Walk at 8km/hour

2. Climb up and come down stairs
3. Run on a treadmill at 8km/hour
4. Do weight bearing

ANS: C‐ 4.9 mph‐ means doing 17 .3 mets
Reference O’Sullivan PDF Pg 558. Running / jogging at 5mph is 8‐9 METs.

POE
A ‐ This is allowed as 5mph falls within 7 MET
B ‐ Similar to recreational games ‐ this is doable too.
D ‐ Weight bearing can be anything. Even normal standing and walking. That can be as
low as 1‐2 METs.

Skipping‐ 8‐12 METS
Freestyle swimming: 9‐10 METS

Case 6
&q3= A therapist is supervising the exercise of cardiac rehabilitation outpatient class
on a very hot day, with temperatures expected to be above 90 degrees F. The class is

scheduled for 2 p.m. and the facility is not air conditioned. The strategy that is
unacceptable is to:

3a= decrease the exercise intensity by slowing the pace of exercise.
3b= increase the warm‐up period to equal the total aerobic interval in time.
3c= change the time of the exercise class to early morning or evening.
3d= make the exercise intermittent by adding rest cycles.

ANS: B
This is not acceptable. As the real bene‫ﻐ‬it of the exercise is during the aerobic training.
The warm up and cool down phases are used as preparatory phases.

POE:
A ‐ If the class is not able to take it, we can do pacing. That also means we can reduce the
intensity of the exercise class.
C ‐ Its alright to change the class time due to technical faults.
D ‐ This is also do‐able. This strategy of intermittent training is used in stage 1 of rehab
and can be utilised at another stage too.

**Ideally temp shud be 6572 deg F or 1822 deg C, humididty 65%

Case 7
&q14= Which of the following is NOT an appropriate reason to terminate a
maximum exercise tolerance test for a patient with pulmonary dysfunction?

14a= ECG monitoring reveals diagnostic ischemia.
14b= patient states he is maximally short of breath.
14c= PaO2 decreases 20 mmHg.
14d= patient reaches age‐predicted maximal heart rate.

ANS: D Submaximal tests that use predetermined endpoint such as age‐predicted
maximal heart rate are usual before discharge‐ PNP ‐4ed ‐ 475

A‐ means dip in ST interval> 2mm
B‐ RPE ‐ to even low work threshold‐ indicates poor functional capacity and sugesstive
of HF
C‐
If the pt not showing any pulmonary dysfunction during exercises D is not a problem it shows that he is having
a good tolerance.
Systolic BP fall> 20 mmhg

Case 8
&q36= A 72 year‐old woman is being treated for depression following the death
of her husband. She is currently taking antidepressant medication (tricyclics) and has a
recent history of a fall. The therapist suspects the precipitating cause of the fall is her
medication as it can cause:
36a= hyperalertness.
36b= cardiac arrhythmias.
36c= dyspnea.
36d= postural hypotension.

ANS: D
The most common serious cardiovascular complication of most tricyclic drugs is orthostatic
hypotension

B in case of pre existing cardiac condition or bundle block

TCAs can behave like class 1A Antiarrhythmics , as such, they can theoretically terminate
ventricular fibrillation, decrease cardiac contractility and increase collateral blood circulation to
ischemic heart muscle. Naturally, in overdose, they can be cardiotoxic, prolonging heart
rhythms and increasing myocardial irritability.

Case 9

Conditions
Cardiomegaly
Case 1

In cardiomegaly, how much is heart is enlarged?

1 .1/2 of chest diameter
2. 1/3
3.1/4
4.2/3

ANS – D
the heart is enlarged more than half the girth of the chest wall
http://www.texasheart.org/HIC/Topics/Cond/dilated.cfm

CHF
Case 1
&q37= A patient and his caregivers should understand the common side effects
of the medication that he is taking. He has Class III heart disease and is continually in
and out of congestive heart failure. He is taking digitalis (Digoxin) to improve his heart
function. The therapist will know he and his caregivers understand the adverse side
effects of this medication if they relate that they will contact the patient's physician if he
demonstrates:
37a= confusion and memory loss.
37b= slowed heart rate.
37c= lnvoluntary movements and shaking.
37d= weakness and palpitations.

ANS: D‐ NPTE
d option is related with heart failure class iv as he is at clas 3 and if he has palpitaions at rest it means class 4
heart disease, which is more serious concern..AND IT IS NPTE NOT APC RECALL.
Digoxin helps make the heart beat stronger and with a more regular rhythm.
Digoxin is used to treat h
eart failure .
Digoxin is also used to treat a
trial fibrillation , a heart rhythm disorder of the atria (the
upper chambers of the heart that allow blood to flow into the heart).
Important information
You should not use digoxin if you have ventricular fibrillation (a heart rhythm disorder
of the ventricles, or lower chambers of the heart that allow blood to flow out of the
heart).
Case 2
&q53= A patient with diagnosis of left‐sided heart failure (CHF), Class II, is
referred for physical therapy. With exercise, this patient can be expected to demonstrate:
53a= severe, uncomfortable chest pain with shortness of breath.
53b= weight gain with dependent edema.
53c= anorexia, nausea with abdominal pain and distention.
53d= dyspnea with fatigue and muscular weakness.

ANS: D
NYHA grading MET*
Class I No limitations. Ordinary physical activity does not cause
undue fatigue, dyspnoea or palpitations (asymptomatic LV dysfunction) . >7
Class II S light limitation of physical activity. Ordinary physical activity

results in fatigue, palpitation, dyspnoea or angina pectoris ( mild CHF) . 5
They are comfortable at rest.
Class III Marked limitation of physical activity. Less than ordinary
physical activity leads to symptoms ( moderate CHF). 2–3
They are comfortable at rest.
Class IV Unable to carry on any physical activity without discomfort.
Symptoms of CHF present at rest ( severe CHF). 1.6
Case 3

ANS:

CARDIAC EXTRAS
Case 1
&q62= A patient with peripheral vascular disease has been referred for
conditioning exercise. The patient demonstrates moderate claudication pain in both legs
following a 12 minute walking test. The MOST appropriate exercise frequency and
duration for this patient is:
62a= 3 times/week, 30 minutes/session.
62b= 3 times/week, 60 minutes/session.
62c= 2 times/week, BID 20 minutes/session.
62d= 5 times/week, BID 10 minutes/session.

ANS: D

Case 2

ANS:

AAA
http://www.racgp.org.au/afp/2013/june/aorticaneurysms/

Abdominal Aortic Aneurysm, obese patient, HTN and Diabetes. He is a smoker and is
being currently treated for AAA.

1. What will be the most relevant cause of AAA in this case
a: smoking
b: weight
c: diabetes
d: Age

Main risk factors are Male, Age greater than 65. And smoking history.
ANSWER = A

In conclusion, our study shows that abdominal aortic aneurysm is a disease of the elderly that is 4–6 times
more prevalent among men than women. Tobacco smoking and low concentrations of serum HDL cholesterol
are strong independent risk factors for abdominal aortic aneurysm in both genders. Our results also indicate a
significant effect of blood pressure on the risk of developing abdominal aortic aneurysm.

additional Q
AAA (Abdominal Aortic Aneurysm)
What are the risk factors for AAA?
● Advancing age>65
● Male gender
● Smoking
● Family history
● Atherosclerosis
● Hypertension
● Hypercholesterolaemia
● Other vascular aneurysm

What advice should be given for patients after AAA repair before discharge home?
Why AAA patients are managed in ICU’s following AAA repair?

Speci‫ﻐ‬ic implications for PRE OPERATIVE physiotherapy management of an AAA:
Whether or not you should cough the patient depends on whether there has been a leak
or the size of
the aneurysm
• < 6 cm ‐ one cough / FET depends on chest condition and indication for coughing
• > 6 cm ‐ risk of rupture therefore no cough preoperatively
Specific implications for POST OPERATIVE physiotherapy management of an AAA:
• At a high risk due to severity of surgery and concomitant diseases.
• Potential to develop respiratory failure and ... require intensive treatment
for at least 5 days with appropriate techniques related to assessment.

• Good pain relief is essential as is good wound support.
• Do not tip.
• Mobilise once cardiovascularly stable and dependent upon patient's condition.

Ultrasound is a relatively cheap, noninvasive, widely available and reliable tool for detecting and
measuring AAAs. It is the modality of choice for screening and surveillance.
Computed tomography angiography (CTA) is fast, reproducible and accurately depicts aneurysm
morphology. It is the investigation of choice when considering potential surgical repair, and enables
multiplanar analysis. Limitations include the need for high doses of intravenous iodinated contrast
(potentially harmful in patients with renal impairment), and the use of ionising radiation.
Magnetic resonance angiography has limited utility in AAA

Cardio patient
She refers incontinence: What the physio should suggest?
A: Go to the urologist
B:Pelvic ‫ﻐ‬loor exercises

Pulmonary

http://bronchiectasis.com.au/physiotherapy ‐ USEFUL

What is the reason for increased work of breathing?
a. Low oxygen saturation
b. Decrease F RC
c. Decreased compliance
d. Decreased vital capacity

D decrease in VC leads to dynamic hyperinflation resulting in reducing the lung compliance, hence
increasing WOB PnP 241

B RV increases hence increasing FRC. T
he FRC may b ecome increased b y 2 mechanisms:
dynamic h yperinflation a nd a ctivation o f inspiratory muscles d uring e xhalation.

Surgeries
Case 1

A 70 Year Old patient has had Right upper lobectomy for lung cancer.
She has a underwater seal drain system connected to her chest and is
also connected to patient controlled analgesia. She has history of
COPD. She is also on oxycodone for pain relief and is currently day 1
post surgery. She has been nil by mouth since surgery.

Q: What is the main risk factor for pulmonary complications for this
patient after surgery?

1: Age
2: Cancer
3: PCA
4: COPD

ANS: D
CROP ឈle Pg 86.

Q: What side effect can we expect from oxycodone?

1: Drowsiness and vomiting
2: Mild pain in the wound site
3: Nausea and hunger
4: Postural hypotension

ANS: A

Reference: http://www.drugs.com/oxycodone.html

Reference P n P Pg 400 4 ed Under opioids section.

Common oxycodone side effects m
ay include:
● drowsiness, headache, dizziness, tired feeling;
● stomach pain, nausea, vomiting, constipation, loss of appetite ;
● dry mouth; or
● mild itching.
● possibility of upper airway obstruction during sleep → hypoxaemia.

4 - postural hypotension - hypotension is there as having similar side
effects as morphine but not mentioned as postural hypotension. It
may cause postural hypotnsion thro’vasodilatation

Q: She has difឈculty with inspiration. How can you help her?

1: Tell her to take her hands together and move up while inspiring
2: Instruct her to squeeze her buttocks as much as she can and hold
3: Teach her to put her ឈst down the mattress and pull
4: Teach her forced expiration to improve her inspiration

ANS: A
Reference - CROP - Pg 94.
This is called Upper limb demand ventilation

Q: Her chest x ray shows bibasal atelectasis, which of the following
techniques would you use to treat that?

1: Incentive spirometry
2: PEP
3: Oxygen therapy
4: Postural drainage

ANS: B
As use of IS is not supported in decreasing the incidence of PPC -
430-431- 4ed- Pn P
4- will decrease FRC in head down position
Crop ‫ﻐ‬ile‐115
Precautions to the use of positive pressure devices include:
• Facial fractures / trauma / surgery
o May prevent the application of a face mask
• Patient’s with intercostal catheters
o Monitor patient for signs of increased air leak via underwater seal system
• Gastric surgery, oesophagectomy and pneumonectomy
o Positive pressure will be exerted onto the surgical anastomosis site
o Requires consultation and approval with patient’s surgeon prior to instigating
• Sinusitis or ear problems

Contraindications to the use of positive pressure devices include:
• Undrained pneumothorax
• Frank haemoptysis or acute haemoptysis of unknown cause
• Large pulmonary bullae
• Lung abscess
• Base of skull fractures (can cause pneumocephaly)
• Haemodynamic instability.

Indications:
1. Increased mucous production and/or sputum retention
2. Atelectasis (e.g. postoperatively)
3. Inability to tolerate other techniques (e.g. history of reflux, osteoporosis)
4. Need for long term airway clearance techniques (e.g. cystic Fibrosis,
bronchiectasis)
5. Need for independence (e.g. providing airways clearance at home)
6. Noncompliance with other forms of treatment

Case 2
70 year old male day 2 post thoracoscopic wedge resection of left
upper lobe. His underwater seal drain is connected to 20cmH20
suction.

Q: What is normal about underwater seal drainage?

1: Bubbling intermittently in suction chamber
2: Bubbling continuously in the suction chamber

3: Swinging of ᣠuid
4: No bubbling

ANS – B
Scenarios:
We are looking for air leak by looking at bubbles. The UWSD suction
should be off.
After suction is turned off, if there is no bubbling, means there is no air
leak.
Ask pt to cough. If there is some bubbling, meaning there is still some air
in the pleural cavity which needs to be removed. If there is no bubbling
with suction off, there is no more air leak. OR there is kinking in the tube.
Depending on the number of compartments in which the air leak is
present, (lesser compartments - less air leak and all 5 compartments
more air leak).
Continuous air leak = drainage systems or pipe has some fault. Also
breakage in the tube system.

Based on the reasoning given above

POE
A and B are out as bubbling is not seen in the suction chamber. It is seen
in the water seal chamber. Also continuous bubbling signiឈes drainage
system fault.
C - When suction is applied (as in this case 20 cm H2O suction) there
should be no oscillation in the ᣠuid.
Reference:
http://www.aci.health.nsw.gov.au/resources/respiratory/pleural_drains/pleural‐drain
s/25
D is out. No bubbling means either the condition has resolved or there is
a kink somewhere. POD2 is a bit too early for the lung to have fully
expanded.

Q: Which of the following is not appropriate while mobilizing this
patient?

1: Pushing up on his left arm

2: Pulling with his left arm
3: Lifting the chest drain above his chest level
4: Right side lying

ANS – C. can cause tension pneumothorax
This seems the most inappropriate. But A and B may be incorrect formation of sentence.
Rt SL is acceptable when mobilizing this patient.

Q: When mobilizing this patient, what would you do manage the drain?

1: Ask the nursing staff to carry the drain unit when he is walking
2: Ask a physio assistant to carry intercostal catheter and drain
3: Fix it to a walking frame
4: Turn off the suction

ANS: C

Q: After mobilizing him what would you do?

1: Make him sit on a chair and say the nurses will help him to return to bed.
2: Ask him to huff strongly with pillow support
3: Make him to sit & ask the patient in next bed to watch him
4: Assist him to return to sitting on bed

ANS: B
After mobilizing , FRC improves, lung expansion increases, ventilation improves, result
in loosening of secretions.

Case 3
THOROCOSCOPY FOR WEDGE RESECTION RIGHT UPPER LOBE. UNDERWATER DRAIN
IN SITU ON SUCTION. TRANSFERRED FROM ICU TO THE WARD.

Question 1: What is normal about underwater seal drainage for the normalized air leak.

a. Bubbling intermittently in under water seal drainage
b. Bubbling continuously in under water seal drainage
c. Intermittent bubbling in the suction chamber
d. No bubbling in suction chamber

ANS: A crop 16
Thats correct. There will be bubbling in the water seal chamber.
Intermittent bubbling: is normal, usually during expiration

Question 2: When mobilizing the patient, what would you do manage the drain?

a. Measure the length of tubes and mobilise within the reach
b. Ask a physio assistant to carry intercostal catheter
c. Fix it to the frame
d. Remove the suction

ANS: C
I am thinking D. Have asked the group on the internet.

Question 3: After mobilizing him what would you do?

a. Make him sit on the chair and say the nurses will take you to the bed.
b. Ask him to stay in the chair and after resting for few min practice breathing exercises
c. Ask to Huff strongly with pillow support.
d. Put him back in bed

ANS: B
Why not C as there is no secretions, aim is to improve ventilation
Pg 430 pnp 4ed topmost para of the page,

Question 4: What should ICU physio record in hand over note?

a. Initial PT Ax and Rx
b. discharge plan and prognosis
c. respiratory care and mobility requirements
e. Physiotherapy interventions (not sure)

ANS: C

Only scope, not open procedure. Handover normally means, background, functional status,
treatment done, progression etc. All given.

Not physio intervention. So go with C

Case 4
Right upper lobe wedge resection with inter costal drain in place

Q:1 After mobilizing patient, physio takes him back to his room and make him to sit in
the chair. What would you do next?

‐ Make him sit on a chair and tell him that the nurses will help him to return to bed.
‐ Ask him to huff strongly with pillow support
‐ Put the patient back to bed
‐ Ask him to do leg exercises after rest

ANS: B
There is a sequence and pattern of how the mobilization takes place. Once you mobilize
the patient, you make them them huff.
Coughing and breathing exercises do follow after mobilizing the patient.
Pg 430 pnp 4ed

Q : 2 How will you modify your assessment for this patient?

‐ avoid auscultation and palpation near wound area
‐ monitor pain while auscultating near wound
‐ Only auscultate anterior and lateral side of lung
‐ Ask patient to take shallow breath while auscultating

ANS: B
We will not avoid any auscultations neat the wound area. We need to still auscultate. But
we just need to monitor pain while we auscultate.

Q : 3 How will you assess the patient?

‐ Sitting on the edge of bed
‐ High supported sitting
‐ R) side lying
‐ Supine lying

ANS: B

As per logic.

Q 3 what is present in post pulmonary complication except???

‐ reduce wbc
‐ yellow sputum
‐ increase temperature

Ans A
Unexplained rise in WBC (>11x10^9 /L)
Pg 406 pnp 4ed

Case 5
65 YEAR OLD FEMALE WHO HAD UPPER LEFT LOBE RESECTION 1 DAY AGO. CHEST
DRAIN IN SITU.

Question 1: How would you assess this pt?

a. Sitting on side of bed
b. High supported sitting
c. Right side lying
d. Supine

ANS – B

Question 2: How would you modify your assessment for this patient?

a. avoid palpation and auscultation around drain site
b. advise to take shallow breaths on auscultation
c. do not move patient
d. monitor pain on movement

ANS ‐ D

Question 3: You have mobilised patient 20 meters and have returned her to her chair.
What would you advise?

a. Sit there and wait for nursing staff to return you to bed
b. Walk again in 1 hour and double your distance
c. wait for a few mins and then practice your breathing exercises
d. support cough

ANS ‐ D
Pg 430 pnp 4ed

Case 6
&q52= Chronic pulmonary changes following a left pneumonectomy would
include all of the following except:

52a= decreased residual volume.
52b= increased tidal volume.
52c= deviated trachea toward the left.
52d= decreased breath sounds on the left.

ANS: B
The lung has been removed, so there is decreased air going inside the lung.
Case 7

ANS:

Conditions
Pneumonia
Infective or chemical agents breach lung defences, in‫ﻐ‬lame lung parenchyma and
smallest bronchioles, then ‫ﻐ‬ill and consolidate alveoli with ‫ﻐ‬ibrous exudate.

Case 1
A 55 yo female is admitted with right middle lobe pneumonia with a
background of history of COPD and bronchiectasis. She is an
ex-smoker but quit smoking 8 months ago. She has had 4 episodes of
pneumonia over the past year. Her blood gases upon admission are
pH 7.21 PaCO2 65 PaO2 89 HCO3 26, Her heart rate is 70 beats /min
& his blood pressure is stable.

Q: What does the ABG results imply?

1: Respiratory acidosis
2: Respiratory alkalosis
3: Metabolic acidosis
4: Metabolic alkalosis

ANS: A

Q: What do you expect to ឈnd on her Chest X ray?

1: Reduced costo phrenic angles
2: Diminished shadow of the right heart border
3: Diminished shadow of left heart border and costophrenic angle
4: Elevation of the diaphragm

ANS: B
http://radiopaedia.org/articles/right-middle-lobe-consolidation
A- as there is no volume loss n no collapse or no no effusion

Major differentiating factors between atelectasis and pneumonia
Atelectasis Pneumonia

Volume Loss Normal or Increased Volume
Associated Ipsilateral Shift No Shift, or if Present Then
Linear, WedgeShaped Contralateral
Apex at Hilum Consolidation, Air Space
Process
Not Centered at Hilum

Q: When you visit her on the ward she is very agitated & her
condition is deteriorating.
What would you do in this situation?

1: Postpone Physio treatment for the next day
2: Ignore the signs and mobilize her anyway
3: Inform the nursing staff immediately
4: Inform physiotherapy manager immediately

ANS: C

Q: The next day her condition is stable. The medical team has
requested that she be mobilized during her Physio session. When you
visit her she refuses to mobilise. What would you do as the next step?

1: You tell her that she has to walk because it is Drs’ order
2: You’ll say OK for not mobilizing today but that she has to walk the
next day.
3: You’ll ask her why she doesn’t want to walk.
4: You’ll request her nurse to mobilise her later on.

ANS: C

Case 2
A 80 y.o. patient admitted with pneumonia. She is drowsy but is responding to
instructions intermittently and has a weak, ineffective cough

Q: The medical team requests regular suctioning. The appropriate method for
suctioning for this patient will be:

1: Nasopharyngeal suctioning
2: Oropharyngeal suctioning
3: No suctioning as patient still has cough reflex
4: Endotracheal suctioning

ANS: A

Q: Which of the following is a contraindication to nasopharyngeal suctioning?

1: Base of the skull fracture

2: Naso gastric tube in either nostril
3: Strong gag re‫ﻐ‬lex
4: Strong bite re‫ﻐ‬lex

ANS: A crop ‫ﻐ‬ile 137

3 n 4 R complications

Q: Which of the following is used to aid Oropharyngeal suctioning?

1: Nasopharyngeal airway
2: Guedel’s airway
3: Gel/lubricant
4: Nasal clip

ANS: B crop ‫ﻐ‬ile 128
c= 139 can be used trauma can be limited

Q: Which of the following techniques would you consider using in addition to suctioning
for airway clearance for the above patient?

1: Postural drainage
2: Percussions & Vibration
3: Assisted /supported coughing
4: All of the above

ANS: D
It is a medico patient, sputum retention is an issue, wont be able to clear secretions. If alert
use more active techniques.
You can do postural drainage, no conra so can.
Percussion/ vib, no contra so can do this too.
Coughing, can as she is responding intermittently.
So can do all, so go with 4.

Case 3

55 YEAR OLD EX SMOKER 50 PACK YEAR HISTORY OF SMOKING, HE QUIT 6 MONTHS
AGO. HAS HAD RECURRENT PNEUMONIA IN THE PAST 4 YEARS. HE HAS
BRONCHIECTASIS. HE SHOWS SOB AND OEDEMA IN LEGS. ON LONG TERM O2
THERAPY. HE SHOULD BE ON CONTINUOUS 2L/MIN.

Question 1: His medical chart says he needs 2l of oxygen via nasal prongs. How much
FiO2 does this correspond to?

a. 24%
b. 28%
c. 32%
d. 35%

ANS ‐ B
Crop ‫ﻐ‬ile 52
Nasal cannula / prongs 1 – 4 0.24 – 0.36 • Patent nasal airway essential
• Unable to accurately determine FiO2
• More comfortable than mask
• More functional (eg eating, drinking) than mask
• Can irritate nares and skin around ears

Estimated FiO2 with nasal prongs
Flow rate (l/min) FiO2
1 0.24
2 0.28
3 0.32
4 0.36

Question 2: He needs lasix with K+ supplement. How do you explain the patient how it
works?

a. It reduces your heart beats
b. It reduces the ‫ﻐ‬luids of your body
c. increases myocardial contractility
d. stretches heart walls and increases volume

ANS ‐ B
CROP ‫ﻐ‬ile. Pg 25
Lasix or frusemide

(diuretic side effects – reduced HR. for that we use K+. 2 kind of diuretics – sparing and
non sparing K+.)
Potassiumsparing d iuretics are diuretic drugs that do not promote the secretion of
[1]
potassium into the urine .
They are used as adjunctive therapy, together with other drugs, in the treatment of
hypertension and management of congestive heart failure
1‐ beta blockers‐‐olol / ca++channel blockers
3‐ digoxin ‐ increases Ca in‫ﻐ‬lux in the myocradial cell n thus increases myocardial
contraction ie + inotropic and more extra cellular Na
Inotropic state depends on the amount of calcium in the cytoplasm of the heart
muscle wall, as contractility of the heart depends on control of intracellular calcium
i.e. control of calcium entry into the cell membrane and calcium storage in the
sarcoplasmic reticulum. The main factors controlling calcium entry are activity of
voltage gated calcium channels and sodium ions, which affects calcium/sodium ion
exchange. Ca inside and na out heat muscle contraction
Dopamine
4‐????

Question 3: He has to have long term oxygen therapy. How do you explain this to the
patient?

a. You can have also for only few hours during the day
b. You need it for most hours of the day
c. You can leave it at home when you go out
d. You can have oxygen when your symptoms get worse

ANS – B
P n P – Pg no. 226 (4rd edition). 15 18 hours per day oxygen therapy

Question 4 : You see the patient coming back from the toilet with the nurse who gave
assistance but the patient is without oxygen. What do you do?

a. Check for desaturation
b. Seek nurse assistance to decide re: reapplying oxygen
c. You tell him to put back the nasal prongs
d. Ask him if he has been wearing it today.

ANS C
He requires it 24/7 so you would get him to put back nasal prongs first then check for
desaturation.
we are allowed to put up O2 therapy so people discussed C.

? Additional Question: The patient has “50 pack year” smoking history what does this
mean?

a. 1 pack a day since he was 5 year old
b. 50 pack per year
c. 2 packs a day for 25 years
d. 50 packs this year
ANS – C

Number of pack‐years = (packs smoked per day) × (years as a smoker)

or

Number of pack‐years = (number of cigarettes smoked per day/20) × number of years
smoked. (1 pack has 20 cigarettes)

Explanation (Smartha) ‐ . If he smoked 2 packs of cigarette daily for 20 years, he would
have a 40 pack year history of smoking. So patient smokes 2 packs of cigarette every day
for 25 years.

Case 4
A 80 y.o. patient admitted with pneumonia. She is drowsy but is responding to
instructions intermittently and has a weak, ineffective cough

Q: The medical team requests regular suctioning. The appropriate method for suctioning
for this patient will be:

A: Nasopharyngeal suctioning
B: Oropharyngeal suctioning
C: No suctioning as patient still has cough re‫ﻐ‬lex
D: Endotracheal suctioning

ANS ‐ A
B‐ As in A there would be no limitation of biting n gag re‫ﻐ‬lex
NPAs have advantages over the OPA but traditionally are less frequently used.
Advantages include:
• An NPA does not stimulate a patient’s gag re‫ﻐ‬lex.
• An NPA is better tolerated than an OPA in conscious patients
• An NPA can often be left in situ for longer periods than a OPA
• Even while the NPA is in situ, a patient is still able to speak
• It can be used when access to the mouth is technically dif‫ﻐ‬icult (trismus, convulsions).

C‐ but the pat is weak
D‐ pat is conscious n not on ET tube

additional Q
baby of smoking mother need O2 therapy

Q1 why babies need oxygen therapy?
a) less no of surfactant
b) restricted growth in XYZ stage of embryology
ANS – reduction of O2 supply to baby because of reduction of CO.
Since smoking destroys surfactant

Q2 what could be the diagnosis?
Bronchiactasis

case 5
Mr D is 53 yr old male is undergoing thoracic surgery. He is having history of
hypertension & pneumonia
On lung function test, his FEV1/FVC = 60% to 70% predicted
FEV1= 80%
After the surgey, he is on PCA (Patient controlled analgesia) and having high BP (140/90
mmHg), temperature 38.5 degree C this morning.

Q:1 Which of the following is not likely to be seen ??post op surgery

a) Reduced functional residual capacity (FRC)
b) Ineffective cough as a result of reduced force vital capacity (FVC)
c) Increase lung compliance due to effect of analgesia
d )ventilation perfusion mismatch due to the effect of surgery

ANS – C
1‐ since he has undergone thoracis sugry

Q:2 Which of the following is not the cause of post op complications??

a) Postoperative atelectasis
b )Hypertension
c) Pneumonia
d) Increase body temperature to 38.5 degree C(not sure)

B??? Mostly on FB answer is B
D is sign of Post op complication

Q:3 Which of the following is considered to improve the functional residual capacity
(FRC) of lung??

a )sitting out of bed
b) Mobilisation
c) Thoracic expansion exercises
d) Continuous positive airway pressure

ANs ‐ B‐ pg 433 Pn P 4ed
Mobilisation means SOOB, standing , walking everything mobile
D ‐ acc to FB‐CPAP‐ pg 431‐ 4ed pNp

Q:4 day 1 following surgery, Mr D refused for mobilisation with physio. What will the
physio do to convenience the patient in order to mobilise??
a) Leave it for the next day.
b) Give him education about mobilisation, ask nurse to help you to get Mr D out of bed.
c) Give him education about mobilisation; ask one of the family members to help you
d) Give him education about mobilisation and allow Mr D to take decision himself
regarding the information provided by you.

ANS – D?

case 6
Post surgery patient. Midline laparotomy. Xray shows right lobe pneumonia on PCA

Q: What would be the reason for postoperative pulmonary complication
1: Hypertension

2: opioid use
3: COPD

ANS ‐ B

Q: You checked the pulse oxymetry before mobilizing your patient. The reading is 50%,
what
do you do?
1: Tell the nursing staff
2: Ignore the reading and mobilize the patient anyway
3: Give the patient some oxygen.
4. delay the treatment

ANS – A. press the bell and tell the nurse.

Q:What is normal about underwaterseal drainage for the normalized air leak.

1: Bubbling intermittently in underwater seal drainage
2: Bubbling continuously in underwater seal drainage
3: intermittent bubbling in the suction chamber
4:No bubbling in suction chamber

ANS ‐ A

Q: What will you observe on the X‐ray
Diminished right heart border and cardiophrenic angle
Diminished left heart border
Flattened diaphragm

ANS ‐ A

Asthma
Chronic in‫ﻐ‬lammatory disorder.
Do case study from ILP acute 2005 pg 49
EIA exercise induced asthma pending.
Case 1
A 6 Year Old kid with asthma was playing with his friend and had an attack of asthma
while playing. This child has had bronchodilators & has presented to hospital

Q: How would you respond if the Mother asks what asthma is?

1: Hypersensitive airways
2: Lack of Sensitivity of airways
3: Airways muscles weakness
4: Floppy airways

ANS: A
As per Asthma de‫ﻐ‬inition, this is hypersensitivity and in‫ﻐ‬lammation of the airways due to
an undue response of the airways to a stimuli.
No muscular weakness.
First bronchocontriction happens then
EARLY = severe bronchospasm
LATE = mucus production and airways obstruction
airways

Q: Which mode of communication will you use to guide his child care staff for
administration of his medications?

1: Email
2: Appointment
3: Telephone
4: In writing

ANS – D
Everything should be documented. And in writing.

I am thinking if this can be also in the form of appointment?

Tell your child’s day care, preschool, school or sporting club that your child has asthma,
and give them a copy of the written asthma action plan.
Myasthmaguideweb pg 16

Q: How would you explain the advantage of use of a spacer to the mother? A spacer will:

1: Increase the deposition in the lung
2: prevent oral irritation
3: Prevent cough
4: Will decrease infection

ANS: A
Spacers help increase deposition in the lung by 20‐30% (Reference AH PDF Pg 96).

The most common side‐effects of inhaled corticosteroid medicines are hoarseness of the
voice and fungal throat infections (candidiasis). The risk can be reduced by taking the
medicine using a spacer (a specially designed plastic container that attaches to the
puffer), and by rinsing the mouth with water after using the puffer.

Q: How can she know if the child’s asthma is stable?

1: if he doesn’t have nausea
2: If he can sleep better
3: If even normal activities become dif‫ﻐ‬icult
4: If he doesn’t cough

ANS: B
One form of asthma is nocturnal asthma. This attack is during the REM phase.
Reference AH PDF Pg 90.

POE
A is not a feature of asthma
C this is an example of worsoning of symptoms.
D In acute phase, there is no cough Cough only comes in late phase. But when improving,
that means cough should be productive too.

GORD common in asthma
GORD may be exacerbated by high doses of beta2 agonists or theophylline.

Case 2
Asthma

Q: Air‫ﻐ‬low obstruction in Asthma is due to

1. Smooth muscle hypertrophy and hyperplasia
2. In‫ﻐ‬lammatory cell in‫ﻐ‬iltration
3. Oedema
4. Goblet cell and mucous gland hyperplasia
5. All of the above

ANS ‐

According to me it is E. These are all the pathophysiological changes during asthma
attack.
1‐ initial response to allergen is bronchospasm mediated through‐ T, B lymphocytes,
mast cells n IgE ______decreases cAMP‐ b ronchospasm
2‐ eosinophil in‫ﻐ‬iltrate
3‐oedema of mucus membrane of bronchi and bronchiole‐ Basement membrane
thickness.
4‐ it is present
Air‫ﻐ‬low obstruction (excessive airway narrowing) in
asthma is the result of contraction of the airway smooth
muscle and swelling of the airway wall due to:
• smooth muscle hypertrophy and hyperplasia
• in‫ﻐ‬lammatory cell in‫ﻐ‬iltration
• oedema
• goblet cell and mucous gland hyperplasia
• mucus hypersecretion
• protein d eposition including collagen
• e pithelial desquamation.
This in‫ﻐ‬lammatory process can cause permanent changes in the airways. Long‐term
changes include increased smooth muscle, increase in bronchial blood vessels,
thickening of collagen layers and loss of normal distensibility of the airway.
Potential triggers for the in‫ﻐ‬lammatory process in asthma include allergy, viral
respiratory infections, gastrooesophageal re‫ﻐ‬lux disease (GORD), irritants such as
tobacco smoke, air pollutants and occupational dusts, gases and chemicals, certain
drugs, and non‐speci‫ﻐ‬ic stimuli such as cold air exposure and exercise.

One table in AH regarding the difference between asthma n COPD

Q: Which of the following is true about diagnosing Asthma?

1. Peak ‫ﻐ‬low meter is the device of choice to measure air‫ﻐ‬low limitation to diagnose
Asthma
2. Spirometry is the lung function test of choice for diagnosing asthma
3. The absence of physical signs excludes the diagnosis of Asthma
4. Allergy testing should not be considered when diagnosing Asthma

ANS ‐ B
Spirometry and PFT are the tests of choice to con‫ﻐ‬irm the history of asthma. (Reference
AH PDF Pg 86).
Pg 443 0f Tulsi docu

Spirometry is the lung function test of choice for diagnosing asthma and for assessing
asthma control in response to treatment.

Q: Which of the following statements about Short Acting Beta agonists is not true?

1. Flixotide is a short acting beta agonist
2. Salbutmol and Terbutaline are examples of short acting beta agonists
3. They can be delivered via metered dose inhalers or nebulisers
4. They are used for acute relief of Asthma symptoms.

ANS ‐ A
Flixotide also called ‫ﻐ‬luticasone proprionate is a corticosteroid.‐ Preventor
N antiin‫ﻐ‬lamatory
http://www.medsafe.govt.nz/consumers/cmi/f/‫ﻐ‬lixotideinhaler.pdf

Q: Which of the following drugs can cause an exacerbation of Asthma?

1. Antihistamines
2. Sedatives
3. Beta‐blockers
4. Oral corticosteroids

ANS ‐ C
POE
A ‐ antihistamines help with reduction of in‫ﻐ‬lammation
B ‐ Sedatives are contraindicated during an acute asthma attack.
Agitation during an attack may be due to bronchospasm and hypoxaemia and is better
treated with beta2 agonists and oxygen.
• Most sedatives, including benzodiazepines and zopiclone (and to a lesser degree,
zolpidem), will blunt respiratory drive.

C causes medicine induced asthma causes bronchoconstriction pg 473
D ‐ Oral corticosteroids also help with Rx.‐ eg prednisolone‐ used in exacerbation
ICS‐ used in exacerbation
Antibiotics rarely used in exacerbation
NSAIDS could increase exacerbation.

Medication‐induced asthma can be separated into p redictable and
unpredictable/idiosyncratic asthma r eactions.
Predictable bronchoconstriction may occur with:

• beta blockers (used in the management of hypertension, cardiac disorders, migraine
and glaucoma)
• cholinergic agents (e.g. carbachol, pilocarpine)
• cholinesterase inhibitors (e.g. pyridostygmine).
Unpredictable medicationinduced asthma exacerbations may occur due to aspirin
and other non‐steroidal drugs (including cyclo‐oxygenase (COX) ‐2 inhibitors) used for
arthritis and in‫ﻐ‬lammatory disorders.
• Be aware of the triad of nasal polyps, asthma and
aspirin intolerance.
• An asthma exacerbation caused by NSAIDs is
characterised by ‫ﻐ‬lushing and rhinorrhoea, often within
a few minutes to an hour after administration.
• Other drugs that may cause reactions include
carbemazepine and parenteral drugs: penicillin, iron
dextran complex, hydrocortisone, ipratropium bromide, aminophylline, N‐acetyl
cysteine, and preservatives such as bisul‫ﻐ‬ites, metabisul‫ﻐ‬ites and benzalkonium chloride.

Case 3
35 year old man with asthma, wheezy since birth with triggering agents including upper
respiratory tract infections, exercise, dog hair, and house dust mites. Admitted to
hospital today by his general medical practitioner because of worsening symptoms and
dif‫ﻐ‬iculty taking his medications. Currently using two metered dose inhalers with a
spacer for the delivery of his medications ‐
Salbutamol (Ventolin), a sympathomimetic (B2‐agonist) and
beclomethasone dipropriate (Becotide),
persistent, non‐productive cough, expiratory wheezes and labored breathing, appears
‫ﻐ‬lushed and very anxious and is having dif‫ﻐ‬iculty completing sentences. Arterial blood
gases on admission:
• SaO2 = 94
(FiO2 = 0.4) • PaO2 (on O2) = 10 kPa (135mm Hg) • PaCO2 (on O2) = 4.1 kPa (31mmHg)
• pH = 7.47
On examination: Heart Rate (HR) = 100beats /min, Temperature = 37.8 deg C,
Respiratory Rate (RR) = 28 breaths/min (shallow, prolonged expiration; short, gasping
inspiration),
FEV1/FVC ratio = 65%,
Auscultation – reduced breath sounds throughout the lung ‫ﻐ‬ields with widespread
expiratory Wheeze

Q: The patient’s chest X‐ray is likely to show evidence of

1. Hyperin‫ﻐ‬lation
2. Hypoin‫ﻐ‬lation
3. An enlarged heart
4. A mediastinal shift
5. Signs of lobar collapse

ANS – A
APC explanation ‐ 1a
This patient is having dif‫ﻐ‬icult exhaling and so will be most likely to have a hyperin‫ﻐ‬lated
chest.
Also Asthma patients generally have a hyperin‫ﻐ‬lated chest as a characteristic.
FEVj and FVC drop during a severe attack with little sign of reversibility (Figure 14.5).
However, if FEVj is measured before and after giving bronchodilators and there is a 15%
increase in FEV1 ‐ this amounts to signi‫ﻐ‬icant reversibility. The FEY1 may be less than
30% of FVC. To tal lung capacity, FRC and RV may be increased due to overinflation
of the lungs.

Medicine show it is a case of asthma as preventor is being used.
Radiographic features

Chest radiograph

Plain ‫ﻐ‬ilms can be normal in upto 75% of patients with asthma.

Reported features with asthma include:
pulmonary hyperin‫ﻐ‬lation
bronchial wall thickening: peribronchial cuf‫ﻐ‬ing (non speci‫ﻐ‬ic ‫ﻐ‬inding but may be present
in ~48% of cases with asthma 1)
pulmonary oedema (rare): pulmonary oedema due to asthma (usually occurs with acute
asthma)
5‐ h ttp://radiopaedia.org/articles/lobar‐lung‐collapse

Q: The patient’s FEV1/FVC ratio indicates he has

1. An obstructive airway pattern
2. A restrictive airway pattern
3. Severe airway obstruction
4. Moderate airway obstruction
5. Signi‫ﻐ‬icant reduction in vital capacity (VC)

ANS ‐ A
APC ‐ FEV1 divided by FVC (FEV1/FVC). This is the proportion of air in your lung which
you can blow out in one second. This ratio indicates an obstructive airway pattern (as it
is less than 70%). In patients with a low FEV1/FVC ratio, the severity of obstruction is
de‫ﻐ‬ined as the absolute value of the FEV1, the lower the FEV1 (as a percent of
predicted), the worse the obstruction.
You do not have the FEV1 so the severity cannot be defined. In Q only ratio is
given we need FEV1 to predict severity.

Also asthma is an obstructive disease.

Crop ‫ﻐ‬ile pg 58 table

Q: What is the rationale for using a spacer for the delivery of Becotide in the patient’s
case?

1. To increase inertial impaction in the large airways
2. To reduce the possibility of oral candidiasis and dystonia
3. Because four or ‫ﻐ‬ive puffs of Becotide can be inserted into the spacer for each breath
4. Because a lower dose of Becotide can be used
5. Because a spacer makes it easier for the person to inhale at a fast inspiratory rate

ANS 3 b (APC) valved spaver works better
For ef‫ﻐ‬icient drug delivery from a spacer, the device should be loaded with one puff at a
time, and the child should take either 4 tidal breaths, or a single vital capacity breath. Ie
1:4

Increasing inertial impaction in the large airways would not be advantageous – the
medication needs to get to the smaller airways that are in spasm . The spacer allows
for better cleaning and helps to prevent these problems.

POE
A ‐ Spacer does not increase the impact in the lungs. It helps with increased deposition
of the drug in the lung. Bypassing oropgarynx.

Inertial impaction : the deposition of large aerosol particles on the walls of an airway conduit. The
impaction tends to occur where the airway direction changes. Small particles have less inertia and
are more likely to be carried around corners and continue in the path of the airflow.

C ‐ 4‐5 puffs can be inserted in the spacer. This is also not true. We need to go by the set
number of puffs prescribed. Totally wrong
D ‐ Same explanation as C
E ‐ Same explanation as A. Also we need to have a slow sustained deep breath . Q uick
breathing will trigger bronchospasm.

Tidal breathing is as effective as single breaths.

Q: Becotide has which of the following actions?

1. It is an anti‐in‫ﻐ‬lammatory steroid
2. It decreases microvascular permeability
3. It decreases bronchial hyperreactivity
4. It inhibits the formation of in‫ﻐ‬lammatory substances such as lymphocytes and
eosinophils
5. All of the above are correct

ANS: APC ‐ E
Becotide does all of these things. It is preventor

Q: Sympathomimetic drugs

1. Bronchodilate the large airways
2. Increase myocardial contractility

3. May produce bronchospasm and peripheral vasoconstriction in low doses
4. Reduce the patient’s capacity for exercise
5. All of the above are correct

ANS by APC ‐ A‐ R apidly acting bronchodilator
Means working as beta agonist eg Epinephrine
Sympathomimetic drugs excite the central nervous system and heart and affect the
diameter of blood vessels. They are used as decongestants and to alleviate bronchial
asthma.
Myocardial contractility is de‫ﻐ‬ined as the ability of the myocardial muscle to shorten
itself and is not greatly altered by these drugs (as opposed to heart rate itself).
Side Effects: Signi‫ﻐ‬icant ß1 and ß2 receptor activation:
● Tachycardia
● Other arrhythmias
● Exacerbate angina

Increases cAMP formation, which is decreased in asthma resulting in symptoms.
Cyclic AMP (cAMP) is a key intracellular second messenger which at increased levels has been
shown to have antiinflammatory and tissueprotective effects

http://www.pharmacology2000.com/Pulmonary/respiratory_anesthesiology/respirato
ry5.htm

Q: Which of the following is true with regard to the patient’s inhaled medications?

1. Particles between 5 and 10 ım ̀ are deposited in the small airways
2. Breath holding increases inertial impaction of the particles
3. Gravitational sedimentation is time dependent
4. Rapid inspiration increases the inertial impaction of the particles
5. Broncho dilatation is mainly achieved in the 5th generation of the respiratory airways

ANS: C
1‐ this size settle in central airways. Bronchosilators eg beta agonist has 2‐5mm size
which settle in lower respi tract.
2‐Affected by speed n size.
3‐ true
4‐ no in diffusion it could help, A
lso we need to have a slow sustained deep breath .
Quick breathing will trigger bronchospasm.

5‐ there r 23 generations in human lungs
There are three main ways in which particles become deposited in the lung:

inertial impaction,
sedimentation, and
diffusion.

Inertial impaction tends to occur in the upper airways when the velocity and mass of
the particles cause them to impact the airway surface. For this reason, inertial impaction
can be in‫ﻐ‬luenced to some degree by hyperventilation. Occur in ‫ﻐ‬irst 10 generations.
Greater the size of particle n greater is the velocity / smallar is the radius of airway
result in inertial impaction

In contrast, sedimentation occurs in more peripheral airways, is gravitational in
character, and tends to be in‫ﻐ‬luenced by breath‐holding, which allows more time for
gravity to have an effect. Common in lat 5‐6 generations.
End‐ inspiratory hold ‐increases deposition in periphery.

Diffusion is based on Brownian motion and is relevant to particles < 1 μm in diameter.
More time is required to settle the particles.Brownian motion increases ar particle size
decreases.

https://books.google.com.au/books?id=wTqLCgAAQBAJ&pg=PA35&lpg=PA35&dq=ine
rtial+impaction+in+the+large+airways&source=bl&ots=F4SvmmvdTw&sig=WXQlPNEv
hYjMpkreWADzA3f14HA&hl=en&sa=X&ved=0ahUKEwjGxL2zlsPNAhUDtpQKHWXuAp
UQ6AEIMzAD#v=onepage&q=inertial%20impaction%20in%20the%20large%20airwa
ys&f=false
Case 4
(March 2013)
Similar asthma scenario

Q: What are you expected to do in the initial assessment?

1. Allergy review
2. Asthma action plan
3. Breathing control
4. Postural drainage

ANS – B (as per Tulsi and Jaspreet).
As asthma action plan will cover everything. Including breathing control.
But I think it should be either B or C.

asthma action plan‐ it is same as self management or what to do in exacerbation

Q: Patient uses a MDI for salbutamol and also Flixotide propionate (Fluticasone). He
doesn’t take ‫ﻐ‬luticasone because he is unsure of what this drug does. He asks you what
this drug does and your response is…

1. It is a steroid that reduces your airway sensitivity
2. It relaxes the smooth muscle of airway quickly
3. It will reduce the airway in‫ﻐ‬lammation by relaxing airway muscles.
4. It will make your sputum less thick and easy to expectorate.

ANS: A
Prevent the release of in‫ﻐ‬lammatory chemicals.

Q: How would you instruct the patient to use his spacer properly?

1. Quick inhalation and 1‐2 sec breath hold
2. Quick inhalation and 10 sec breath hold
3. Deep and slow inhalation and 1‐2 sec breath hold
4. Deep and slow inhalation and 10 sec breath hold.

ANS: D
As per Tidy’s PT 15th ed PDF Pg 99, the deep breath needs to be held for about 5‐10
seconds for maximal bene‫ﻐ‬it.
Fire one puff of the medicine into the spacer, breathe in slowly and deeply, then hold
your breath for about 5 seconds or as long as comfortable. Young children should
breathe in and out normally for 4 breaths, before the next puff is ‫ﻐ‬ired into the spacer.
End inspiratory hold to increase time for gravitational settlement.

Q: How can the patient monitor his asthma?

1. Peak expiratory ‫ﻐ‬low rate
2. Peak inspiratory ‫ﻐ‬low rate
3. Spirometry
4. 24 hrs sputum collection

ANS: A

POE

B ‐ Dont know if there is anything like this
C ‐ spirometry is done by the medical team to measure the ranges of PFT etc.
D ‐ This can be used but in case of monitoring infection only but A will be a stronger
outcome measure.
Mostly cough is nonproductive in asthma opp to COPD.

Reference Tidy’s 15th ed ‐PDF pg 98. Table with peak ‫ﻐ‬low action plan.

Case 5

35 year old male ‐ Suffering from Asthma since childhood. His symptoms are worsening
since last three days

Q: 1 What technique will you teach him help him with dyspnoea?

‐ Pursed lip breathing
‐ Thoracic expansion exercises
‐ Breathing control
‐ Forward lean positioning

ANS: C
2‐ chest already expanded
Breathing control and forward lean position both can be used.
But breathing control is more effective in reducing asthma attacks and forward lean
position may be helpful in some patients (only).
Reference: AH PDF pg 94‐99.

Q : 2 Patient is not using spacer regularly. What advise will you give him to encourage
use of spacer?

‐ It prevents candida infection in throat
‐It spreads drugs evenly in the airways
‐ It prevents coughing while taking the medication
‐ It allows faster administration of medication

ANS: B

It depends on the case , if spacer is use for adminitration of beta agonist for relief of
exaggration i ll go with A, and if it is use for administration of steroids long term for
prevention of asthma than i ll go with C .

The most common side‐effects of inhaled corticosteroid medicines are hoarseness of the
voice and fungal throat infections. The risk can be reduced by taking the medicine using
a spacer (a specially designed plastic container that attaches to the puffer), and by
rinsing the mouth with water after using the puffer.

Q : 3 What is ‫ﻐ‬lixotide?

‐ preventor
‐ reliever
‐ symptom controller
‐ combination

ANS: A
Fluticasone is used as a preventor. It is used daily to help reduce irritation of bronchi.
Reference: http://www.medsafe.govt.nz/consumers/cmi/f/‫ﻐ‬lixotideinhaler.pdf

Reliever :B2 agonists (short acting)
Salbutamol (ventolin)
Terbutaline (bricanyl)
Airomir, Asmol, Epaq
side effects: nausea, tachycardia, headache, tremor

Anticholinergics Ipatropium bromide (atrovent) note: maximum effect is 30‐60mins,
therefore in asthma should be used with a B2 agonist (mainly used in COPD)
side effects: dryness of mouth, cough

Symptom controller :B2 agonists (long acting)
Salmeterol (serevent)
Eformoterol (foradile, oxis)
side effects: nausea, tachycardia, headache , tremor
for patients with frequent episodes of nocturnal asthma who are receiving Rx with oral
or optimal doses of inhaled corticosteroids
the onset of bronchodilation is delayed, symptom controllers should therefore NOT be
used to treat an acute asthma exacerbation

Q : 4 How will patient self monitor the effect of exercises programme ?

‐ Peak inspiratory ‫ﻐ‬low
‐ Peak expiratory ‫ﻐ‬low
‐ FEV

‐ FVC

ANS: B
Reference Tidy’s 15th ed ‐PDF pg 98. Table with peak ‫ﻐ‬low action plan.
PEF‐Maximal expiratory ‫ﻐ‬low achieved (occurs early in the
forced expiratory manoeuvre)
Index of air‫ﻐ‬low limitation mainly due to obstruction in
the large airways

PIF: Maximal inspiratory ‫ﻐ‬low achieved (occurs at about 50% FVC)
FEV1 more sensitive in COPD n not self monitored.
FVC‐as above

Case 6
50 year old female was admitted with Asthma. Has allergy to dust, mites, pollens and
symptoms increased from 3 days admitted to hospital. salbutamol and ‫ﻐ‬lixotide was
given and asthma is being controlled.

Q 1 What is the role of physio to control dyspnoea

a) Sputum clearance
b) Breathing control
c) Purse lip breathing

ANS: B
Breathing control is more effective in reducing asthma attacks.
Reference: AH PDF pg 94‐99.
A‐ in acute stage cough is nonproductive
C? Not read about PLB in asthma

similar Q
Question 1:What is the primary focus for physiotherapy treatment?

a. Reviewing medication
b. Breathing control
c. Sputum clearance
d. Investigation of allergen

ANS ‐ B

Q 3 Patient don’t use spacer how PT explain the importance of spacer to the patient?

or

What is the rationale for using spacer?

a) Evenly spread of drug in airways and goes in the airways and not in the stomach
b) Because it is cheap and increases compliance
c) It decreases candidasis infection
d) Easy to use and takes less time

ANS: A
It depends on the case , if spacer is use for adminitration of beta agonist for relief of
exaggration i ll go with A, and if it is use for administration of steroids long term for
prevention of asthma than i ll go with C .

Case 7

A 60 Year Old woman with history of COPD and asthma is permanently on oxygen and
gets short of breath on mild exertion. She can only walk from her room to bathroom and
living room. She needs 2 hours to get dressed and is very breathless washing and
combing her hair.

Q: Her BMI is 14. What does this mean? She is:

A: Underweight
B: Normal
C: Overweight
D: Obese

ANS: A

Q: What can we do to improve her breathlessness while brushing her hair?

A: relaxation exercise
B: Give her gentle strengthening exercises for upper limbs, one arm up at a time

C:deep breathing exercise
D: Give her more Oxygen

ANS: B

case 8

Lachie is a 4 year old child, playing at friends place. Had acute exacerbation of
asthma, was treated in hospital . Doctors tells the mother that he can go home but
requires physiotherapy treatment and refers him to an outpatient physio clinic.

1. What is incorrect about asthma?

a. Hyper secretion of mucus.
b. Hyperplasia of Goblet cells.
c. Thinning or destruction of alveolar wall.
d. Edema of upper respiratory tract.

ANS – C

POE
A and D are definitely correct.
A There is hyper production of mucous in asthma
B goblet cells and smooth muscles hyperplasia. Which contributes to smooth
muscle spasm.
D Oedema is seen of the bronchi and bronchioles.

2. What are the most common triggers for extrinsic asthma in this case?

a. Smoke
b. Exercise
c. Cold air
d. Dust mites

ANS D
bronchial asthma resulting from an allergic reaction to foreign substances, such as inhaled
aeroallergens, pollens, dust mites, mold,animal dander, or ingested foods, beverages, or d rugs.

Hence in this case it may very well be dust mites.

3. Relievers for asthma are

a. short acting Beta Agonists .
b. long acting beta – Agonists
c. Steroids
d. Anticholinergic

ANS: A

POE
B ‐ The long acting beta agonists are CONTROLLERS. These are not given in case of
emergency as they take time to work. These are taken 2x/day for symptom control and
used in combination with steroids.
http://www.asthma.partners.org/NewFiles/BetaAgonist.html
C ‐ Steroids are preventor medicines.
D ‐ Anticholinergics are never used alone. Always with some other medictions.
http://www.webmd.com/asthma/anticholinergics‐for‐asthma

4. On his visit what would the physio do for treatment? ( something related to
after the treatment at home and not the treatment at site)

a. Asthma action management plan.
B ACBT
c. Strategies to relieve breathlessness.

ANS C
Yes coz by now, the asthma action plan should already be in place.
case 9

Q: What problem she would have after admission: Poor breathing control

Q: Rational to Use steroids
A: reduce airways sensitivity Case
As prevntor

case 10
COPD and asthma of a 60YO women: GP refers to admit.
ABG shows hypoxaemia otherwise normal.
Gets Breathless on simple activity and shortness of breath. Initially used to have 1lt o2,
now increased to 2lt.She can only walk from her room to bathroom and living room. Not
eaten since four days. On GCS drowsy, obeys commands and opens eyes to verbal
command

Q: Who will you refer her to

1: Dietician
2: OT
3: Speech therapist
4: GP

ANS ‐ A

Q: What can could be her cause for breathlessness

1: hypoxaemia

ANS ‐ A

Q: You want to start physio what will you do

1: Discuss with doctor regarding drowsiness
2: Ask nurse to sit out of bed
3: Delay physio for 24hours
4: Sit in high supported sitting and give chest PT

ANS A
A will be most appropriate as this will ensure atleast that next day the patient is not still
drowsy.

Q: What is the best way to suction

A. Oropharyngeal
B. Nasopharyngeal in situ in between treatments
C. Frequently remove suction catheter

ANS – B

case 11
To move this question to respiratory infection.
Female, chronic smoker. Chronic lung infection , on anti biotics, feeling breathlessness.
ABG has been done.(can’t recall the values of ABG)

1.What will be the immediate management?
Antibiotics and nebulizer
Antibiotics, oxygen therapy,nebulizer
Oxygen therapy

ANS – B. but look at the question. He is on Ab so C is more be‫ﻐ‬itting.

case12
35 year old man with asthma.
‐ wheezy since birth with triggering agents including upper respiratory tract infections,
exercise, dog hair, and house dust mites.
‐ admitted to hospital today by his general medical practitioner because of worsening
symptoms and dif‫ﻐ‬iculty taking his medications.
‐ currently using two metered dose inhalers with a spacer for the delivery of his
medications ‐ Salbutamol (Ventolin), a sympathomimetic (B2‐agonist) and
beclomethasone dipropriate (Becotide)
‐ persistent, non‐productive cough, expiratory wheezes and laboured breathing
‐ appears ‫ﻐ‬lushed and very anxious and is having dif‫ﻐ‬iculty completing sentences.
Arterial blood gases on admission
• SaO2 = 94 (FiO2 = 0.4)
• PaO2 (on O2) = 10 kPa (135mm Hg)
• PaCO2 (on O2) = 4.1 kPa (31mmHg)
• pH = 7.47
On examination
• Heart Rate (HR) = 100beats /min
• Temperature = 37.8 oC
• Respiratory Rate (RR) = 28 breaths/min (shallow, prolonged expiration; short, gasping
inspiration)
• FEV1/FVC ratio = 65%

• Auscultation – reduced breath sounds throughout the lung ‫ﻐ‬ields with widespread
expiratory wheeze

1. The patient’s chest X‐ray is likely to show evidence of

a) hyperin‫ﻐ‬lation
b) hypoin‫ﻐ‬lation
c) an enlarged heart
d) a mediastinal shift
e) signs of lobar collapse

ANS – A.
Reference – 2005 Q paper. A dif‫ﻐ‬iculty exhaling so most likely to have hyper in‫ﻐ‬lated
chest.
http://emedicine.medscape.com/article/353436‐overview
http://www.radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_pathol
ogy_page6

2. The patient’s FEV1/FVC ratio indicates he has

a) an obstructive airway pattern
b) a restrictive airway pattern
c) severe airway obstruction
d) moderate airway obstruction
e) signi‫ﻐ‬icant reduction in vital capacity (VC)

ANS – this is proportion of air in lung which pt can blow in 1 sec.
Lower fev1/fvc it is an obstructive pattern.
P n P – cardio pulmonary function test – Pg 61. 4th edition. Topic ‐ Its under general
principles for airway function.
FEV1/FVC ‐‐ This is the percentage of the vital capacity which is expired in the ‫ﻐ‬irst
second of maximal expiration. In healthy patients the FEV1/FVC is usually around 70%.
In patients with obstructive lung disease FEV1/FVC decreases and can be as low as
20‐30% in severe obstructive airway disease.
Restrictive disorders have a near normal FEV1/FVC.

FEV1/VC (or FEV1/FVC) is the FEV1 expressed as a percentage of the VC or FVC
(whichever volume is larger) and gives a clinically useful index of air‫ﻐ‬low limitation.

3. What is the rationale for using a spacer for the delivery of Becotide in the patient’s
case?

a) to increase inertial impaction in the large airways
b) to reduce the possibility of oral candidiasis and dystonia
c) because four or ‫ﻐ‬ive puffs of Becotide can be inserted into the spacer for each breath
d) because a lower dose of Becotide can be used
e) because a spacer makes it easier for the person to inhale at a fast inspiratory rate

ANS – B. becotide is a steroid. Spacer allows for better cleaning. Use of spacer helps to
prevent these problems.
http://www.nevdgp.org.au/info/lungf/corticosteroid‐health.html

4. Becotide has which of the following actions?

a) it is an anti‐in‫ﻐ‬lammatory steroid
b) it decreases microvascular permeability
c) it decreases bronchial hyperreactivity
d) it inhibits the formation of in‫ﻐ‬lammatory substances such as lymphocytes and
eosinophils
e) all of the above are correct

ANS ‐ E

5. Sympathomimetic drugs

a) bronchodilate the large airways
b) increase myocardial contractility
c) may produce bronchospasm and peripheral vasoconstriction in low doses
d) reduce the patient’s capacity for exercise
e) all of the above are correct

ANS ‐ A

6. Which of the following is true with regard to the patient’s inhaled medications?

a) particles between 5 and 10 ım ̀ are deposited in the small airways
b) breath holding increases inertial impaction of the particles
c) gravitational sedimentation is time dependent

d) rapid inspiration increases the inertial impaction of the particles
e) bronchodilatation is mainly achieved in the 5th generation of the respiratory airways

ANS – C. process of elimination.
A and E is wrong. B and D are out as one is holding and one is breathing quickly. None of
which is correct.
P n P has clearly mentioned that gravitational sedimentation is time dependent.
. Allergic Asthma‐ atopic

Allergic ( extrinsic ) asthma is characterized by symptoms that are triggered by an allergic reaction.
Allergic asthma is airway obstruction and inflammation that is partially reversible with medication.
Allergic asthma is the most common form of asthma, affecting over 5 0% of the 2 0 million asthma
sufferers. Many of the symptoms of allergic and n onallergic asthma are the same (coughing,
wheezing, shortness of breath or rapid breathing, and chest tightness). However, allergic asthma is
triggered by inhaled allergens such as dust mite allergen, pet dander, pollen, mold, etc.
resulting in asthma symptoms.
Click h ere for more indepth information on allergic asthma and related topic
d. Non‐Allergic Asthma‐ non atopic

NonAllergic ( intrinsic ) asthma is triggered by factors n ot related to allergies. Like allergic asthma,
nonallergic asthma is characterized by airway obstruction and inflammation that is at least partially
reversible with medication, h owever symptoms in this type of asthma are NOT associated with an
allergic reaction. Many of the symptoms of allergic and n onallergic asthma are the same (coughing,
wheezing, shortness of breath or rapid breathing, and chest tightness), but n onallergic asthma
is triggered by other factors such as anxiety, stress, exercise, cold air, dry air,
hyperventilation, smoke, viruses or other irritants. I n n onallergic asthma, the immune
system is n ot involved in the reaction.

Empyema
Empyema is a collection of pus in the pleural cavity.

The condition of empyema usually arises secondary to pre‐existing lung disease, such as
bacterial pneumonia, tuberculosis, lung abscess, or bronchiectasis.
On Xray th e empyema can be seen as a D‐shaped shadow, the straight line of the D
being on the lung surface. Pleural aspiration or tap will con‫ﻐ‬irm the diagnosis as the
sample is often thick and purulent, and may be foul‐smelling

Case 1
Toby, a 2 year old boy is diagnosed with basal empyema. He has been
in ICU for 10 days and now transferred to the ward. When you visit
him his parents are present. Toby is very frightened of anyone from
the medical team and refuses to talk to you or engage with you. His
chest drain has now been removed. He is still on analgesia. He is
receiving oxygen via nasal prongs and is also on intravenous
antibiotics.

Q: During your subjective assessment what would you ឈrst ask Toby’s
parents?

1: Was Toby comfortable to sleep last night and what does his cough
sound like?
2: Has the bed sheets been changed today?
3: Has Toby had a shower today?
4: Has Toby had breakfast already?

ANS: A

Q: The doctor has requested you to make him walk. How will you
proceed?

1: Instruct the mother to get him up into standing supporting him
with her hands because he’ll be weak from the bed rest.
2: Tell his mother to walk with him to the door holding him by the
hand
3: Tell his mother that she will need to hold the tubes while you make
him walk
4: Ask his mother to stand by the door and ask Toby to come to her

ANS: A
Reason: go back to toby scenario, been in ICU for 10 days, chest
drains comes off, on nasal prongs. Given that he was in ICU not sure
what resp support he got. Very likely he is deconditioned now as he
has not done much for 10 days. Eliminate the options.
Option 1: sounds like a good option, need to know how good he is in
standing, may need support. Best to let the mum do it.
2: Mum is doing it, no assessment don’t know strength or standing
balance. Won’t go with 2
3: will scream and make him run away, wont tough the baby yet.
Won’t make him walk by myself.
4: This is worse as she is far away so not this as well.
So 1 is the option I will go for as it is checking the standing balance
and etc.
If toby was 10, we would still get him to stand check strength etc
xrst. Get clinical staff to help to carry drains if not present then use
family member if they understand. We can do more hands on
compared to the toby who is 2.

Q: How can you improve his lung volumes?

1: Ask him to blow bubbles
2: Ask him to burst the bubbles you make
3: Demonstrate deep breathing exercises
4: Ask him to copy your cough

ANS: A

Q: Toby’s mother is asking you if the nasal prongs can be removed, as
Toby doesn’t like them. What would your response be?

1: The nasal prongs can be removed if the child is not happy
2: It is best to wean off oxygen gradually and remove when Toby can
maintain good oxygen levels

3: She can check with the doctors if they can be removed

4: The nasal prongs can be replaced by a facemask.

ANS: B
Low ow nasal prongs- 1-4 L/m (28% means - 4L)
High ow nasal prongs/ opto ow ->30 L/m
Reasoning: nasal prongs are for a reason, oxygen is a drug. Make it
more comfortable or distract them. Can’t just say option 1.
Not 4 as well, nasal prongs can delivery up to 40L per min, face mask
only does 6L per min. Don’t know if he will accept face mask also.
3: legally and on paper, doc should be prescribing it. Indian therapists
have good training so we can wean them and up and down, give
oxygen. Write on paper, talk to nurse and doctor xrst. So cant say
check with doc as it is simple to explain it.
2: we can explain to her, that his oxygen level is not adequate and we
explain that. Though on paper it is doc, in practice we do it. In
emergency we can give facemask as well.

Case 2
PAEDS CARDIO ‐ EMPYEMA
5 YEAR OLD TOBY WAS ADMITTED TO THE ICU AND STAYED THERE FOR 10 WEEKS.
THE EMPYEMA IN THE LEFT LOWER LOBE HAS BEEN DRAINED AND NOW HE HAS
BEEN MOVED TO THE WARD. TOBY IS VERY AFRAiD AND RELUCTANT TO SPEAK TO
ANY OF THE STAFF MEMBERS, IN PARTICULARLY TO THE PHYSIOTHERAPIST. HE
WON’T SPEAK A WORD DURING EXAMINATION.
TOBY’S PARENTS ARE THERE AND THEY WANT TO ASSIST IN TOBY’S MANAGEMENT.
THE ICCS ARE
OUT BUT HE STILL HAS NASAL PRONG AND IV.

Question 1: In which position would you assess Toby?

a. High supported sitting
b. SOOB in mothers arms
c. SOOB in Physio’s arms

ANS: B

Question 2: Before mobilizing you want to use demand ventilation to improve his lung
function.

How would you do this?

a. ask Toby’s mother to hold and raise his arms in the air
b. ask Toby to raise his arms in the air a couple of times quickly
c. ask mother to distract Toby while you raise his arms in air
d. blow bubbles in front of him and ask Toby to burst them

ANS: D
Crop ‫ﻐ‬ile ‐112
Demand ventilation :Demand ventilation involves the use of p assive , a
ctive or active
assisted limb exercises to increase metabolic activity and subsequently stimulate an
increased demand for ventilation (increased breathing volume and rate).
Examples of demand ventilation include:
• Rapid upper or lower limb ‫ﻐ‬lexion / extension performed passively, active‐assisted or
actively
• Mobilisation / walking

Question 3: How would you make Toby walk?

a. ask the parents to stand at the door and ask him to walk towards them
b. you can help Toby and encourage him to walk to the door
c. stay in front of Toby so he can see you.
d. ask mother to support him at hips & make him walk
e. Hold the tubes while he s walking ???

ANS: D
ans A acc to
dec 2014 n june 2015

Question 4: After you have done your session what position would you leave Toby to be
in?

a. high supported sitting
b. Sitting out of bed
c. right side lying
d. supine

Ans – Safety reasons so we don’t leave him sitting out of bed.

So we go with A.

ANS: A

Case 3

Toby 2 years old with drained emphysema in left upper lobe was in ICU for 10 days,
shifted to ward, drains are not in place anymore but still has IV in situ. Afraid of medical
personnel especially the physiotherapist and even don’t speak to them.

Q 1 In, which position physio, should assess his chest?

a) High position sitting
b) Sitting by the side of bed
c) In physios arms
d) In mothers arms

ANS: D

Q 2 How to increase his ventilation

a)Blow bubbles and make him burst them
b)Tell him to lift his hands up and down
c)Tell him to lift his hand up on inspiration and bring his hand down on expiration

ANS: A

Q 3 How to make him walk to improve his condition. What advice physio gives his
parent regarding his help.

a)Ask parent to hold his hand and walk him to door
b)Ask parent to stand at door and call out to Toby
c)Ask parent to hold the drains while you walk Toby
d)He is very weak so, to support him hole Toby at hips.

ANS: B

Q 4 How physio will position him after treatment ‫ﻐ‬inishes?

a)High supported sitting
b)Sitting out of bed
c)Sitting to the side of bed
d)Tipping right side lying

ANS: A

COPD

chroinc Bronchitis, COPD
What can be seen?
Increase thining of soft tissue
Decreased VC
Increased thoracic expansion
F orced Vital capacity decrease

PK B??
FB ans D
A Emphysema is a condition where the air sacs (alveoli) become distended and the walls
between them break down causing larger air spaces.

http://l.facebook.com/l.php?u=http%3A%2F%2Ferj.ersjournals.com%2Fcontent%2Ferj%2F35%
2F3%2F676.full.pdf&h=vAQHmeIx

http://erj.ersjournals.com/content/erj/35/3/676.full.pdf

Emphysema‐ Emphysema is a condition of the lung characterised by permanent
dilatation of the air spaces distal to the terminal bronchioles with destruction of the
walls of these airways. It is nearly always associated with chronic bronchitis from which
it is dif‫ﻐ‬icult to distinguish during life.

Emphysema may be secondary to other factors, such as:
• obstructive airways disease ‐ e.g. asthma, cystic
‫ﻐ‬ibrosis, chronic bronchitis
• occupational lung diseases ‐ e.g. pneumoconiosis
• compensatory to contraction of one section of the lung ‐ e.g. ‫ﻐ‬ibrous collapse or
removal, when the remaining lung expands to ‫ﻐ‬ill the space.

Centrilobular (centri‐acinar) emphysema tends to affect the respiratory bronchioles
with most of the alveoli remaining normal.
Panlobular (panacinar) emphysema results in widespread destruction of most alveoli as
well as respiratory bronchioles. Panacinar emphysema predominantly affects the lower
lobes.

Primary emphysema is usually of the panacinar (panlobular) type. In centrilobular
emphysema the upper zones of the lung are usually affected.

Owing to increased intrathoracic pressure the jugular veins fill on expiration.
Chest shape
The chest becomes barrel‐shaped, ‫ﻐ‬ixed in inspiration with widening of the intercostal
spaces. There may also be indrawing of the lower intercostal spaces and supraclavicular
fossa on inspiration. This is associated with the dif‫ﻐ‬iculty of ventilating stiff lungs
through narrowed airways. The ribs are elevated by the accessory muscles of
respiration and there is loss of thoracic mobility.
Poor posture
There may be a thoracic kyphosis plus elevated and protracted shoulder girdles.

Read pathology of emphysema from tidys 309

Case 1
A 60 Year Old woman with history of COPD and asthma is
permanently on oxygen and gets short of breath on mild exertion.
She can only walk from her room to bathroom and living room. She
needs 2 hours to get dressed and is very breathless washing and
combing her hair.

Q: Her BMI is 14. What does this mean? She is:

1: Underweight
2: Normal
3: Overweight
4: Obese

ANS: A
Underweight: Your BMI is less than 18.5
Healthy weight: Your BMI is 18.5 to 24.9
Overweight : Your BMI is 25 to 29.9

Obese : Your BMI is 30 or higher

Q: What can we do to improve her breathlessness while brushing her
hair?

1: Ask her to take a break in between activity
2: Give her gentle strengthening exercises for upper limbs, one arm up at a time
3: Exercise training to relax and strengthen her respiratory muscles
4: Give her more Oxygen

ANS – B
ref : pg 248 alaxandra hough
I agree with your reasoning. Thx for the reference.

Reason: Loss of shoulder girdle strength causes excessive stress on respiratory muscles
(IC and accessory muscles) to support arms and torso. This in turn shifts breathing load
to the diaphragm creating a challenge to the respiratory system.
Unsupported arm exercises followed by gentle progression is encouraged. This will have
carry over effect on the respiratory muscles and can pass as equivalent to IMT.

Q: When should a patient be excluded from pulmonary rehabilitation? When he/she
has:

1: Unstable angina
2: History of cancer
3: Arrhythmia
4: Stable Angina

ANS – A.
Pulmonary toolkit says unstable angina only. So this will be the answer.A
P n P Pg 480.
Most patients with unstable angina are excluded from the programme.

Pg PDF 226 ‐ Alexandra Hough

The case notes should be scrutinized to check that exercise training is safe.
absolute Contraindications

include acute disease, symptomatic angina, recent embolism or myocardial infarct,
second or third‐degree heart block, deep vein thrombosis and resting systolic BP above
240 mmHg or diastolic above 120 mmHg.
Relative contraindications
include disabling stroke or arthritis, haemoptysis (depending on the cause), metastatic
cancer, unstable asthma, resting heart rate (HR) below 1 00 and resting systolic
pressure above 1 8 0 mmHg or diastolic above 95 mmHg (Bach and Haas, 1 996). Liaison
with the physician is suggested if PaC02 is above 8 kPa (60 mmHg).

People with insulindependent diabetes bene‫ﻐ‬it from exercise training, which can also
improve glucose tolerance, but extra vigilance is required to identify hypoglycaemia (p.
1 1 6).
Steroidinduced osteoporosis is not a contraindication and indeed is an indication for
sensible weightbearing exercise (Inman et at., 1 999).
People with heart failure usually bene‫ﻐ‬it from exercise training: those with mild disease
may take longer to recover from activity and those with more advanced disease require
a low‐intensity programme (Pi‫ﻐ‬ia, 1 996). People with intermittent claudication can
improve their walking distance

The following drug history is relevant:
• drugs such as betablockers render the BP and pulse unreliable for monitoring
purposes (p. 334)
• if prescribed and indicated, bronchodilators and antiangina drugs should be taken
before exercise
• s teroids should be at the lowest effective dose to minimize muscle weakness.

Case 2
A patient with acute exacerbation of COPD and heart failure

Q: What position in lying can increase gaseous exchange?

1: Lying with head down tip (30 deg)
2: High side lying on right
3: High side lying on left
4: Supine lying
5: Prone lying

ANS – B
Reference Tidy’s 15th edition ‐ Pg ‐ 91.
P n W ‐ Pg 133
Rt lateral position is preferred to Lt lateral because the Rt lung is bigger in size than the
left and hence in this posiiton, the Lt lung is not compressed.

Secondly, in Rt SL position, the heart and adjacent lung tissues are subject to less
comression.

POE
A emphysematous patients were less breathless, had reduced accessory muscle activity
and had a significant reduction in ventilation when positioned in a 16° head down position
REF Pn W PG 138 N ot 1 def

B Patients with uniformly distributed bilateral lung disease may derive greater benefit
when the right lung is lowermost (Zack et al 1974). In this case, arterial oxygen tension is
increased secondary to improved ventilation of the right lung, which may reflect thE
increased size of the right lung compared with the left and that, in this position, the heart
and adjacent lung tissue are subjected to less compression.
Usually go for upright positions, to improve gaseous exchange and pulmonary air.

C : we don’t know which lung is affected. If pneumonia in R lung then put good lung down.
Lung down gets more perfusion, improving V/q matching. So put good lung down. Bad
lung up. Improves in drainage as well.
pt has HF and if u keep pt in left sidelying compression on heart increases

D (pulmonary complications)positions are nonphysiologic and are associated with
significant reductions in lung volumes and flow rates, and increased work of breathing p g
132 pnw
Cardiac complications ‐ gravity dependent position increases the central blood volume
and may precipitate venous congestion, reduced compliance and pulmonary oedema.
Loss of SV and orthostatic intolerance is also possible.

E P
rone position – max alveoli are on the posterior wall of lungs and if patient can tolerate
and must be used. PG 133 PnW
However haemodynamically unstable patients may not be able to tolerate this situation
and hence should not be forced. 2 variants are possible for the prone position
‐ Prone abdomen restricted
‐ Prone abdomen free (with a hole in the bed so that abdomen drops in freely).

Understand how Heart failure can occur in COPD, long term hypoxia, leading to
pulmonary vasoconstriction. Puts more load on the Right heart as it pumps to the lungs.
Leading to failure. Cor Pulmonary

HF is almost a chronic complication of COPD

Q: What does increased JVP (Jugular Venous Pressure) signify?

1: Unstable heart disease
2: Medical emergency
3: Increased ‫ﻐ‬luid volume
4: Hypertension
5: Increased intracranial pressure

ANS – C.
Reference: the JVP provides a quick assessment of the ‫ﻐ‬luid volume. Reference P n P –
13.
http://www.ncbi.nlm.nih.gov/books/NBK300/
The normal mean JVP = 6‐8 cm H2O. Deviations from normal can indicate ‐ hypovolemia
or impaired cardiac ‫ﻐ‬illing.

POE
A ‐ This option is very close but it is incorrect.
B ‐ not necessarily
C ‐ correct option
D ‐ No.
E ‐ Not ICP

JVP
Jugular Venous Pressure normal 0 ‐ 2 cm Assesses volume of blood in great vessels
entering the heart.
Increased in (R)HF , 2* to (L)VF / CAL (Cor Pulmonale

Q: Why do musculoskeletal problems arise in pulmonary disease?

1: Hyperin‫ﻐ‬lation of the chest
2: Compensatory breathing pattern with shoulder elevation
3: Reduced exercise tolerance & inactivity
4: All of the above

ANS: D
There are lot of positional compromises in these patients.
Some of these are listed above.
Others are kyphotic chest, protracted shoulders, ‫ﻐ‬lexed neck etc.

Q: What does a RPE (Rate of Perceived Exertion) score of 9 mean on Borg Scale?

1: Extremely light 7.5
2: Somewhat Hard 13
3: Very light 9
4: Light 11

ANS: C
This is the Borg 15 point scale.
Case 3
A 78 year‐old male (Mr M), admitted to a medical ward following a history of feeling
unwell for four days, has been experiencing increasing breathlessness. he is
complaining of moist cough & dif‫ﻐ‬iculty clearing sputum.
Past medical history: chronic obstructive pulmonary disease (COPD), chronic atrial
‫ﻐ‬ibrillation, ischaemic heart disease (IHD) ‐ with moderate impairment of left
ventricular function, re‫ﻐ‬lux oesophagitis and prostatism.
Medications include Prednisolone; Atrovent via metered dose inhaler with spacer;
Flixotide; Perindopril; Prazosin; Frusemide; Ranitidine; Aspirin

Arterial blood gas (ABG) on admission on 28% O2 via venturi mask:
pH ‐ 7.32/ ACIDOSIS
PaO2 ‐ 60mmHg/ Hypoxaemia

PaCO2 ‐ 75 mmHg/ ACIDOSIS
HCO3 ‐34mlEq/L / Alkalosis
SaO2 90% Hypoxaemia

Other ‫ﻐ‬indings on admission: Heart rate (HR) ‐ 85 beats/min, Blood pressure (BP)
100/60 mmHg, Respiratory rate (RR) ‐ 30/min, Auscultation ‐ decreased breath sounds
throughout, widespread polyphonic wheeze and bibasal inspiratory crackles. Cough is
weak and moist sounding. He is sweaty, short of breath during conversation and
orthopnoeic; He is very thin and extremely frail and has signi‫ﻐ‬icant bruising on his arms
and legs.
Immediate medical management: Intravenous hydrocortisone and antibiotics, Ventolin /
Atrovent / saline given four hourly via a nebuliser, Digoxin and increased levels of
Perindopril and Frusemide, Oxygen therapy

Q: Which of the following is an indication of Mr M’s acid‐base disorder?

a) Respiratory alkalosis with partial compensatory metabolic acidosis
b) metabolic alkalosis with partial compensatory respiratory acidosis
c) respiratory acidosis with partial compensatory metabolic alkalosis
d) metabolic acidosis with partial compensatory respiratory alkalosis
e) respiratory alkalosis with compensatory metabolic acidosis

ANS: C
https://www.youtube.com/watch?v=WUf‐cPpnrXw
ABG ebook pdf (By Tulsi)

Q: Which of the following statement(s) about the mechanism of Mr M’s orthopnoea
is/are FALSE?

a) orthopnoea is due to an increase in pulmonary venous congestion
b) abdominal contents cause an increased mechanical load on the diaphragm
c) reduced closing capacity results in V/Q mismatching
d) orthopnoea is often associated with haemoptysis
e) all of the above are false

ANS: D
haemoptysis is due to anastomosis of arteries of bronchial wall with pulmonary
capilaries i.e. is present in bronchiectesis

Q: The physiotherapist ‫ﻐ‬inds that when Mr M moves quickly from a standing to a supine
position he experiences breathlessness. Which of the following statements about
possible causes of the breathlessness are TRUE?

• I ‐ the effect of increased preload on the heart
• II ‐ the effect of decreased preload on the heart
• III ‐ the effect of increased right ventricular end diastolic volume
• IV ‐ the effect of ‫ﻐ‬luid backing up in the lungs
• V ‐ the effect of increased ejection fraction

a) I, III and IV
b) I, II and V
c) III, IV and V
d) II and IV
e) I and III

ANS: A

Q: Which of the following would be the MOST appropriate management strategies to
assist airway clearance for Mr M?

a) Pursed lip breathing, thoracic expansion exercises
b) Active cycle of breathing techniques (ACBT), modi‫ﻐ‬ied gravity‐assisted drainage
positioning
(GADP)
c) sustained maximal inspirations (SMI), percussion
d) gravity‐assisted drainage positioning (GADP), shaking
e) Positive expiratory pressure (PEP) mask, breathing control

ANS: B
becoz of large amount of secretions

Q: Which of the following statements about a Venturi mask is TRUE?

a) it is used for the delivery of oxygen for patients with a hypercapnic respiratory drive
b) the high ‫ﻐ‬low of oxygen entrains a small volume of ambient air
c) a ‫ﻐ‬ixed FiO2 can be delivered to the patient
d) it can be used for the delivery of the patient’s inhaled medications
e) CO2 accumulation in the mask is prevented by periodically removing the mask

ANS: C

Q: Which of the following represents the LOWEST risk factor for IHD?

a) Cigarette smoking
b) Stress
c) Family history of IHD
d) Hypertension
e) Diabetes mellitus

ans B as this is external factor which could b controlled

Case 4
Old case of chroinc Bronchitis, COPD

What can be seen?

Increase thining of soft tissue
Decreased VC
Increased thoracic expansion
Forced Vital capacity decrease

ANS: B
A‐ seen in emphysema

Case 5

50 female COPD and bronchiectasis.
a 55yo rt middle lobe pneumonia with background of copd and bronciectasis

With a lady with R middle lobe in‫ﻐ‬iltatres X ray :

a. diminished costo phrenic angles and right boarder of heart blunted
b. Raised diaphragm
c. Shadow of right heart border
d.?????

ANS – Pg 41. 3rd edition. Assessment skills techniques and Mx. There is a thing on
thoracic imaging. Rt upper lobe, middle lobe and lower lobe. Right middle lobe – on PA
radiograph moves down. Blurring of right border. May be easily overlooked.
ANSWER – A. diminished costophrenic angles is a ‫ﻐ‬inding of COPD. Also a ‫ﻐ‬inding of
consolidation.

ANOTHER ONE
With
a. diminished breath sound
b. coarse crackles and ‫ﻐ‬ine inspi crackles
c. ‫ﻐ‬ine crackles
d. ????? maybe stridor?????

ANS B.
Bronchiectasis‐ coarse crackles
Crackles are heard predominantly on inspiration but both inspiratory and expiratory
crackles are heard in bronchiectasis (coarse) and ‫ﻐ‬ibrosing alveolitis
(‫ﻐ‬ine). AH‐ 55

don’t remember if it s early late inspi or expi

Drowisness of the patient What would you do ?
a. tell the doctor about drowsiness
b. no physio before 24 hours
c. give incentive spirometer
d. ???

Ans ‐A

Other one . Patient needs to practice Forced expi techniques ????
a. to correct breathing pattern
b. improve lung volume
c. to clear secretion form peripheral airways
d. to clear secretions from central airways

ANS C

Then Question on how to do FET with a tissue paper
a. deep breath and blow hard and fast
b. deep breath and blow until all the air comes out???
c. Moderate breath and blow as hard and fast
d. Moderate breath and blow as long as you can
ANS ‐ C

B cannot because it causes paroxysmal couging. CROP ‫ﻐ‬ile has good explanation. Pg 110.

FET ‐ mid lung vol inspiration
Huff‐ high / large lung vol inspiration

You ve got a low saturation. But it is inaccurate ? why could be the reason
a. shivering of the patient
b. low light
c. too much O2 or something similar ?????
d. ?????

ANS A

Case 6
70 year‐old male with chronic obstructive pulmonary disease (COPD).
‐ referred to an outpatient pulmonary rehabilitation programme.
‐ can walk up to 100 metres before having to stop due to breathlessness
‐ lives in a ground ‫ﻐ‬loor unit.
His lung function results are:
• FEV1 ‐ 0.5 litres
• FEV1/FVC = 35%
• Resting oxygen saturation 93% on air
Previous medical history includes
• right total hip replacement four years ago
• gout affecting the feet and ankles !

55. Which are the two most likely pathophysiological causes of this patient’s
breathlessness during exercise?

a) air‫ﻐ‬low limitation, respiratory muscle dysfunction
b) decreased chest wall compliance, decreased lung volumes
c) decreased lung compliance, decreased venous return
d) increased cardiac afterload, peripheral muscle ischaemia
e) increased cardiac afterload, decreased venous return !

ANS: A
Physiological mechanisms involved in dyspnoea
Physiological mechanism Example
Increase in effort of breathing due to increased
air‫ﻐ‬low resistance or decreased respiratory
compliance, aggravated by hyperin‫ﻐ‬lation
Asthma or COPD with negative effects on
respiratory muscle performance
Increase in dead space ventilation due to
decreased regional lung perfusion relative to
ventilation
Lung hyperexpansion, vascular occlusion from

pulmonary emboli
Stimulation of chemoreceptors by hypoxaemia
or hypercapnia
Ventilation‐perfusion mismatch in pulmonary
embolus, metabolic alkalosis, increased
temperature, or sepsis
Reduction in central or neural drive to the
inspiratory muscles
Central nervous system depressant drugs. Reduction in respiratory muscle function
Guillain‐Barré syndrome and myasthenia gravis, general deconditioning accompanied
by lactic acidosis during exercise with stimulation of ventilation Possible stimulation of
vagal irritant receptors Asthma

56. Before prescribing an exercise program for this patient, which of the following tests
or assessments would you consider to be the MOST important to perform?

a) ability to walk upstairs, incremental upper limb ergometry test, upper limb strength
b) chronic respiratory disease questionnaire, shuttle or 6 minute walk test, this patient’s
use of walking aids
c) air‫ﻐ‬low limitation using a peak ‫ﻐ‬low meter, pulmonary function testing, SF‐36
d) Bruce or Balke treadmill protocol test, strength of quadriceps and hip abductor
muscle groups
e) COPD self‐ef‫ﻐ‬icacy scale, COPD coping scale, alcohol consumption, !

ANS: B
The CRQ is an interviewer‐administered questionnaire measuring both physical and
emotional
aspects of chronic respiratory disease, whereas the SF‐36 is a multi‐purpose, short‐form
health
survey that yields an 8‐scale pro‫ﻐ‬ile of functional health and well‐being scores as well as
psychometrically‐based physical and mental health summary measures and a
preferencebased
health utility index. It is a generic measure, as opposed to one that targets a speci‫ﻐ‬ic age,
disease, or treatment group such as the CRQ. Air‫ﻐ‬low limitation and pulmonary function
testing
are not as speci‫ﻐ‬ic as the shuttle or 6 minute walk test in terms of pre‐exercise
screening/assessment.
Use of gait aids is relevant for this particular patient in light of history and the fact that if
these are not appropriate, they may be causing inef‫ﻐ‬icient use of energy when walking.

57. All of the following techniques will help this patient to recover from his
breathlessness after walking EXCEPT

a) pursed lip breathing
b) forward lean positioning
c) ‫ﻐ‬ixing the shoulder girdle muscles
d) thoracic expansion exercises
e) breathing control !

ANS: D
Thoracic expansion exercises will not help with recovery from breathlessness in a
patient
with
COPD as these exercises have an emphasis on inspiration, expiration being quiet and
relaxed.
Due to the COPD, his main problem is exhalation rather than inspiration – this air
remains in
the lungs and impedes fresh air being inhaled and allowing oxygen transfer. When he is
breathless he needs to concentrate on exhalation, not inspiration.
Pursed lip breathing is one of the simplest ways to control shortness of breath. It
provides
a
quick and easy way to slow your pace of breathing, making each breath more effective.
Pursed lip breathing:
• Improves ventilation
• Releases trapped air in the lungs
• Keeps the airways open longer and decreases the work of breathing
• Prolongs exhalation to slow the breathing rate
• Improves breathing patterns by moving old air out of the lungs and allowing for new
air
to enter the lungs
• Relieves shortness of breath
• Causes general relaxation

58. While supervising this patient’s rehabilitation program, the physiotherapist
becomes concerned about the accuracy of this patient’s pulse oximetry reading. Which
of the following statements about pulse oximetry using a ‫ﻐ‬inger probe is FALSE?

a) peripheral vasoconstriction m ay give an i naccurate reading
b) motion artefact may give an inaccurate reading
c) pulse oximetry will be accurate even when the pulse is irregular
d) o ptical interference may occur if the reading is taken in a room with bright ambient
light
e) inaccurate readings may occur when values are very low (e.g. below 80%) !

ANS: C
Irregular pulse rate creates inaccurate readings. It is true that inaccurate readings may
occur of
values are low. CROP ‫ﻐ‬ile reference. 2005 question.

59. Which non‐invasive test can be used to quantify the strength of the respiratory
muscles?

a) forced vital capacity comparing values in sitting and standing
b) peak inspiratory and expiratory mouth pressures
c) positive expiratory pressure mask
d) chest radiograph
e) pulse oximetry !

ANS: B
Mouth pressures quantify strength as they re‫ﻐ‬lect force created by the muscles on
inspiration
and expiration.

60. Which of the following statements about the effects of a pulmonary rehabilitation
program are FALSE?

• I an increase in maximal workload occurs
• II oxygen consumption for a given workload is decreased
• III improved self‐con‫ﻐ‬idence reduces patient anxiety about exercise
• IV reduced ventilation is required at a given submaximal workload
• V resting heart rate is reduced

a) I, II and III
b) II, III and IV
c) II and IV only
d) III and V only
e)I and V only

ANS: E
The effects of pulmonary rehabilitation program are to increase exercise capacity this is
re‫ﻐ‬lected by d ecreased oxygen consumption and r educed ventilation for a given
workload.
Studies looking at controlled pulmonary rehabilitation trials have shown the following:
• Better exercise capacity and endurance
• Improved muscle strength

• Reduced perceived level of breathlessness
• Increased knowledge about respiratory disease and management
• Enhanced mood, reduced anxiety, reduced depression
• Enhanced ability to perform activities of daily living
Maximal workload itself is unlikely to increase but endurance is increased at
submaximal workloads.

case 7
Pulmonary rehab: Asthma for a long time, Could walk 500m. We want to increase his
endurance.he is sedentary for most of his life.

Q:Physio want to check his exercise tolerance ,what is the appropriate measure for it
6 min walk test
Graded exe test
Borg dyspnea scale
St George questionarrie

Ans‐ A
Ref toolkit ‐ measure functional ex capacity

Q:after assessing his exe tolerance physio gave a walking programme. To be effective
how
long does he have to walk per day?
1: 10min
2: 40min
3: 20min
4: 30min

A‐4

Q:how many days per week walking is affective?
1: 3‐4/ weeks
2: 4‐5/ w
3: 1‐2/w
4: 2‐3/w

Ans‐ 2

Q:Pt completed his pul rehab and gained exercise tolerance and he wanted to continue it
what physio will advice him
A Stop walking
B Continue to walk for 3‐5/wk

C Join gym
D Decrease exercise for 2‐3 times/wk.

Ans‐ B

case 8
1.what is her diagnosis
a.respiratory acidosi
b.respiratory alkolosis
c.metabolic acidosis
dmetabolic alkolosis

2.what is the use of venture mask
a.constant oxygen supply
b.works irresptive of patient breathing
c.all the above
ANS A

3.what suction to use
a.nasopharyngeal
b.guedels etc
ANS ‐ a to avoid gag n bitting re‫ﻐ‬lex n aspiration

4.what are the contraindication for nasopharyngeal suctioning
a. base of skull fracture
b, both nostril nasogastric tubes etc
ANS A
http://www.icid.salisbury.nhs.uk/ClinicalManagement/Physiotherapy/Pages/Nasopha
ryngealAirwayManagementandNasphoryngealSuctioninginAdults.aspx

case 9
pt with exacerbation of COPD. X‐ray showing rt lower lobe opacity. taking
medication by spacer( steroids, bronchodilator etc)

Q1 what is rationale for using spacer?
a) to increase the deposition in lung
b) Because it is cheap and increases compliance
c) to increase impaction of drug in upper airway
d) to increase gravitational sedimentation

ANS – A.
Reference ‐ Spacers are used to improve the deposition of the drug in lungs…. pg no 169
pryor and Prasad. With inspiratory hole it should be slowly.

Q2 the opacity seen in rt lower lobe is consistent with

A) diminish shadow of rt heart border
B) diminish shadow of descending aorta
C) diminish shadow of right hemi diaphragm
D) shifting of trachea

ANS – C. If it is middle and upper lobe there can be shifting of trachea.
Reference Pg 41. Pnp.
Right lower lobe collapse is a mirror image for left lower lobe collapse.

Q3 what are the signs of infection?

Additional Q
COPD (Chronic Obstructive Pulmonary Disease)
What position in lying increase gaseous exchange?
What does increased JVP (Jugular Venous Pressure) signify?
Why musculoskeletal problems arise in pulmonary disease?
What does a RPE (Rate of Perceived Exertion) score of 9 mean in Borg Scale?
‐ Very light

Case 10
&q77= A 62 year‐old patient has chronic obstructive pulmonary disease.
Pulmonary test results include all of the following except increased:
77a= total lung capacity.
77b= FEV1/FVC ratio.
77c= residual volume.
77d= functional residual capacity.

ANS: B
A‐
B‐ ratio should be <70%
In the COPD p atient, routine p ulmonary function tests d epict the characteristic p attern
of volumedependent a irway o bstruction. Spirometry typically reveals a reduction in the
FEV 1 /FVC ratio a nd a n e ven g reater relative d ecline in FEV, which may d ecrease
between 2 5% a nd 7 5% o f vital capacity (Table 1 ). As a irflow o bstruction worsens, a
normal volume o f g as can n o longer b e e xhaled in the time a vailable, a nd vital capacity
declines. Measurement o f lung volume consistently reveals a n increased residual

volume (RV) a nd a n ormaltoincreased functional residual capacity (FRC). The RV

may b e 2 to 4 times h igher than n ormal, b ecause a s the e xpiratory a irflow slows, g as
becomes trapped in a irways that close p rematurely. The FRC may b ecome increased
by 2 mechanisms: d ynamic h yperinflation a nd a ctivation o f inspiratory muscles d uring
exhalation. Hyperinflation flattens the diaphragm, which increases the work of
breathing , d iminishes the capacity for e xercise, a nd increases d yspnea. Hyperinflation
becomes worse with e xercise, causing d ynamic h yperinflation, which a dds to the load
of inspiratory muscles.
As a result o f these p rocesses, tidal b reathing may take p lace a t lung volumes a s h igh

as 1 to 2 L a bove n ormal levels. In the p atient who h as significant a irflow o bstruction,
an increased FRC p rovides the b enefits o f a n e nlarged a irway d iameter which
provides g reater radial support a nd thus less a irway resistance a nd a n increased
driving p ressure (ie, e lastic recoil) required for e xhalation. The c ost to the patient of a n
increased FRC is the greater work of breathing incurred a t the higher lung v olume.
http://www.medscape.com/viewarticle/707973_5

There is reduction of FEV1 and the forced vital capacity
(FVC) is grossly reduced. The residual volume (RV) will be increased at the expense of
the vital capacity (VC) because of air trapping and the inability of the
expiratory muscles to decrease the volume of the
thoracic cavity. The expiratory ‫ﻐ‬low‐volume curve is grossly abnormal in severe disease;
after a brief interval
of moderately high ‫ﻐ‬low, ‫ﻐ‬low is strikingly reduced as
the airways collapse, and ‫ﻐ‬low limitation by dynamic
compression occurs. A scooped‐out appearance is
often seen.
307 tidys

Case 11
&q94= A patient with COPD has developed respiratory acidosis. The
physical therapist instructs a PT student participating in the care to monitor the
patient closely for:
94a= disorientation.
94b= tingling or numbness of the extremities.
94c= dizziness or lightheadedness.
94d= hyperreflexia.

ANS: A

Due to cerebral vasodilatation increasing cerebral blood ‫ﻐ‬low n ICP resulting in
disorientation, acute confusion, headache, mental obtundation
Acute respiratory acidosis need assisted ventilation

Case 12
ANS:

Respiratory Failure
Type 1‐Hypoxemia with normal CO2 as some part of lungs is still intact
Type2‐ Hypoxemia usually Pao2<<60mm Hg n h ypercapni a>>55mm Hg‐ respiratory
acidosis
Case 1
A patient admitted to a respiratory ward is in type 2 respiratory failure and Right middle
lobe pneumonia.

Q: Why is Oxygen given to patients during a respiratory failure?

1: To make the patient feel better
2: To maintain PaO2 at or above 60mm Hg
3: To lower the heart rate
4: To relieve pain

ANS – B
CROP ‫ﻐ‬ile pg 64. O2 therapy general principal and approach. – PaO2 is below 60mm Hg

Q: What is the common Oxygen saturation level (SpO2) aimed for in a patient with
COPD?

1: 75 ‐80%
2: 90 ‐92%
3: 80 – 100%
4: Above 100%

ANS – B
CROP ‫ﻐ‬ile. Pg 35.
90‐94% for COPD because of hypoxic drive. They need low PaO2 to maintain the
respiratory drive. Copd pat dont rely on low Paco2 ie centrally but on peripheral
receptors ie pao2, low level of o2 stimulate ventilation

Q: Which of the following is the best interface to provide Oxygen therapy for more than
24 hours during an acute exacerbation of COPD?

1: Simple Face mask
2: Rebreather mask
3: Venturi mask
4: Trache Mask

ANS – C
CROP oxygen saturation is not very good in A and B. So C would be the best option. Its
given under oxygen therapy.

Q: What do you expect to ‫ﻐ‬ind on chest auscultation?

1: Stridor
2: Fine crackles bi basally
3: Coarse crackles in right base
4: Pleural rub

ANS: C
4‐ as no pleura is involed
AH‐55
Late inspiratory crackles, signs of pneumonia.
The basal alveoli of a normal lung, deflated at the residual volume, inflate in late inspiration; the basal
airways are the first to close towards the end of expiration [20]. Therefore, crackles will most often
appear at the early stage of a disease at basal areas of the lungs.
Fine cracles in acute pneumonia
Coarse in resolving pneumonia

Q: The patient’s breathing pattern will be:

1: Slow & Deep
2: Prolonged inspiration
3: Fast & Shallow
4: Cheyne Stokes breathing

ANS: C
1‐ normal

Q: What could be the reason for increased work of breathing in a patient with COPD?

1: Air‫ﻐ‬low limitation due to edema and /or sputum retention
2: Altered respiratory mechanics due to hyperin‫ﻐ‬lation
3: Deconditioning due to fear of shortness of breath leading to reduced activity
4: All of the above

ANS – D
There will be hyper in‫ﻐ‬lation in COPD. If D is not given the A will be the second best
option.

Q: After 5 days the patient still has still green sputum but his ABGs and functional status
have improved. What is an appropriate discharge plan for this patient?

1: Refer the patient to pulmonary rehabilitation
2: Delay discharge until his cough clears
3: Discharge with a home exercise program
4: Refer him to a Physiotherapy outpatient clinic

ANS – C (given by AAPTA moderator)
I am Between A and B. But will prefer A.
P n P PDF Pg 471 and 472 ‐ PR is MDT intervention that is predominantly concerned
with issues with patient’s disability. Techniques are aimed at reducing the work of
breathing muscles and improving disability ahve been an integral part of the
rehabilitation.
Effective positioning, mobilization, relaxed breathing and techniques aimed at sputum
clearance are recognized as Rx interventions.
Pt and family education is part of this technique. As such it is a holistic treatment
strategy which involves pt education and MDT approach.

Pulmonary Fibrosis
fine inspiratory crackles can be heard at the lung bases on auscultation,
Lateinspiratory crackles originate in alveoli and peripheral airways as they open at the end of
inspiration and are associated with pneumoma, fibrosis or pulmonary oedema.

Case 1
A 40 year old male admitted with history of Pulmonary Fibrosis. He is awaiting lung
transplant.

Q: Pulmonary Fibrosis is a condition in which

1: The airways are ‫ﻐ‬loppy
2: The lung gets scarred & thick
3: There is abnormal chronic sputum production
4: There are ‫ﻐ‬ibrotic nodules in the lungs

ANS: B
1‐ tiny alveli r not ‫ﻐ‬loppy they r scarred
3‐ cough is generally dry n in latter stages pat my produce clear phlegm
4‐ ?

Q: What does it look like on X‐ray?

1: localized opacity in lower lobes
2: Reduced peripheral vascular markings
3: Crowding of ribs bilaterally with loss of volume
4: Diffuse reticulo nodular pattern in both lungs

ANS: D?

Q: Any of the following could contribute to developing PF except:

1: Connective tissue disorders
2: Cigarette Smoking
3: Increased alcohol intake
4: Occupational contaminants

ANS; C
1‐ lupus, scleroderma/RA can cause scarring secondarily
2‐ most prominent cause
4‐

Q: Which of the following is not commonly included in managing PF?

1: Supplemental Oxygen Therapy
2: Pulmonary Rehabilitation
3: Autogenic drainage
4: Lung transplantation

ANS: C as there are a little secreation n that is clear phlegm in latter stage.

Case 2
59 year old female. Pulmonary ‫ﻐ‬ibrosis since 10 years.
O2 dependent. Before 1 lit O2 and now increased to 2 Lit.
She gets very tired and breathless with normal activities. Takes more than 2 hours for
showering and grooming.
BMI is 14

Q: 1 What does BMI indicate?

‐ Underweight
‐ Overweight
‐ Normal
‐ Obese

ANS: A

Underweight: Your BMI is less than 18.5
Healthy weight: Your BMI is 18.5 to 24.9
Overweight : Your BMI is 25 to 29.9
Obese : Your BMI is 30 or higher

Q: 2 You performed 6 minute walk test for her. What will it indicate to decide future
physio programme?

‐ No. of meters walked in 6 minutes formula (80% of 6 MWT)
‐ O2 saturation level

‐ Dyspnoea score on exertion
‐ Minutes walked

ANS: A
Reference: P n P 477
The 2 important paramters to be tested are dyspnoea score, HR, Spa2. But the 6MWD (6
Min Walk Distance) is literally a test measuring distance walked in 6 minutes.
Compare to previous tests completed by that patient. A difference of 54m was found to
be a clinically signi‫ﻐ‬icant change in function (Solway et al 2001)
CRop ‫ﻐ‬ile‐ 64

Q : 3 What is false statement for measuring QOL ( quality of life ) ?

‐ It shows bene‫ﻐ‬its of Pulmonary rehab
‐ It gives ideas of her disabilities
‐ It shows statistics for exercises ( not sure but something related to statistics )
‐ It shows how much you have improved with pulmonary rehab

ANS: C
C is most appropriate. The main aim of PR is to improve QoL.

Q : 4 She is feeling tired in ADLs like combing hair and brushing teeth. What will you
teach her to help with her ADLs?

‐ Relaxation
‐ Deep breathing exercises
‐ Upper limb strengthening exercises
‐ Unilateral elevation exercises

ANS:
OA: C
AAPTA chose C
In pulmonary toolkit. to help ADL we need to strengthen her ULs.
Alexander Hough 248
Relaxation wont make her feel better. Gentle p rogressive arm exercises reduce the

breathlessness associated with upper limb activities, with a carry‐over effect on the
respiratory muscles that can be equivalent to inspiratory muscle training (Hodgkin et
ai., 2000, p. 1 5 8 ) .
Unsupported arm exercise should b e included unless this causes abdominal paradox (p.
37). Loss of shoulder girdle support forces the intercostal and accessory muscles to
stabilize the arms and torso, which shifts the breathing load to the diaphragm, creating a
challenge for people with COPD (Figure 9 . 14).

Fine late inspiratory crackles occurred in restrictive pulmonary diseases.

Cystic Fibrosis
Objectively, auscultation gradually shows wheezes as a bronchiolitis‐like process
develops in the small airways, then widespread crackles develop. The radiograph is
normal at ‫ﻐ‬irst, then shows patchy opacities in the apical regions, then signs of
widespread bronchiectasis, emphysema and ‫ﻐ‬inally cor pulmonale.
Growth may be stunted because of energy imbalance, energy supply being reduced by
malabsorption and anorexia, and energy demand increased by up to 25% (Shepherd, 1 9
8 8 ) because o f excess WOB. alexander Hough‐ 100

Case 1
5 year old child with Cystic Fibrosis admitted with Right upper lobe pneumonia.

Q: Which among the following would be on top of the physiotherapy problem list for this
child?

1. Pain
2. Sputum retention
3. Reduced physical activity levels
4. His mother’s ineffective percussion technique

ANS – B

Q: Which of the following systems is not involved in cystic ‫ﻐ‬ibrosis?

1. Respiratory system
2. Gastrointestinal system
3. Nervous system
4. Reproductive system

ANS – C

Q: Which of the following statements is true about living with cystic ‫ﻐ‬ibrosis?

1. People with CF require a high energy, high protein diet, high fat & high salt diet.
2. Children with CF loose excessive amounts of salt through sweat during exercise and
are at high risk of dehydration
3. People with CF may require “tune up” admissions in hospitals to have antibiotics and
additional chest physiotherapy.
4. All of the above

ANS ‐ D
1‐ high energy‐coz

3‐ PAT CAN have home treatment with antibiotics n physio pg 560 pnp4ed
If the cough gets worse despite treatment, your CF doctor may recommend either a
different oral antibiotic, or possibly admission to Monash Children’s at 10 Monash
Medical Centre for intravenous antibiotics and intensive chest physiotherapy (often
called a “tune‐up”)
http://www.monashchildrenshospital.org/icms_docs/3565_An_introduction_to_Cystic_
Fibrosis_for_parents_and_families.pdf

Q: Which of the following statements is not true about cystic ‫ﻐ‬ibrosis?

1. Both parents must be carriers for a child to develop CF
2. Genetic testing is the gold standard to diagnose CF
3. When both parents are carriers there is a 25% chance for each child to have CF
4. In Australia one in 25 people is a carrier of CF gene.

ANS –B
B (given by AAPTA)
Komal ‐ On average one in 25 people carry the CF gene (most of whom are unaware they
are carriers).
Cystic ‫ﻐ‬ibrosis (CF) is an autosomal recessive condition. The incidence in Australia is
1/2500 with a carrier frequency of 1/25.(1) It is most common in Caucasian people,
and extremely rare in Asian, African and indigenous Australian populations.

Newborn screening detects 90% of babies with CF
The primary screen is immunoreactive trypsinogen (IRT)
Infants are missed because the IRT is not elevated suf‫ﻐ‬iciently

Case 2
25 year old female with cystic ‫ﻐ‬ibrosis admitted for a “tune up” . Her physiotherapy
regimen consists of twice daily exercises in the gym & Mask PEP – 2 hourly post
nebulisers

Q: Which of the following statements is true about CF?

1. It is caused by a autosomal dominant genetic disorder
2. It is caused by a autosomal recessive genetic disorder
3. It is caused by a allosomal dominant genetic disorder
4. It is caused by a allosomal dominant genetic disorder

ANS – B
Cystic Fibrosis (CF) is a recessive genetic condition. The gene involved in CF gives
instructions for the cells to make a protein that controls the movement of salt in and out
of cells.
This salt transport gene lies on chromosome 7. Everyone has two copies of chromosome
7 and therefore everyone has two copies of the salt transport gene. Scientists have called
it the CFTR (Cystic Fibrosis Transmembrane Regulator) gene.
CF is the most common life threatening, recessive genetic condition affecting Australian
children.
Symptoms can include poor weight gain, troublesome coughs, repeated chest infections,
salty sweat and abnormal stools.
Cystic Fibrosis is a genetic disease that affects a number of organs in the body
(especially the lungs and pancreas) by clogging them with thick, sticky mucus.
Repeated infections and blockages can cause irreversible lung damage and death. Mucus
can also cause problems in the pancreas preventing the release of enzymes needed for
the digestion of food. This means that people with CF can have problems with nutrition.
CF is an inherited condition. For a child to be born with CF both parents must be genetic
carriers for CF. They do not have CF themselves. See Causes.
More than a million people carry the CF gene. Nationally, that's one in 25 Australians
but the incidence is even higher in Tasmania where it's one in 20 people.
In Australia, all babies are screened at birth for CF.
At present there is no cure for CF, but the faulty gene has been identi‫ﻐ‬ied and doctors
and scientists are working to ‫ﻐ‬ind ways of repairing or replacing it. One of the main
objectives of the CFA Research Trust is to fund this work.
With today’s improved treatment most people with CF are able to lead reasonably
normal and productive lives. A great amount of time is being directed towards ‫ﻐ‬inding
new and improved ways of treating CF and of ‫ﻐ‬inally ‫ﻐ‬inding a cure.

Q: How does a PEP device work?

1. reduces muscle spasm in airways
2. Improves length tension relationship for diaphragm

3. Splints open small airways by creating a back pressure & gets air behind sputum
4. Applies constant positive pressure throughout inspiration & expiration.

ANS – C Expiratory positive pressure is primarily used to prevent airway collapse during
expiration CROP FILE 114
4‐BiPAP machines utilize ‫ﻐ‬low and pressure measurement to cycle between inspiration
and expiration.

IPPB
https://www.nbt.nhs.uk/sites/default/‫ﻐ‬iles/attachments/Intermittent%20Positive%2
0Pressure%20Breathing%20(IPPB)%20known%20as%20%E2%80%9CThe%20Bird
%E2%80%9D_NBT002821_0.pdf
Ref ‐ h
ttps://en.wikipedia.org/wiki/Autosome

Q: Which of the following are examples of oscillating PEP devices?

1. Mask PEP & Incentive Spirometer
2. Venturi Mask & Mask PEP
3. Acapella & Bubble PEP
4. Bubble PEP & CPAP

ANS ‐ C

Mask are for Fio2 delivery, not PEP pg 52 crop ‫ﻐ‬ile
3‐ CROP FILE PG 6 // pg 24 ‫ﻐ‬ile from tulsi notes physiotherapyforcyctoc‫ﻐ‬ibrosis pdf
https://www.cmft.nhs.uk/media/199918/positve%20expiratory%20pressure%20mas
k%20cm10050%20tig83%2009.pdf

Q: PEP Therapy is contraindicated in

1. Undrained Pneumothorax
2. Tachycardia
3. Tachypnoea
4. Ischemic heart disease

ANS ‐ A crop ‫ﻐ‬ile 114

Case 3
(Sept 12 & March 2013)

A 10 year old child with CF. Her mother has been practising head down postural
drainage twice a day.

Q: Why might the doctor not support gravity assisted postural drainage as a form of
treatment for this child?

1. Risk of Gastro‐ oesophageal re‫ﻐ‬lux
2. Children usually don’t feel comfortable in head down positions
3. Head down position can increase intracranial pressure
4. Head down position can cause cardiac congestion

ANS: A

Q: The child’s physiotherapist suggests using bubble PEP to assist secretion clearance.
What instructions would she provide?

1. Use it till the secretions loosen up and then expel the secretions by coughing/huf‫ﻐ‬ing
2. Use it till there is no more secretion
3. Use it only for 30 min
4. Use whenever needed

ANS: B

Q: She is going to join a gym. What would you suggest her mother?

1. Something appropriate to child’s age and engaging her
2. Aerobic exercises
3. Perform secretion clearance techniques after gym program.
4. All of the above

ANS: D

Q: Technique to drain posterior basal lobe

1. Prone with head down 20degree
2. Prone

3. Right & left side lying head tip 20 degree
4. Sitting

ANS: A

Case 4

10 year old Jauie, Cystic Fibrosis. She had a history of productive coughing and
secretions. Her mom was using head down position for Postural drainage at home. She
is presenting with worsening of coughing and sputum

Q : 1 What can be the hurdle in the position that they were using at home for PD?

‐ Increased Intra cranial pressure
‐ increased gatro oesophageal re‫ﻐ‬lux
‐ shortness of breath
‐ Position is wrong

ANS – B

Q : 2 Physiotherapist would like to introduce PEP to assist with secretion clearance.
What Should the physio advice regarding its use ?

• Use it for 30 minutes daily
• Use it for 10 minutes only because you will get fatigue
• Use it in cycles with huff/ cough to clear secretions until none are left in lungs
• Use the PEP to loosen secretions and then do a huff or cough to clear them

ANS – C
Book ‐ Alezandia Hough pg 194. Pg 211. Pt handout on breathing technique
OA is C

Q : 3 It is important that a regular exercise program is included in her overall
management.
What factors are important to include to increase her compliance?

• Include aerobic exercise
• Include strengthening exercise for UL
• Exercises should be enjoyable, engaging and interesting for patient
• Include exercises mainly to improve lung function

ANS –C

Q : 4 How will PEP help?

• It will help with loosening secretions
• It will improve exercise tolerance
• It will improve lung compliance
• It will make her more independent

ANS – A (Tulsi). Some others also said C.
AAPTA Answer = A
B‐ ex tolerance is not linked tp PEP
C‐ Pulmonary compliance (or l ung compliance ) is a measure of the l ung 's ability to
stretch and expand. In clinical practice it is separated into two different
measurements, static compliance and dynamic compliance . Static l ung
compliance is the change in volume for any given applied pressure.
DNot look valid

Case 5
A 10 year old child with CF. Her mother has been practising head down postural
drainage twice a day.

Q: Why might the doctor not support gravity assisted postural drainage as a form of
treatment for this child?

1. Risk of Gastro‐ oesophageal re‫ﻐ‬lux
2. Children usually don’t feel comfortable in head down positions
3. Head down position can increase intracranial pressure
4. Head down position can cause cardiac congestion

ANS; A

Q: The child’s physiotherapist suggests using bubble PEP to assist secretion clearance.
How will this help her present situation

1. Make her independent in terms of her treatment
2. Effective secretion removal
3. Makes breathing easy
4. Improves her lung capacity

ANS: A

Q: She is going to join a gym. What would you suggest her mother?

1. Something appropriate to child’s age and engaging her
2. Aerobic exercises
3. Perform secretion clearance techniques after gym program.
4. All of the above

ANS: D

case 6
27 year old female had suffered from Cystic Fibrosis from a young age . She had
started to feel breathless and was admitted to the hospital for tune up
(exacerbation).

1.What is false about cystic fibrosis?

seen only in females.
Seen in both males and females.
c. Autosomal recessive disorder diagnosed by sweat test.
d. effects pancreas, lungs, sinus, reproductive system, GIT.

Ans a

2. What are the functions of PEP devices?

Improves lung volume.
Allows air to get behind secretions, block small airways and mobilise them.
Helps moisten the secretions.

Ans b

Another Q from FB:

https://www.facebook.com/groups/254003434711405/search/?query=%20fun
ctions%20of%20PEP%20devices very very imp
http://ntmaustralia.com/methods/
http://lamaustralia.org.au/newproducthelpsclearmucus/

3. Examples of Oscillatory PEP devices

a. Acapella, Flutter
b. Astri pep, Flutter
c. Peri PEP, Flutter
d. Acapella and asripep

Ans a

4. How would you instruct the patient when using PEP devices?

a. Deep sustained inspiration and hold for 10 seconds.
b. Breath at mid lung volume followed by cough/huff.
c. Breathing at tidal volume followed by FET.
d. Breathing making sure pressure in 2030 mm Hg during mid expiration.

ANS – C
P n P pg 151
Technique used for Positive Expiration Pressure devices
• Often performed in an upright, forward lean position
o Table in front of patient, leaning forward on elbows
o Neutral or slightly extended spinal posture, not ‫ﻐ‬lexed
• Some devices e.g. AstraPEP or PariPEP can also be performed in postural drainage
positions
• Slightly larger than normal tidal volume breathing and with a slightly active expiration
o ± with a small inspiratory hold
o Avoid forceful expiration into expiratory reserve volume.
• Expiratory pressure of 10‐20 cm H2O during middle of expiration
• The pressure should be able to be maintained for 2 minutes of tidal volume breathing
• Patients should then perform a FET then HUFF or cough
• Cycles of PEP should continue until sputum clears
• The duration and frequency of treatment is adapted to each individual. A patient with
stable lung
disease might perform PEP 10 ‐ 15 minutes, 2x/day

case 7
Q :How to use the spacer
Q:What sort of activity the physio should advise?
A: Aerobic exercise

case 8
cystic ‫ﻐ‬ibrosis‐ 10 year old admitted to hospital because of lung problem..mother doing
postural drainage with head tilt down

Q1: complication due to PD
a. GOR
b. Increase ICP
c. SOB
d. Wrong position
ANS – A

Q2: what is your advice in using PEP device
a. use it for 30 min
b. use it for 10 min
c. use it in cycle

ANS – C
Cycles of PEP should continue until sputum clears
stable lung

Upright. And forward lean posture. C ROP file – Pg 117 – 118.
PEP is done in cycles with a huff.
Or check youtube

q3. Physio plan in gym
a. aerobic exercise
b. engaging interesting activity
c. improve lung function
d. All of the above

ANS – D. ootherwise B
B‐ for adherence and compliance of patient

Case 9
22 years old lady ‐ Cystic Fibrosis

1)What is false about CF?

a. Autosomal Recessive disease
b. Affect GIT, Pancrease, Lungs, Reproductive
organs.
c. Chronic infection & thick secretions lead to

Chronic Bronchitis
d. Affects only in caucasian and most commonly
females

Ans: D
A‐ true CAR
B‐ true as per pnp
C‐?
D‐ CF is ‘autosomal recessive’ meaning that it occurs equally in males and females, the CF gene must
be inherited from both parents and it can ‘skip’ generations.
http://www.cysticfibrosis.org.au/vic/learn/

2)What will you advice for using PEP?
a. Breath at tidal volume & Forced expiration
b. Breath at TLC & normal active expiration
c. Breath more than tidal volume & slight active
expiration
d. Expire at the rate of 20‐30 cmH2O

Ans‐ c
Slightly larger than normal tidal volume breathing and with a slightly active
expiration
o ± with a small inspiratory hold
o Avoid forceful expiration into expiratory reserve volume.
• Expiratory pressure of 10‐20 cm H2O during middle of expiration
• Patients should then perform a FET then HUFF or cough
• Cycles of PEP should continue until sputum clears
stable lung

10‐20 cm H2O====7.3‐ 14.7 mmHg
3) PEP devices can help to…
a. Improve airway resistance
b. Strengthen respiratory muscles
c. Improve lung function
d. Improve FRC(don’t remember D exact but they
were asking about advantage other then secretion
clearance)

D
Or A as PEP increases airways pressure to keep them open during expiration.

4) PEP devices are…

a. AstraPEP & Acapella
b. AstraPEP & Flutter
c. Acapella & Flutter

Ans ‐ C
Crop ‫ﻐ‬ile
Pneumothorax
Case 1
A 20 year old male is admitted with Right Pneumothorax, Lung contusion & Flail chest
post motor vehicle accident. He is managed with a underwater seal drain. The doctors
have requested the physio to review his chest.

Q: How should the chest drain be located in relation to patient’s position?

1. Always at the foot end of the patient
2. Always above the patient’s chest to facilitate drainage
3. Always below the patient’s chest
4. Always next to the suction port on the wall

ANS ‐ C

Q: Which of the following statements de‫ﻐ‬ines a Flail Chest accurately?

1. Flail chest occurs when a series of ribs are fractured at least 2 sites anteriorly and
posteriorly.
2. Flail chest occurs when there is a fracture of a series of ribs and the sternum at
multiple sites.
3. Flail chest occurs when there is a fracture of a series of vertebrae and the sternum at
2 sites
4. Flail chest occurs when there is fracture of scapula, clavicle and the ‫ﻐ‬irst 4 ribs.

ANS – A

Q: What would you observe for in the underwater seal drainage system as part of your
chest assessment?

1. Length of the suction tubing
2. Bubbling, Swinging, Suction & Drainage
3. Bubbling, Level of pain and Drainage

4. Bubbling, Wound site and Swinging

ANS: B

Q: Which of the following could be the cause for respiratory failure in this patient?

1. Inability to cough and clear sputum due to pain
2. Hypoventilation
3. Paradoxical movement of the chest
4. All of the above

ANS: D

Q: What would be the most appropriate combination of techniques for chest
physiotherapy for this patient?

A. Autogenic drainage, Supported Cough and Incentive Spirometry
2. Bubble PEP, Postural Drainage and Supported Coughing
3. Thoracic expansion exercises, Huf‫ﻐ‬ing & Supported Coughing
4. Incentive Spirometry without inspiratory hold & Percussion

AN. But AAPTA has given C
IS reported not effective in above condition
CPAP better than IPPV

Post trauma case.
Do a problem list according to the scenario. Likely physio problems. Pain, don’t know if he
is a smoker, or has sputum issue. Risk of sputum retention. As coughing will be painful.
Reduced mobility, as mobile as normal. Risk of developing stiffness.
Autogenic drainage, used for airways clearance. Not good idea to use on person who
unstable. Used on chronic sputum production. Start with low volume then move to high
volume.
Small amount of sputum you use ACBT. Very common used, first line of Mx. If does
not work then do others like bubble pep, humidification etc.
Chose active technique, as we want them to be independent with their clearance.
Larger amount of sputum then use Pep, postural drainage etc.
Be cautious when using bubble pep with UWSD, look for air leaks.
3: do TEE is important, and do more huff than supported coughs.

4. do IS but cant use Inspiratory hold as it may increase size of pneumothorax. Percussion
alone may not help. Loosen up secretions.

TEE or modified ACBT use that.

Q: How is pulmonary contusion de‫ﻐ‬ined?

1. Blood/hemoserous ‫ﻐ‬luid in‐between visceral and parietal pleura
2. Blood/hemoserous ‫ﻐ‬luid in the interstitial space and in alveoli
3. Blood/hemoserous ‫ﻐ‬luid between parietal pleura and rib cage
4. Blood/hemoserous ‫ﻐ‬luid between heart & lungs

ANS – B
(no reference)
Pathophysiology
Normally, oxygen and carbon dioxide diffuse across the capillary and alveolar
membranes and the interstitial space (top). Fluid impairs this diffusion, resulting in less
oxygenated blood (bottom).

Pulmonary contusion results in bleeding and ‫ﻐ‬luid leakage into lung tissue, which can
become stiffened and lose its normal elasticity. The water content of the lung increases
over the ‫ﻐ‬irst 72 hours after injury, potentially leading to frank pulmonary edema in
more serious cases.[20] As a result of these and other pathological processes,
pulmonary contusion progresses over time and can cause hypoxia (insuf‫ﻐ‬icient oxygen).
Bleeding and edema

In contusions, torn capillaries leak ‫ﻐ‬luid into the tissues around them.[33] The
membrane between alveoli and capillaries is torn; damage to this capillary–alveolar
membrane and small blood vessels causes blood and ‫ﻐ‬luids to leak into the alveoli and
the interstitial space (the space surrounding cells) of the lung.[11] With more severe
trauma, there is a greater amount of edema, bleeding, and tearing of the alveoli.[17]
Pulmonary contusion is characterized by microhemorrhages (tiny bleeds) that occur
when the alveoli are traumatically separated from airway structures and blood
vessels.[24] Blood initially collects in the interstitial space, and then edema occurs by an
hour or two after injury.[30] An area of bleeding in the contused lung is commonly
surrounded by an area of edema.[24] In normal gas exchange, carbon dioxide diffuses
across the endothelium of the capillaries, the interstitial space, and across the alveolar
epithelium; oxygen diffuses in the other direction. Fluid accumulation interferes with
gas exchange,[34] and can cause the alveoli to ‫ﻐ‬ill with proteins and collapse due to
edema and bleeding.[24] The larger the area of the injury, the more severe respiratory
compromise will be.[17]

case 2
‫ﻐ‬lail chest 6 and 7th ribs. unable to cough,around icc,nasal prongs 3l.
Q1: PT management for secretion
a. Autonomic drainage and supported cough
b. ACBT and nasopharyngeal suction
c. Suctioning and spirometry
d. Thoracic expansion with supported cough

ANS – Pt is unable to cough. So A and D are out.
CROP ‫ﻐ‬ile
Spirometry not supported.

B could be as aggressive PT is required specially suction

additional Q
1.Flial chest
1..Flial chest ,breathing pattern,‐paradoxical breathing etc

additional Q
. Cause of respiratory failure
a. sputum retention
b. hypoventilation
c. ‫ﻐ‬lial segment
d.all the above
ANS – B

Brochiectasis
Upper lobe predominence in early CF
Tidys
The condition most commonly affects the lower lobes, the lingula and then the middle
lobe. It tends to affect the left lung more than the right, although 50% of cases are
bilateral. T he upper lobes are least affected since they drain most efficiently with
the assistance of Gravity
N mostly medium sized airways

Case 1
60 year old female with bronchiectasis, chronic smoker admitted with shortness of
breath, on antibiotics.

Q: What will be the immediate management or ‫ﻐ‬irst line of treatment?

1. Antibiotics and Nebulizer therapy
2. Oxygen therapy & IV hydration

3. Antibiotics, oxygen therapy, Nebulizer therapy
4. Intubation and positive pressure ventilation

ANS ‐ C
acute exacerbations, depending on the severity of the episode, oral antibiotics and
ambulatory care are usually tried ‫ﻐ‬irst.19 More severe exacerbations require
hospitalisation with intravenous antibiotics combined with intensi‫ﻐ‬ied physiotherapy
and other airway clearance methods, including nebulised therapy. Response to therapy
includes reduction in sputum volume and purulence, improvement in cough
characteristics (wet to dry or cessation of cough), general wellbeing, QoL and markers of
systemic in‫ﻐ‬lammation (C‐reactive protein), demonstration of microbial clearance, and
“return to baseline” state.

http://lungfoundation.com.au/wp‐content/uploads/2013/12/Position‐statement‐on‐B
ronchiectasis‐from‐TSANZ‐and‐ALF.pdf

Severe Heamoptysis can limit IPPB app

Q: This patient has Cor pulmonale. What is Cor pulmonale?

1. Right Heart Failure due to chronic hypoxia
2. Left Heart failure due to chronic hypoxia
3. Biventricular failure due to chronic hypoxemia
4. Coronary artery disease due to a pulmonary cause

ANS – A
Cor pulmonale is defined as an alteration in the structure and function of the right
ventricle (RV) of the heart caused by a primary disorder of the respiratory
system. Pulmonary hypertension is often the common link between lung dysfunction
and the heart in cor pulmonale. Rightsided ventricular disease caused by a primary
abnormality of the left side of the heart or congenital heart disease is not considered
cor pulmonale, but cor pulmonale can develop secondary to a wide variety of
cardiopulmonary disease processes. Although cor pulmonale commonly has a
chronic and slowly progressive course, acute onset or worsening cor pulmonale with
lifethreatening complications can occur. [1]
http://emedicine.medscape.com/article/154062overview

Q: This patient has dif‫ﻐ‬iculty clearing sputum due to a weak cough. How can you assist
her cough?

1. Use prone position to increase intra‐abdominal pressure
2. Use prone position with head down tip
3. Apply abdominal pressure with hands during expiration
4. Teach Breath hold

ANS ‐ C
http://www.icid.salisbury.nhs.uk/ClinicalManagement/SpinalInjuries/Documents/6fff
dfca0‫ﻐ‬b44beca49efadabc5e5f0fAssistedCoughingMethod3.pdf

In drows pat, use nasotracheal suction to stimulate coughing if not done so by IPPB or
chest shaking= PnP4ed pg183

During an assisted cough the physiotherapist applies pressure to the chest wall in
synchrony with a
patient’s cough in order to increase the PEFR achieved. Two common methods include
1. an inwards pressure applied to the lower lateral ribs
2. a AP pressure applied to the upper anterior chest wall
Stimulating a cough
If a patient does not have a strong, effective spontaneous cough, several methods can be
used to try
and stimulate a stronger cough.
1. Tracheal rub. The physiotherapist uses a ‫ﻐ‬inger or thumb to rub using blunt (i.e. ‫ﻐ‬lat
‫ﻐ‬inger/thumb,
not pointed) pressure across the trachea above the supra‐sternal notch.

Q: Which is the following is the imaging of choice for diagnosing Bronchiectasis?

1. High resolution CT scan of chest
2. Low resolution CT scan of chest
3. Chest X ray
4. MRI chest

ANS – A. gold standard
Ref – P n p Pg 551, 4ed
3‐ insensitive in bronchiectesis

Case 2
58 year old female‐ bronchectasis. X‐ray opacity is found

Q:1 What will a Physio found on auscultation ?
a) wheeze over inspiratory‐‐‐‐‐X

b) wheeze and crackles all over
C) ‫ﻐ‬ine late expiratory crackles______X
d) bilateral coarse crackles

A H ‐ 55
Crackles indicate secretions or parenchymal disorder (Piirila et aI., 199 1 ) and are
created when air is forced through airways that have been narrowed by oedema,
in‫ﻐ‬lammation or secretions, or when airless alveoli or peripheral airways snap open.
They are principally heard on inspiration and their timing depends on the source.
Early‐inspiratory crackles arise in the large airways, may be heard at the mouth, are
independent of gravity and are often heard in COPD. Early and midinspiratory
crackles are characteristic of bronchiectasis or other hypersecretory disease .
Absence of crackles does not always indicate absence of secretions Oones and Jones,
2000). Late‐inspiratory crackles originate in alveoli and peripheral airways as they open
at the end of inspiration and are associated with pneumoma, ‫ﻐ‬ibrosis or pulmonary
oedema

Crackles are heard predominantly on inspiration but both inspiratory and
expiratory crackles are heard in bronchiectasis (coarse) and fibrosing alveolitis
(fine).

Secretions and collapsing airways on expiration cause coarse wheezes and
crackles

The crackles in bronchiectasis appear in early or mid inspiration
Waveform analysis has shown that the crackles in this disease are c oarse (2CD >9 ms),
and their upper frequency limit is high. An early onset of
crackling and its late endpoint within the inspiratory
cycle are also typical of bronchiectasis

ANS ‐ B
Reference 551 and 582 pg Pyor and Prasad.
On auscultation: Inspiratory and expiratory crackles with occasional wheeze

Answer B according to ILP acute 2005. (March 2015 papers)
C ‐rhonchi

D‐ rales

Wheezes
Wheezes are generated by vibration of the walls
of a narrowed airway as air rushes through.
Expiratory wheeze, combined with prolonged
expiration, is usually caused by bronchospasm.
Wheeze on inspiration and expiration can be
caused by other forms of airways obstruction
such as mucosal oedema, pulmonary oedema,

sputum, tumours and foreign bodies. A monophonic
wheeze can mean local airway obstruction
from a foreign body or tumour. A wheeze
increases the work of breathing.

Table 3.3 Distinguishing features of bronchiectasis and
chronic obstructive pul monary disease‐‐‐‐‐‐‐‐‐‐A H 98

Q:2 What will be the appropriate position for gravity assisted postutal drainage for
posterior basal lobes?

a) Prone lying position with pillow under hips
b) R) side lying
C) First R) side lying and then L) side lying
d) Prone lying position with pillow under abdomen and 20 degree tilting of table

ANS ‐ D
Posterior basal Foot of bed raised ~45cm Prone lying

553 Pryor and Prasad.

Q:3 She has a problem of urinary incontinence and wanted advice from you. What advice
will you give as a Physiotherapist?

A) she can improve by doing pelvic ‫ﻐ‬loor exercises
B) You should consult urologist, only he can help you for this problem
C) It will improve by it self if your coughing will be controlled
D) Nothing can be done in this kind of pulmonary condition

ANS – A
A is correct.
Reference Pryor and Prasad
3rd edition pg 8

Q:4 What will you advise her to monitor her progress with ACBT ?

a) volume of sputum
b) SOB
C) Pain
d) Coughing

ANS – A

case 3
Lady, mid ‫ﻐ‬ifties, has been diagnosed with bronchiectasis after having
contracted whooping cough. She has had increased of volume of sputum the
past 3 weeks. Bi basal ‫ﻐ‬ine crackles
Good sat

Question 1 : ????
she has to have long term oxygen therapy. How do you explain this to the patient?
a. You can have also for only few hours during the day
b. You need it for most hours of the day
c. You can leave it at home when you go out
d. You can have oxygen when your symptoms get worse

ANS – B‐ 18 hours /day

Question 2 : you want to drain the post basal bronchus. What position will you
use
a.
b.prone with a pillow under the front hip tilted 20 degrees
c.prone with a pillow under the belly
d.
ANS ‐ B
P n Webber – pg 152 – pics of drainage position.

Question 3 : What would you tell your patient if she is complaining about urinary

incontinence
1) It is frequent with your condition, strengthening your pelvic ‫ﻐ‬loor muscles will
help you
2) It is frequent with your condition, you should wear some pads
3) You should reduce your activites outdoors.
4) You should go to your doctor to ‫ﻐ‬ind out the cause.
ANS ‐ A

Question 4 : Patient is now ready for discharge, what would you ask her to
monitor once at home:
a‐vol of sputum
b shortness of breath
c. ??
d ??

ANS – A
Pnp 4ed 579

Pulmonary Trauma
Case 1
23YEAR OLD MALE, MOTOR BIKE ACCIDENT 1 DAY AGO. # RIBS 5 & 6. HE HAS A
CATHETER IN HIS CHEST. RR: 20, HE IS IN CONSIDERABLE PAIN AND IS ON OXYGEN
THERAPY.

Question 1: What would indicate sudden worsening in his state?

a. Increase Respiratory Rate
b. Decrease respiratory rate
c. Productive cough
d. Increase in his pain.

ANS
But A as given by AAPTA. N acc to FB also

Question 2: How would you treat him?

a. ACBT with supported cough
b. Autogenic drainage with supported cough
c. Active Cycle of Breathing and suction
d. Active Cycle of Breathing and nasopharyngeal suction

ANS – A
Generally ACBT, then Autogenic. The autogenic cannot be given immediately postop.

Question 3: How would you monitor him during treatment?

a. Breath sounds and auscultation
b Temperature
c. BP
d. Pain level

ANS: D

Question 4: How would reassess to know you were effective in your treatment?
(This recall)
you mobilise the patient, what do you evaluate the mobilisation effect?

a. Breath sounds and auscultation
b Temp
c. Pain
d. BP

ANS – A or C?
But A given by AAPTA.
ANS – when we mobilize the patient it will have an effect on their secretions. And after
mobilizing – this will have effect on their saturation

Separate question
Question 1 You want to do sit to stand with this patient. How will you prepare yourself
for it knowing that the patient is impulsive
A tell the patient to keep sitting in the wheelchair till I ask you to stand
Put the wheelchair against the parallel bar or the table

Pulmonary Rehab
Case 1
A client with COPD & Asthma for a long time is able to walk 500m
and is listed for attending pulmonary rehabilitation. He would like to
improve his endurance.

Q: To be effective how long does he have to walk per day?

1: 10min
2: 15min
3: 20min
4: 30min

ANS: D
Reference: Pulmonary rehab toolkit.
For sedentary pat start with 10 min then proceed to 30 min

UL endurance training is adviced for 10 mins and LL endurance training
exercises are adviced for atleast 30 mins.
The recommended exercises are for 3 times per week. But if cannot
achieve 3x then atleast 2x per week is recommended.

Q: How long does it take for the rehabilitation program to become
effective?

1: 2 - 4 weeks
2: 4 - 6 weeks
3: 8 - 12 weeks
4: More than 12 weeks

ANS: C
Reference: Pulmonary rehab toolkit

Programs should last for a minimum of 68 weeks.
Most of the studies that have shown a n improvement in e xercise capacity have used

programs of 8 to 12 weeks in duration. These programs have included a t least 2 supervised
sessions e ach week.

Q: Which of the following is not a commonly used outcome measure
for pulmonary rehabilitation?

1: 6 minute walk test
2: St George’s Respiratory Questionnaire
3: Motor Assessment Scale
4: Borg scale for rate of perceived exertion

ANS – C
Chronic respiratory disease questionnaire is another common one.
MAS is used for stroke.
MAS is only used for stroke patients. Not for CP.

Q: The intensity of exercise can be monitored & progressed using Borg scale for
perceived shortness of breath. The prescribed range for exercise intensity on this scale
is:

1: 0 -2
2: 2-5
3:3-6
4:7 -10

ANS – B
In pulmonary toolkit it is given 3 – 4. So better to go with B as 2 – 5.
Since 6 is very severe exertion.
3 is moderate.
6 is strong and very strong. In Australia they follow modiឈed borg
scale.

Case 2
75 y.o male referred by his local general practitioner for pulmonary rehabilitation

Q: Before prescribing an exercise program for this patient, which of the following tests
or assessments would you consider to be the MOST important to perform?

1: Ability to walk upstairs, incremental upper limb ergometry test, upper limb strength
2: Chronic respiratory disease questionnaire, Shuttle or 6 minute walk test, Patient’s use
of walking aids
3: Air‫ﻐ‬low limitation using a peak ‫ﻐ‬low meter, pulmonary function testing, SF‐36
4: Bruce or Balke treadmill protocol test, strength of quadriceps and hip abductor
muscle groups
5: COPD self‐ef‫ﻐ‬icacy scale, COPD coping scale, alcohol consumption

ANS – B
Pulmonary toolkit also gives 6 MWT and chronic respiratory disease questionnaire. So
go with B.
Reference P n P ‐ 481 ‐ 484

Topic headings:
Ax of ADLs
15 item London chest ADLS Scale

Ax of dyspnoea
VAS
Borg Scale of Perceived Exertion
Dyspnoea component of the CRQ (Chn Respiratory Questionnaire)
Baseline and Dyspnoea Index (BDi)
Medical Research council (MRC Score).

Ax of Health Related QOL
HRQoL Questionnaire

Q: Which are the two most likely pathophysiological causes of this patient’s
breathlessness during exercise?

1: Air‫ﻐ‬low limitation, respiratory muscle dysfunction
2: Decreased chest wall compliance, decreased lung volumes
3: Decreased lung compliance, decreased venous return
4: Increased cardiac afterload, peripheral muscle ischaemia
5: Increased cardiac afterload, decreased venous return

ANS – A
Between A and B. pathophysiological changes so?
Air‫ﻐ‬low limitation will affect lung volumes.

Q: All of the following techniques will help this patient to recover from his
breathlessness after walking EXCEPT

1: Pursed lip breathing
2: Forward lean positioning
3: Fixing the shoulder girdle muscles
4: Thoracic expansion exercises
5: Breathing control

ANS: D (Given by AAPTA session)

Possible explanation ‐ the COPD and these breathless patients ahve hyperin‫ﻐ‬lated chest
and CO2 retention.Hence thoracic expansion may cause increased hyperin‫ﻐ‬lation. These
patients need more of muscle retraining.
Reference: Pulmonary rehab toolkit
For patients with severe dyspnoea, fixing the shoulder girdle by using a wheeled walker (rollator) for
walking training or when using a stationary cycle for cycle training allows:
● The accessory respiratory muscles to work more efficiently.
● This lean forward position may help to dome the diaphragm, improving its length/tension
relationship.
● Note: These two strategies may result in a slight reduction in ventilatory constraints to
exercise, allowing a greater work level to be achieved by the lower limb muscles e.g
quadriceps, gastrocnemius and gluteal muscles.
POE:
Based on the above reference
B and C are out.
A and E will help with breathing control.

Q: While supervising this patient’s rehabilitation program, the physiotherapist becomes
concerned about the accuracy of this patient’s pulse oximetry reading. Which of the
following statements about pulse oximetry using a ‫ﻐ‬inger probe is FALSE

1: Peripheral vasoconstriction may give an inaccurate reading
2: Motion artifact may give an inaccurate reading
3: Pulse oximetry will be accurate even when the pulse is irregular
4: Optical interference may occur if the reading is taken in a room with bright ambient
light
5: Inaccurate readings may occur when values are very low (e.g. below 80%)

ANS: C
It could be E.

Crop ‫ﻐ‬ile 47 It is only accurate for haemoglobin oxygen saturations in the range from
70‐100%.
Irregular s ignals can post problems for a pulse oximeter. The problem s ignals can be
caused by irregular heartbeats or by patient's movements. If this is the problem, one
can tell by looking at the SpO2 waveform which is available on s ome pulse oximeters.
https://www.amperordirect.com/pc/help‐pulse‐oximeter/z‐pulse‐oximeter‐limitations
.html

PaO2 is a more sensitive measure of respiratory function than
SpO2. Falls in SpO2 are usually a late sign of respiratory failure

Respiratory rate is a more sensitive indicator of respiratory failure except where it is
depressed by narcotic analgesia

Case 3

Pulmonary rehabilitation

Q: Which of the following is a contraindication for pulmonary rehabilitation?

1: Unstable angina
2: COPD
3: Bronchiectasis
4: Stable angina

ANS ‐ A

Q: The target range for perceived exertion for Pulmonary rehabilitation is:

1: 6‐7
2: 8‐9
3: 9‐11
4: 11 ‐13 ‐

ANS – D
14 is the max. Exercise range can be from mild ‐ moderate exertion (Reference P n P)
(12 to 13 is equivalent to the 3 – 4 on Borg scale and about 40% of heart rate reserve or
the VO2 Max (60% HRmax) ting of 15 is equivalent to 5‐6= 65% of heart rate reserve or
Vo2 max (75% HRmax).
2‐ slight 3‐ moderate 4‐ somewhat hard

Q: An important minimum requirement for program design for pulmonary
rehabilitation is:

1: LL endurance
2: LL strength
3: UL endurance
4: UL strength

ANS ‐ A
Reference: http://www.pulmonaryrehab.com.au/index.asp?page=48

A pulmonary rehabilitation program m
ust i nclude, at
minimum, lower limb endurance exercise training.

Arm endurance exerceises
A pulmonary rehabilitation program should include unsupported arm exercises with or without added
weights (depending on patient’s degree of disability).

LL endurance exercises
it should be remembered that to achieve the greatest changes in a functional activity such as walking, it
may be better to train in walking

Lower limb aerobic exercises (uses large muscle mass):
● Walking training for all patients.
● Stationary cycling training if possible.
UL STRENGTH TRAINING
Strengthening the muscles in the upper limbs is important as these muscles are used on an everyday
basis. Studies indicate that strength training for the upper limb muscles results in moderate
improvements in upper limb strength (for further details (see O’Shea 2004 ). A relationship has been
shown between upper limb strength and upper limb work capacity for patients with chronic obstructive
pulmonary disease which suggests that having stronger upper limb muscles may help patients perform
functional tasks (i.e. by enhancing the strength of the biceps and triceps muscles).
The studies that have examined strength training for the upper limbs have focused on the accessory
muscles of inspiration and muscle groups used in everyday functional tasks. These muscles include:
● Pectoralis major
● Latissimus doris
● Trapezius
● Biceps
● Triceps
Upper limb strength training can be combined with upper limb endurance training in a comprehensive
program in order to gain the benefits from both modes of training. Arm endurance capacity has been
shown to be greater following combined endurance and strength training than from endurance training
alone

LL STRENGTH TRAINING
Skeletal muscle weakness is present in patients with COPD and this weakness can affect lower limb
strength.
Strengthening the muscles in the lower limbs is important as these muscles are used on an everyday
basis. A relationship has been shown between lower limb strength and lower limb work capacity.
Strength training can improve muscle strength, peak work capacity and endurance time.
A combination of strength and endurance training results in greater increases in both strength and
endurance than either form of training alone.
Having stronger lower limb muscles may help patients to perform short bursts of activity (such as
getting on a bus), and may also reduce falls.
An adequate lower limb strengthening program can be devised with or without weight equipment.
Exercises should be performed slowly and smoothly.

Q: What would you measure during PR?

1: Oxygen saturation
2: Respiratory Rate
3: Body temperature
4: Blood pressure

ANS – A. Pulmonary rehab toolkit.

Oxygen saturation should be regularly monitored using a pulse oximeter especially
during lower limb exercise training. This is particularly important at the start of a
training program and when the intensity or the duration of exercise is increased.

Patients who desaturate below an oxygen saturation of 88% during exercise training,
despite the use of interval training, should be assessed to determine the bene‫ﻐ‬it of
supplementary oxygen. These patients should be assessed in a hospital‐based program
to determine the bene‫ﻐ‬it of oxygen and the required ‫ﻐ‬low rate for exercise. Assessment
for supplementary oxygen is done by providing oxygen via nasal prongs at a ‫ﻐ‬low rate of
2‐4 L/min for during the speci‫ﻐ‬ic exercise that causes desaturation. If the patient shows
improved oxygen saturation or improved exercise tolerance or reduced dyspnoea when
using oxygen, supplementary oxygen should then be given in future exercise training
sessions.

Speci‫ﻐ‬ic exercises that often cause desaturation in susceptible patients include moderate
to high intensity walking, climbing stairs, doing step‐ups and sit‐to‐stand.

In general, cycling induces less oxygen desaturation than walking in patients with COPD.

Desaturation during small muscle mass exercise (e.g. arm exercise) is not very common.

Patients found to bene‫ﻐ‬it from supplementary oxygen should, where possible, be
provided with supplementary oxygen to use during their unsupervised home exercise
training program. These patients should be encouraged to use oxygen for all physical
activity involving large muscle mass (eg. showering) within their home setting.

Patients receiving LTOT (long‐term oxygen therapy) must train using supplementary
oxygen. It is usually necessary to increase the ‫ﻐ‬low rate by 1‐2 L/min, above the
prescribed ‫ﻐ‬low rate, when the patient is exercising.

Supplementary oxygen in patients with chronic lung disease is provided mainly for
safety reasons and to decrease the work of the right heart (i.e. by minimising hypoxic
vasoconstriction of the pulmonary vessels

In patients who desaturate during exercise, the benefit of supplementary oxygen during exercise to
enhance the training effect of exercise is not well established

Q: What does pulse oximeter measure?

1: Diffusion of oxygen
2: Oxygen saturation
3: Pulsus paradoxus
4: Oxygen ‫ﻐ‬low from the wall

ANS ‐ B

Q: Which of the following factors can affect accuracy of pulse oximetry reading?

1: Excessive motion of the patient
2: Good perfusion at the probe site
3: Adequate he.moglobin
4: Heart failure

ANS ‐ A

Case 4
Pulmonary Rehabilitation

Q: While supervising this patient’s rehabilitation program, the physiotherapist becomes
concerned about the accuracy of this patient’s pulse oximetry reading. Which of the
following statements about pulse oximetry using a ‫ﻐ‬inger probe is FALSE?

1. Peripheral vasoconstriction may give an inaccurate reading
2. Motion artifact may give an inaccurate reading
3. Pulse oximetry will be accurate even when the pulse is irregular
4. Optical interference may occur if the reading is taken in a room with bright ambient
e) inaccurate readings may occur when values are very low (e.g. below 80%)

ANS – C

Case 5
&q28= An elderly patient has been hospitalized for the past three days with
pneumonia. The physician is being pressured to discharge her tomorrow. The patient
lives with her sister in a ‫ﻐ‬irst ‫ﻐ‬loor apartment. The physical therapist has determined her
ambulation endurance to be only up to 15 feet, not enough to allow her to get from her
bed to the bathroom (a distance of 20 feet). The therapist should recommend:
28a= postponing her discharge until she can walk 20 feet.
28b= a skilled nursing facility placement until her endurance increases.
28c= a bedside commode, and referral for home health services.
28d= outpatient physical therapy until her condition improves.

ANS: C

Case 6

PULMONARY REHABILITATION: THE MALE PATIENT WITH COPD HAS BEEN
SEDENTARY THROUGHOUT HIS LIFE.

Question 1: Patient wants to quit coming to the hospital for exercises after 4 weeks and
continue with the home based exercise program .What will be your advice to him?

a. You should continue to come for another 2 weeks to get maximum bene‫ﻐ‬it out of this
program
b. If you stop now you will get minimum bene‫ﻐ‬it out of it
c. We won’t be able to progress /monitor the progression of exercises then
d. Ask your doctor if OK to stop

ANS ‐ C
I am leaning towards D. As the decision to stop should be approved by the Dr. as he was
the one who has initially referred for the PR prog.

ANS – pulmonary toolkit. 6 – 8 weeks. He is already coming for 4 weeks – and
Programs should last for a minimum of 6‐8 weeks.

Most of the studies that have shown an improvement in exercise capacity have used
programs of 8 to 12 weeks in duration. These programs have included at least 2
supervised sessions each week.
Doubt between C and D.

To maintain the improvements in exercise capacity and quality of life after the
completion of a pulmonary rehabilitation program, patients need to continue to
exercise. People with severe physical limitations (multiple co morbid conditions and /
or frequent hospital admissions) will bene‫ﻐ‬it from a longer pulmonary rehabilitation
program.

Options for maintenance exercise programs:


once a week, supervised exercise program in a health facility, community or hospital
outpatient setting plus unsupervised exercise on 2 to 4 other days per week.
or

unsupervised home exercise program with regular review (e.g. every 3 to 6 months) at
the pulmonary rehabilitation program

Question 2: Before designing the exercise program for the client the physio is doing six
minute walk test with the patient during which he gets short of breath and stops for a
brief rest. What will you measure at this stage?

a. pulse and BP
b . oxygen saturation
c . breathlessness as on BORG scale
d . Respiratory Rate

ANS – B

ANS ‐ Spo2 and HR – pulmonary toolkit.
BP is the last. So the pulse and oxygen. If patient stops during 6 MWT, measure his Spo2
and HR.
If the Patient Stops During the Six Minutes
Allow the patient to sit in a chair if they wish.
Measure the SpO2% and heart rate.
Ask patient why they stopped.
Record the time the patient stopped (but keep the stopwatch running).
Give the following encouragement (repeat this encouragement every 15 seconds if
necessary):

“Begin walking as soon as you feel able.”
Monitor the patient for untoward signs and symptoms.
ANS B

Question 3: What will be your advice regarding the intensity of exercises/walking
programme at home

1. 70% of the six minute walking test/Shuttle test speed
2. 10% of the six minute walking test /Shuttle test speed
3. 10 or slight discomfort on the dyspnoea scale
4. 30 minutes of slight dyspnoea on the BORG dyspnoea scale

ANS PK‐ 4 AS in 3 they are saying about discomfort not dyspnoea.
But AAPTA says A.

same Q with different options
Question 3: What will be your advice regarding the intensity of walking program
at home
b. 80% of the six minute walking test speed
c. 75% of the six minute walking test speed
d. 10 min of slight discomfort on the dyspnoea scale
e. 30 minutes of slight dyspnoea on the BORG dyspnoea scale

ANS a
Put a marker on the distance walked.
Seat the patient or, if the patient prefers, allow to the patient to stand.
Note: The measurements taken before and after the test should be taken with the
patient in the same position.
Immediately record oxygen saturation (SpO2)%, heart rate and dyspnoea rating
on the 6MWT recording sheet.
Measure the excess distance with a tape measure and tally up the total distance
Spo2, HR and BORG scale. (BP with arm ergometry komal)
ANS A
[12:16:09 PM] Komal Sanghavi: 80% average speed on 6MWT

75% peak speed on ISWT

Dyspnoea rating of 3 (moderate)

Continuous or interval

30 minutes

4 or 5 times a week that includes 2 or 3 supervised sessions and home exercise
training

Walking training
for qs 3

Question 4: What other type of exercises what you like to include in his home exercise
programme

a. balance exercise
b. ‫ﻐ‬lexibility exercise
c. Inspiratory muscle training

d. upper limb strengthening

ANS D
Pul rehab is only for people who have long term lung issues like COPD and Pul fibrosis.
Mainly done on OPD basis and who is stable. Done in community rehab program, group
program. 6 8 week program they attend . An hr of exercise followed by education session.
Don’t do inspiratory strength training.

Strengthening the muscles in the upper limbs is important as these
muscles are used on an everyday basis. Studies indicate that strength
training for the upper limb muscles results in moderate improvements in
upper limb strength (for further details (see O’Shea 2004 ). A relationship
has been shown between upper limb strength and upper limb work
capacity for patients with chronic obstructive pulmonary disease which
suggests that having stronger upper limb muscles may help patients
perform functional tasks

POE C
Inspiratory muscle training (IMT), performed in isolation using a threshold
loading device or targetflow resistive device at loads equal to or greater
than 30% of an individual’s maximum inspiratory pressure generated
against an occluded airway (PImax) has been shown to increase
inspiratory muscle strength and endurance and reduce dyspnoea in
patients with COPD. Training may also result in modest improvements in
6 minute walking distance and healthrelated quality of life. However, it
remains unclear whether IMT combined with a program of wholebody
exercise training confers additional benefits in dyspnoea, exercise
capacity or healthrelated quality of life in patients with COPD. At
present, the evidence does not support the routine use of IMT as
an essential component of pulmonary rehabilitation program

Case 7

55‐year‐old male. Smoker, Respiratory infection. Congestion. Dyspnoea, Mild fever.
COPD, Breathlessness

Q : 1 What % of O2 do you expect can be used?

‐ 24 %
‐ 28 %
‐ 32 %

‐ 36 %

ANS: B
1–2 L/min via nasal cannulae or 2–4 L/min via 24% or 28% Venturi mask in
patients with acute exacerbations of COPD or conditions known to be associated
with chronic respiratory failure .*
http://onlinelibrary.wiley.com/doi/10.1111/resp.12620/pdf

Group discussion ‐ For every litre per minute, FiO2 increases by 4%.
P n P pg 224
Answer = D
Komal says B. Oxygen therapy in the acute setting (in hospital)[4]
For most COPD patients, you should be aiming for an SaO2 of 88‐92%, (compared with
94‐98% for most acutely ill patients NOT at risk of hypercapnic respiratory failure).
Mark the target saturation clearly on the drug chart.
The aim of (controlled) oxygen therapy is to raise the PaO2 without worsening the
acidosis. Therefore, give oxygen at no more than 28% (via venturi mask, 4 L/minute) or
no more than 2 L/minute (via nasal prongs) and aim for oxygen saturation 88‐92% for
patients with a history of COPD until arterial blood gases (ABGs) have been checked.[5]

Q : 2 On palpation, what will you ‫ﻐ‬ind?

‐ Consolidation of lungs
‐ Changes in chest wall expansion
‐ collapse of small airways
‐ wheezing

ANS: B
You will feel opening and closing of the chest wall only in palpation.
Reference ‐ P & P Pg 16

POE
A and C on Xrays
D on auscultation.

Q : 3 You teach him forced expiratory technique with tissue. What will you instruct the
patient?

‐ Take a deep breath and blow out hard and fast
‐ Take a deep breath and blow out as hard and fast as possible until all air comes out

‐ Take a moderate breath and blow out hard and fast
‐ Take a moderate breath and blow out hard and fast until all air comes out

ANS: C
FET = de‫ﻐ‬ined as 1 ‐ 2 huffs from mid lung volume followed by a relaxed controlled
breathing.
Hence the OA should be C
If you breath out all breath then it will cause paroxysmal coughing. P n P 191 3rd ed

Q : 4 He is concerned about SOB while walking. How will you prepare him?

‐ We will come back to bed if you fell SOB
‐ My assistant will follow with the wheelchair if you need to take rest in between
‐ You will not feel SOB
‐ It is a common sign so do not worry about it

ANS: B.
This is the best option currently. But if the option “LEAN AGAINST THE WALL” is given,
we will choose that. As leaning will take pressure off the diaphragm.

Case 8
67 year old male. self employed . COPD and pneumonia.
Smoker ‐ stopped before 6 months. Osteoporosis.

Q : 1 What exercise testing will you do prior to start treatment?

‐ Six minute walk test
‐ Shuttle walk test
‐ BORG
‐ Sr. George questionnaire

ANS: A
Reference pulmonary toolkit
before exercises you do 6 MWT or incremental shuttle test.
6MWT is reliable in frail and elderly patients.

Q : 2 What can be best advised for osteoporosis?

‐ 30 minute walking daily

‐ 20 minute walking daily
‐ 10 minutes moderate exercises
‐ 40 minute exercises

ANS: A
http://osteoporosis.org.au.tmp.anchor.net.au/sites/default/‫ﻐ‬iles/‫ﻐ‬iles/recommendedex
ercisesLS.pdf
A variety of weight‐bearing activities and progressive resistance training for at least 30
min, 3‐5 times per week. AVOID prolonged periods of inactivity.
N ote : Leisure walking on its own is not recommended as an adequate strategy for bone
health, although it has bene‫ﻐ‬i ts for general health and ‫ﻐ‬i tness. Swimming and cycling
are also considered low impact sports that are not speci‫ﻐ‬i cally bene‫ﻐ‬i cial for bone
health.

Q : 3 How will you assess intensity of exercises?

‐ 80% of 6 minute walk test
‐ 5‐6 dyspnoea score on Borg scale
‐ 80% of shuttle walk test

ANS: A
Reference: Pulmonary toolkit

Q: 4 after completing pulmonary rehab, patient asks you that how often he needs to do
exercises to maintain the current condition or to maintain improvement?

‐ Continue home program 3‐5 days in a week
‐ You do not need to do exercises any more
‐ You need to attend once in a month‐supervised program

ANS: A

● once a week, supervised exercise program in a health facility,
community or hospital outpatient setting plus unsupervised
exercise on 2 to 4 other days per week.
or

● unsupervised home exercise program with regular review (e.g.
every 3 to 6 months) at the pulmonary rehabilitation program
Case 9
COPD and asthma of a 60YO women: She attended pulmonary rehab now she is on home
programme . She has been on oxygen and gets Breathless on simple activity. Initially
used to have 1lt O2 only at night ,now it has been increased to 2lt continously. She took 2
hours to dress up in the morning.

Q1 Her BMI is 14 what does that mean?

a) Underweight
b) Normal
c) Overweight
d) Obese

ANS: A

Q2 What can we do to treat her breathlessness

a) Relaxation exs
b) Give her gentle strengthening exercises of UL, one
c) Breathing exercises
d) Give her more O2

ANS; C
IMO the answer is B.

POE:
A ‐ she has exertion on simple tasks. so A is out.

Q3 After end of pulmonary rehab physio check the QOL mesurement what is false about
QOL MEASURE?

a) It shows that she felt less fatigue in activity
b) Reduced depression level
c) QOL measure shows data and statistics about improvement
d) QOL MSR shows the improvement in quality of activity after p rehab

ANS: C (AAPTA)
Whats true about QoL is D. But what is false is C. Hence this is the answer.

POE
A and B are components of QoL. So they are out.

Q4 she felt fatigue while brushing her teeth, washing her hair and brushing her hair.
What physio should give as treatment?

a) Relaxation exs
b) One upper limb exs
c) Deep breathing exs

ANS: C

Case 10
Pulmonary rehab: Asthma for a long time, Could walk 500m. We want to increase his
endurance. He is sedentary for most of his life.and we want to increase his endurance.

Q1 Physio wants to check his exercise tolerance, what is the appropriate measure for it

a) 6 min walk test
b) Graded exe test
c) Borg dyspnea scale
d) St George questionarrie

ANS: A

Question3:How many days per week should he walk in order to gain the bene‫ﻐ‬its from
walking?
a. 3‐4/ week
b. 4‐5/ week
c. 1‐2/week
d. 2‐3/week
ANS – B. its 3 – 5. So we are going with 4 ‐ 5

Q3 Pt completed his pul rehab and gained exercise tolerance and he wanted to continue
it what physio will advice him

a) Stop walking
b) Continue to walk for 3‐5/wk
c) Join gym
d) Decrease exercise for 1‐2 times/wk.

ANS: B
Reference PR toolkit.

Case 11
A client with COPD & Asthma for a long time is able to walk 500m and is listed for
attending pulmonary rehabilitation. He would like to improve his endurance.

Q: How would you explain the advantage of use of a spacer to the mother? A spacer will:

A: Increase the deposition in the lung
B: prevent oral irritation
C: Prevent cough
D: Will decrease infection

ANS: A

Case 12
&q41= A contraindication to initiating joint mobilization on a patient with
chronic pulmonary disease may include:
41a= re‫ﻐ‬lex muscle guarding.
41b= long term corticosteroid therapy.
41c= concurrent inhalation therapy.
41d= functional chest wall immobility.

ANS: B
Coz of the risk of # due to osteoporosis

Case 13 facebook Q

Middle aged lady with ?COPD/Asthma. She is on long term oxygen therapy & is having
increasing difficulty with activities of daily living such as showering & brushing her hair She has
a BMI of14
2.She fatigues quickly during activities of daily living such as brushing her hair. What will you
incorporate into your treatment to improve this?
a. upper limb strengthening exercises
b. deep breathing exercises
c. relaxation
3. You complete a 6 minute walking test with her.What does the result indicate?
a. oxygen saturation level
b. dyspnoea score
c. ? metres walked in 6 minutes

Pulmonary General
Case 1
A 50 year old female is admitted to a hospital following overseas travel with fever,
shivering & shortness of breath

Q: Respiratory rate does not alter with

1: Gender
2: Age
3: Time
4: Anxiety
5: Narcotics

ANS – A
RR is affected with gender and this is supported by medline plus. How about time.
Sleeping time RR will be lower.

Q: Body temperature does not change with

1: Pregnancy
2: Age
3: Time
4: Infection

ANS –C
given in pnp pg 8, lowest in the early morning and highest in the afternoon.
Age – higher normal temperature for children as compared to adult. So age. Body
temperature does not change with Infection in immunosuppressed.

Q: Temp is regulated by

1: Hypothalamus
2: Shivering
3: Vasoconstriction
4: All of the above

ANS – D. but hypothalamus also causes vasoconstriction and vasodilatation. So go with all
of the above.
Homeostatis

Q: Respiratory centers are located at

1: Carotid and aortic arches
2: Femoral artery
3: Cerebellum
4: Cerebral cortex

ANS – A
IN CNS they are in medulla and baroreceptors near the arches. Reference – CROP ‫ﻐ‬ile. Pg
35. Carotid and aortic artery is also responsible for arterial blood ‫ﻐ‬low.

Respiration is controlled via functions of the brainstem . The most important driver
of ventilation is CO2 levels, which acts on central and peripherally located
chemoreceptors that transmit information to the brainstem’s respiratory centre. Central
chemoreceptors respond to changes in cerebrospinal ‫ﻐ‬luid pH (hydrogen ion
concentration) which is related to CO2 production / concentration in arterial blood.

Peripheral chemoreceptors located in the carotid and aortic arteries are also
responsive to arterial blood CO2, O2 and pH levels.

Case 2
aged care, 87 year old male, with history of atrial ‫ﻐ‬ibrillation, dementia. Facility manager
called you to see and manage this patient. Family is on overseas visit for 2 month,
therefore they left patient in aged care facility for care.

Q 1‐ To whom you should take consent before managing this case?

1. Facility manager
2. Physician
3. 3. Family member
4. 4. Don’t need a consent

Q2.patient had a fall during your visit, no injury to patient, you will report the incidence
to‐
1. Physician
2. Facility manager
3. Personal care assistant
4. No need to report.

ANS: 2

Q3.after all your effort, patient does not get better, physician questions you, you will
submit following in response?
1. Current treatment scenario.
2. All assessment and treatment with date of implementation.
3. Case history
4. Improvement in case scenario from the date you start

ANS: B

Case 3
&q43= A computer programmer, with no signi‫ﻐ‬icant past medical history,
presents to the emergency room with complaints of fever, shaking chills and a
worsening productive cough. Complaints of chest pain over the posterior base of the left
thorax is made worse on inspiration. An anterior‐posterior X‐ray shows an in‫ﻐ‬iltrate on
the lower left thorax at the posterior base. This patient's chest pain is MOST likely
caused by:
43a= in‫ﻐ‬lamed tracheobronchial tree.
43b= angina.
43c= trauma to the chest.
43d= infected pleura.

ANS: D

Case 4
&q63= The radiographic view shown in the diagram that demonstrates the
observed spinal defect is:
63a= lateral.
63b= frontal.
63c= oblique.
63d= posterolateral.

ANS: C

Case 5
&q131= During a physical therapy session, a 67 year‐old woman with low back
pain tells the therapist that she has had urinary incontinence for the last year. It is
particularly problematic when she has a cold and coughs a lot. She has not told her
physician about this problem because she is too embarrassed. The therapist's BEST
course of action is to:
131a= examine the patient, document impairments and discuss ‫ﻐ‬indings with the
physician.
131b= refer the patient back to the physician.
131c= examine the patient, document impairments, then send her back to her
physician.
131d= examine the patient and proceed with her back treatment.

ANS: A

Case 6
ANS:

Abdominal
Conditions
AAA
Case 1

70 year‐old obese man (Mr J)
‐ history of smoking (40 pack years but ceased 10 years ago)
‐ transferred to a medical ward from the intensive care unit
‐ surgical repair of an abdominal aortic aneurysm (AAA) four days ago.
‐ prolonged stay in the intensive care unit due to haemorrhage, hypoxaemia
and bilateral lower lobe collapse
‐ now stable at rest, afebrile
‐ heparinized‐ anticoagulant eg warfain
‐ no evidence of sputum retention
‐ has not been out of bed.

His attachments are
• oxygen (6 litres ‫ﻐ‬low rate) via a Hudson mask
• central venous pressure (CVP) line
• intravenous (IV) line
• patient controlled analgesia (PCA) with a narcotic (pethidine) infusion
• bore drain
• indwelling catheter (IDC) !

7. From the following lists, identify the MOST important elements for the
physiotherapist to assess or check PRIOR to commencing any physiotherapy
intervention for Mr J?

• I abdominal girth, breathing control, dizziness, headache, ‫ﻐ‬luid balance
• II peripheral sensation, CVP, dyspnoea level, pursed lip breathing
• III blood loss from bore drain, CVP, breathing pattern, oximetry
• IV ‫ﻐ‬luid balance, arterial blood pressure, level of pain, pulse
• V intercostal catheter drainage, paradoxical breathing, loss of facial colour, nausea

a) I and III
b) II and IV
c) III and V
d) III and IV

e) IV and V !

ANS: D
Abdominal girth is not an important element; breathing pattern is more important than
speci‫ﻐ‬ic aspects of the breathing pattern; loss of facial colour and nauseas may occur
during
treatment but are not important elements prior to treatment; elements listed in III and
IV
are
most important as they have safety implications and will guide the level of intervention
selected.

8. From the following lists identify the MOST important elements for the physiotherapist
to assess or check DURING physiotherapy intervention for Mr J?

• I Borg fatigue score, headache, paradoxical breathing, dyspnoea level
• II auscultation, loss of facial colour, oximetry, arterial blood pressure
• III temperature, CVP, breathing control
• IV forced expiratory volume in one second, vital capacity, visual analogue pain score
• V breathing pattern, dizziness, pulse, sweating
Page 6 of 26

a) I and III
b) II and V
c) III and IV
d) III and V
e) IV and V !

APC ANS ‐ B
The elements listed in II and V will provide sensitive information regarding any negative
responses to intervention and should be monitored for change. The Borg fatigue scale is
Not appropriate for the level of intervention that will be used with this patient. Again,
Breathing pattern is more important than speci‫ﻐ‬ic aspects of the breathing pattern.
Spirometry measures are not the most important during intervention.

Paradoxical breathing : evident in supine lying

9. Bronchial breathing may be heard in Mr J because he has

a) upper airways obstruction
b) a pleural effusion
c) X‐ray evidence of consolidation without obstruction from sputum

d) respiratory depression
e) a pneumothorax !

ANS C (APC)
A‐ no hx or symptom of upper airways obstruction
B‐ ‫ﻐ‬luid between pleural cavity. In X ray f luid within t he horizontal or oblique f issures. Fluid postion
changes in different body positions.
In pleural effusion X ray‐ mediastinum deviated to opp side pg 37 P n 4ed
In Lobe collape xray mediastinum pulled towards affected side.

D‐ respiratory depression‐ since pat. Is stable at rest
http://www.livestrong.com/article/236906‐signs‐of‐respiratory‐depression/
E‐no sign of respiratory depression

Bronchial breath sounds may be heard over partial collapse or in lung consolidation ‐
the inspiratory and expiratory elements are of equal duration with a space between due
to lack of alveolar component.
When the bronchus is obstructed, breath sounds will be absent. (The
Other options do not cause bronchial breathing.)

http://www.meddean.luc.edu/lumen/meded/medicine/pulmonar/pd/b‐sounds.htm
Bronchial breathing anywhere other than over the trachea, right clavicle or right interscapular space is
abnormal. Presence of bronchial breathing would suggest:
● Consolidation
● Cavitation
● Complete alveolar atelectasis with patent airways
● Mass interposed between chest wall and large airways
● Tension Pneumothorax
● Massive pleural effusion with complete atelectasis of lung
In all these conditions, there are no ventilation into alveoli and the sound that is heard originates from
bronchi and is transmitted to the chest wall.
Experienced physicians could discriminate between consolidation and cavitation by noting the quality of
bronchial breathing. In consolidation, the bronchial breathing is low pitched and sticky and is termed
tubular type of bronchial breathing. In cavitary disease, it is high pitched and hollow and is called
cavernous breathing . You can simulate this sound by blowing over an empty coke bottle. In tension
pneumothorax bronchial breath sounds has a metallic quality and is called a mphoric breathing.

There is no sign of pneumothorax in above Q

The bronchial breath sounds over the trachea has a higher pitch, louder,
inspiration and expiration are equal and there is a pause between inspiration and
expiration. The vesicular breathing is heard over the thorax, lower pitched and
softer than bronchial breathing .

In a n ormal airfilled lung , vesicular sounds are heard over most of the lung fields,
bronchovesicular s ounds are heard between the 1st
and 2nd
interspaces on the
anterior chest, bronchial sounds are heard over the body of the sternum, and
tracheal s ounds are heard over the trachea.

https://www.ole.bris.ac.uk/bbcswebdav/institution/Faculty%20of%20Health%20Scien
ces/MB%20ChB/Hippocrates%20Year%203%20Medicine%20and%20Surgery/Respi
ratory%20%20Breath%20sounds/page_10.htm

10. All of the following would help the physiotherapist recognise clinically that Mr J has
a post operative chest infection EXCEPT

a) restlessness and irritability
b) abnormally raised temperature not otherwise explained
c) decreased respiratory rate
d) tachycardia
e) increasing amounts of sputum !

ANS: C
All other responses are consistent with a post‐operative chest infection. It would be
expected that respiratory rate would be increased in most cases.

11. Which of the following factors are responsible for keeping Mr J’s alveoli open

• I lung inertia
• II hysteresis
• III interdependence
• IV surfactant
• V carbon dioxide

a) I and III
b) II and IV
c) III and IV
d) I and V
e) II and III !

ANS: C
Surfactant has the unique property of decreasing the surface tension of smaller alveoli
in other words it evens out the surface pressures between alveoli of different size by the
surfactant differentially spreading across small and large alveoli so that in the end they

express similar surface tensions even at different size. The net result is that the alveoli in
the presence of
surfactant tend to retain their size and smaller ones do not collapse into larger alveoli.
In
addition to surfactant, another mechanism that aids in stabilizing the lung structure is
the
interdependence of the alveoli ‐ they are all connected to each other so that if one
alveolus
begins to collapse it acts to pull ‐ stretch other alveoli that surround it and therefore act
against
their own surface tension that is resisted and therefore the alveoli act to help stop each
other
from collapsing.

Note: Compliance is the slope of the pressurevolume curve. But when plotting
lungchest wall volume vs. pressure, the curve is not the same during inflation and
deflation. The dependence of a property on past history is termed h ysteresis .

INERTIA: resistance offered by chest wall or chest cavity

12. A CVP line is used to monitor which of the following?

a) right atrial pressure
b) left atrial pressure
c) pulmonary artery pressure
d) pulmonary capillary wedge pressure
e) jugular venous pulse

ANS: A
CVP stands for central venous pressure and is a term used to describe the pressure in
the
thoracic vena cava near the right atrium. A CVP line is an intracardiac monitor inserted
in
the
right atrium.

See APC hard copy of Q

Surgeries
Case 1
A 64year old female has had an abdominal surgery for removal of her
pancreatic cyst. On observation she is of thin built. She is complaining
of shortness of breath at rest and is in considerable pain besides
being on analgesics. Her chest X ray has revealed minor bilateral
inឈltrations. Her ABG ឈndings are:
pH 7.48,
PaCO2 28mmHg,
HCO3 26,
PaO2 87mmHg,
SaO2 90%.
On her observation charts her vital signs are recorded as follows:
SpO2 96%, HR 110bpm, RR 22, Temperature 37 & BP 137/80.

Q: What do the ABG ឈndings indicate?

1: Compensated respiratory acidosis
2: Uncompensated respiratory alkalosis
3: Uncompensated metabolic alkalosis
4: Uncompensated respiratory acidosis

ANS: B

Q: What could be the cause of her tachycardia?

1: Pain
2: Hypertension
3: Post-operative complications
4: Anxiety

ANSL A
Pg 8 pnp 4ed

Q: Her Physio has taught her to do forced expiratory technique. What
is the purpose of his technique?

1: to correct breathing pattern

2: to improve lung volume

3: to clear secretions from peripheral airways
4: to clear secretions from central airways

ANS: C

Q: How can a Physio train a patient to do an effective huff?

1: Instruct the patient to take a deep breath and blow hard and fast
2: Instruct the patient to take a deep breath and blow until all the air
comes out
3: Instruct the patient to take a moderate depth breath and blow as
much as possible
4: Instruct the patient to take a moderate breath and blow forcefully
but stop before the lungs are empty

ANS: c huff should be long enough to loosen the secretions but too
long can trigger paroxysmal coughing.
Pg 140 pn p 4ed

Q: What is risk factor for post op pulmonary complication in this
patient’s case?

1. Age
2. COPD
3. Metastasis.
4. Opioid use

ANS: D

Case 2
45 year old male seen by you on day 1 post Hemicolectomy.

Q: What is the most likely complication after this surgery?

1: Hypertension
2: Chest infection
3: COPD
4: Depression

ANS: B
C- requires long time

Q: As the treating Physio for this patient you checked his oxygen
saturation with pulse oximetry before mobilizing. The reading is 50%,
what would you do?

1: Tell the nursing staff
2: Ignore the reading and mobilize the patient anyway
3: Give the patient some oxygen.
4: Delay the treatment

ANS: A
Reasoning: Pulse oximetery is not very reliable below 60%, make sure
equipment is telling the truth. So swap with other spot to see if it the
same. Not reliable is cold hands, tremors, shivering. We waste time in
clinical practice checking. Always check how accurate. Look at trace
or pulsating light, look at HR also. Check HR from another source, as
Pulse oxy also gives HR too. RR should be up, hyperventilating,
cyanotic etc. Wont be alert and talking to you. If pt is in distress and
the O2 is less then you hit the buzzer, so same as telling nurse. Sats
should be 95% and above.
First thing to do is alert someone then set up the mask and all. So hit
the button xrst or call then nurse. Then give O2.

Q: Which of the following can change the Pulse oximetry reading?
1: Shivering of patient

2: Low light in the room

3: Peripheral vasodilatation
4: Cold weather

ANS: A
Pg 49 crop ឈle

Q: Which of the following is not a sign of a post operative pulmonary
complication?

1: Elevated white cell count
2: Increased blood pressure
3: Chest X ray changes
4: Abnormal breath sounds

ANS: B

1: Elevated white cell count: in chest infection eg bacteria
2: Increased blood pressure
3: Chest X ray changes: evidence for atelectesis and pneumonia
4: Abnormal breath sounds: abnormal lung auscultation, ( dependent
atelectesis, reduced breath soundscommon in ឈrst 2 days of surgery
Pg 406 pn p 4ed pg 85 crop ឈle

Case 3
55 year old woman – post right hemicolectomy. Patient is drowsy and in a lot of pain
post‐op. She is reluctant to use the PCEA (morphine).

Potential side effects of PCEA technique are exactly the same as for other modes of
epidural analgesia maintenance, although they tend to be less frequent and less severe.
Examples include: hypotension, loss of the desire to void, leg weakness, and alteration of
the bearing down reflex and birthing sensation. Potential complications following epidural
access apply regardless of the technique employed to deliver the epidural solution. For
example failure to establish good analgesia, post dural puncture headache, high epidural
block, total spinal, neurological injury, infection and haematoma.

file:///C:/Users/Ajay/Downloads/patient_controlled_epidural_analgesia__labour_
ward_only.pdf

Q: What would you advise the patient regarding the use of PCEA?

1. Do not press it; you’re at risk of overdosing the medication.
2. There is lockout time for PCEA, so even if you press it too many times the dose
wouldn’t be delivered when it’s locked out.
3. The medication would take 10min to have its effect.
4. You are right in using your PCEA minimally to aid your recovery.

ANS – B.
Reference CROP ‫ﻐ‬ile.

Q: What could be the cause of patient’s drowsiness?

1. Adverse effect of opioid use
2. Effect of GA
3. Risk of CVA post hemi colectomy
4. Hypoglycaemia

ANS My group says A.
But AAPTA answer is B.

GA has profound effect on lungs eg reduced FRC

if pain is present you do encourage the patient to use the pain medication other wise the
recovery takes longer.
You cant OD with PCA/PCEA. Lock out time is 5 min to 10 mins.
Able to cough better, breath better move better once painkiller is taken.
Generally last for 48 to 72 hrs, and effects on lungs it can last for a week or 2 weeks.
Older you are the longer it takes. Liver has to process it.

Q: What should you do before you mobilise the patient?

1. Speak to the nursing staff
2. Check the patient’s sensation
3. Check the patient’s muscle strength
4. All of the above

ANS: D

Q: What post‐surgical complications is the patient at risk of?

1. Arrhythmia
2. Risk of CVA post hemi colectomy
3. Hypoglycemia
4. Post‐operative pulmonary complications

ANS: D

Incision used in R Hemicolectomy is R paramedian, midline, R oblique refer vertical
incision

Case 4
Hemicolectomy case. Chest X‐ray shows right middle lobe opacity
How is it in the X‐ray,

a. Loss of shadow in right
b. Loss of cardiophrenic angle
c. Apex
d. Costophrenic angle decreased and increased height of diaphragm
e. Heart border and cardiophrenic angle decrease

ANS: E
A‐ not appropriate
B‐
C‐ heart apex is on left side
D‐ subtle changes or mostly absent
E more prominent changes
http://radiopaedia.org/articles/right‐middle‐lobe‐collapse

similar Q
Respiratory patient with infection
Question 1: Chest X‐ray shows Right middle lobe opacity
What would you see in the X‐ray?
a.Loss of shadow in right
b.Loss of cardiophrenic angle
c.Heart border and castophrenic angle decrease
d.Costophrenic angle decreased and increased height of diaphragm

ANS – C. it’s a bad lobe. Right middle lobe opacity.
In COPD – diaphragm gets ‫ﻐ‬lattened because of hyperin‫ﻐ‬lation.

Case 5
50+ YEAR OLD LADY WITH RECENT PANCREATIC CYST REMOVAL. IN CONSIDERABLE
PAIN DESPITE TAKING LOTS OF ANALGESIA (MORPHINE.) DROWSY. SHE HAS
BILATERAL INFILTRATIONS IN THE LUNGS. ABG: PH ‐ 7.55, CO2 ‐ 28, HCO3 – 24, 02 –
NORMAL – RR: 30 HR ‐110

Question 1: What do the ABG indicate?

a. Uncompensated respiratory alkalosis
b. Uncompensated metabolic alkalosis
c. Compensated respiratory acidosis
d. Uncompensated respiratory acidosis

ANS: A as no compensation in HCO3

Question 2: What could be the cause of her Tachycardia?

a. Pain
b. Anxiety
c. Post operative complication
d. Infection

ANS: A pg 398 p n p 4ed
Pain results in HT, tachycardia, sweating, decreased gut motility.

Question 3: You are assessing her legs and want to do the Homan’s test. How would you
do it?

a. Flex Knee and quickly dorsi‫ﻐ‬lex ankle
b. Extend knee and quickly dorsiflex ankle
c. Flex knee and slowly dorsi‫ﻐ‬lex ankle
d. Extend knee and carefully dorsi‫ﻐ‬lex ankle

ANS – B
Homan’s sign Crop ‫ﻐ‬ile‐pg 83

o Positive = discomfort in the calf muscles on passive dorsi‫ﻐ‬lexion of the foot with the
knee
straight.
o Present in less than one third of patients with con‫ﻐ‬irmed DVT.
o Positive in more than 50% of patients without DVT (i.e. non‐speci‫ﻐ‬ic).

If the dorsi‫ﻐ‬lexion is not forceful, an accurate result may not be obtained, and the test
result may be falsely negative.6

Question 4: What can be the cause of her post operative pulmonary complications?

a. Age
b. Opioid use
c. Metastasis
d. COPD

ANS: B
a. Age: less than 60, she is 50
b. Opioid use: it causes respiratory depression
c. Metastasis: no hx
d. COPD: no hx

Pancreatic cyst removal
clamp ICC
clamp Drain and empty suction chamber
remove suction from wall and open vent

Opioid cause respiratory depression.
Pancreatic removal is lower abdominal surgery so COPD is not a factor
similar case

Q‐ 60 yr old lady having abdominal surgery. On morphine analgesia, x‐ray
showing rt middle lobe opacity.

Q1 what is risk factor for pulmonary complication?
A) lower abdominal surgery
B) upper abdominal surgery
C) thoracic surgery
D) age> 60

ANS ‐ B
Reference – CROP ‫ﻐ‬ile. Upper abdominal surgery can cause complications.

After upper abdominal surgery, vital capacity , FRC and diaphragmatic motion have been
demonstrated to
be markedly reduced for 1 week. Abdominal muscle activity is impaired, particularly on
the ‫ﻐ‬irst postoperative
day.
Surgery for adults in P n P.
20 – 30% with upper abdominal surgery, Lower abdominal surgery risk is 2 – 5%
Lowest in cardiac surgery 5‐7%
16% in oesophageal sugery

Q2 what are the side effect of morphine?
a) respiratory depression
b) hallucination
c) Nausea & vomiting
d) All of the above
ANS ‐ D

Reference – CROP ‫ﻐ‬ile says ‐ Respiratory depression
• Hypotension
• Impairs gastrointestinal motility
• Prolonged sedation in renal failure
Komal Sanghavi: Some of the adverse effects wear off in days. Nausea and vomiting
usually settle over the ‫ﻐ‬irst week of treatment, as does drowsiness. It is not routine to
use a drug to control nausea, but it may be necessary to use metoclopramide or
haloperidol to control nausea or vomiting over the ‫ﻐ‬irst few days of treatment. The
doses are then reduced and stopped, if possible, because of their long‐term adverse
effects.

C onstipation, gastric stasis and hallucinations may not be self ‐limiting. Every patient
who takes opioids regularly needs a laxative . Docusate sodium with senna is a good
choice to start with, but there are a large number of preparations to choose from, each
with different pharmacological actions and latency. Gastric stasis is important to
recognise because it responds to treatment with cisapride or another prokinetic agent.

Hallucinations may be precipitated by morphine and other drugs and can be part of a
delirium. Their presence always requires a clinical review of the patient and often the
help of a psychiatrist. H allucinations may require treatment with haloperidol and/or
benzodiazepines. The opioid may need to be reduced or stopped
[11:55:11 AM] Komal Sanghavi: from austrailian magazine

Leona: h ttp://m.thorax.bmj.com/content/54/5/458.full

Q3 the rt middle lobe opacity in the x‐ray is consistent with
A) diminish shadow of descending aorta
B) Diminish shadow of rt hemi diaphragm.
ANS – A. P n P reference pg 41

Case 6

PATIENT POST UPPER COLON CANCER REMOVAL. NO HISTORY OF COPD. THE PATIENT
IS DROWSY. SHE IS ON PCA (MORPHINE) AND VERY DROWSY BUT RESPONDS TO
COMMAND. SPO2 98%.

Question 1: What may cause postoperative pulmonary complications?

a. COPD
b. Cancer
c. Opioid use
d. Age

ANS ‐ C
Opioid cause respiratory depression.
*Pancreatic removal is lower abdominal surgery so COPD is not a factor.

Question 2: The pulse oximeter is giving a low reading, under which condition might it
give a false reading?

a. Shivering of the patient
b. Low light in the room
c. Vasodilatation
d. low levels of saturation

ANS A

It is only accurate for haemoglobin oxygen saturations in the range from 70‐100%.

(a) Poor signal detection can be the result of:
• The presence of ‫ﻐ‬lickering or bright ambient light near the sensor
• Poor peripheral perfusion (eg secondary to hypovolaemia, severe hypotension, cold,
cardiac failure, peripheral vascular disease, vasoactive drugs)
• Movement of the patient during monitoring (eg shivering or tremor)
Low cardiac output, vasoconstriction, hypothermia

Question 3: What should you do as part of your treatment?

a. Inform the doctor about the drowsiness
b.give a incentive spirometer

ANS – A
Presently, there is little evidence to support the use of incentive spirometry to decrease
the incidence
of post‐operative pulmonary complications following cardiac or upper abdominal
surgery. Ten studies
have found no positive short‐term effect or treatment effect of incentive spirometers.
Only one study
has been supportive, but showed deep breathing and intermittent positive‐pressure
breathing were
equally more effective than no treatment in preventing post‐operative pulmonary
complications
following abdominal surgery.

Question 4: What side effect can we expect from oxycodone?

a. Dif‫ﻐ‬iculty to be awake
b. increase respiratory rate
c. dryness of mouth
d. urinary urgency

ANS – C
a. Dif‫ﻐ‬iculty to be awake
b. increase respiratory rate: same as morphine , decreases RR X
c. dryness of mouth
d. urinary urgency

Additional question on pulse oximetry ‐ If oxygen saturation is 48 and it is accurate,
then what would be symptoms?

a. Normal skin color
b. Loss of skin color
c. Irregular breathing
b. purse lip breathing

ANS – B
purse lip breathing‐ common in COPD

Case 7
58 year old female ‐ operation cholecystostomy. She is non smoker and has been
working as full time librarian. You are seeing her on 1st post op. Day. Her ABGs readings
are as below.
Ph: 7.41
Paco2 ‐ 41
Hco3 ‐ 27
SpO2 ‐ 89
On PCA ( 0.1 ml ? Fantalyn )

Q : 1 What does ABG indicate?

‐ Normal
‐ Hyperoxaemia
‐ respiratory acidosis with hypoxaemia
‐ Metabolic alkolosis with hyperoxaemia

ANS: A

Q :2 She is on pain managemnet through PCA. How will you say that she is managing
well with the Pain?

‐ Abilty to operate PCA
‐ Dosage of PCA used
‐ Her demand of analgesics
‐ Complains of pain on movement

ANS: C (as per group) and D as per March 2015 document.
PCA bolus dose d emands versus actual bolus doses are recorded: low bolus
dose demands may indicate poor use or well controlled pain. High bolus dose
demands may indicate inadequate pain relief, poor education re PCA button use,
or anxiety.

PCA = Pt Controlled Analgesia

Q : 3 How will you commence physio treatment ?

‐ Daily physiotherapy session to prevent post Pulmonary complication
‐ You will liaise with nurse to commence early mobilization
‐ You will see her 2/3 times a day
‐ She doesn't need any physio treatment

ANS: B
Also another document (March 2015 gives ans as A)
Form of low risk and high risk
low risk below age 65, w/o premorbid factors
so he wouldnt be retaining sputum. Main job is early mobn. Lower abdominal surgery. B
will be correct answer. Prior information sheet in australia..
Prior informaation sheet

risk factor profile, see if person if the person is at a higher risk of breathing. Low risk then
no focal chest Rx. Only mob and supported coughing.
Risk factor profile.
Age 60>
Smoker
Obese
Premorbid lung condition
Per morbid ex tolerance (low ex tolerance)
Cancer
Sick normally(cardiac failure)
Poor nutritional risk, low albumin etc.
How long the Sx was, under GA more than 23 hrs then high risk.
Then you can do chest treatment, ACBT, BC ext.
She is a low risk so wont do daily physio.
Cant say doesn’t need any physio treatment. Atleast review her once. So go with option 2.

Crop ‫ﻐ‬ile; pf 91
Colorectal surgery is often carried out via laparoscopic procedure or via laparotomy
incision. Vertical midline i ncisions are common in laparotomy but the choice of
vertical versus transverse incisions depends on a surgeon’s preference. Transverse
incisions may reduce analgesia use and pulmonary compromise, but these bene‫ﻐ‬its have
not been found to have any clinically‐detectable impact on complication rates and
recovery times. A belief that vertical incisions had an increased risk of wound
dehiscence and hernia formation is not supported by recent research.

Physiotherapy for patients having abdominal surgery aims to rapidly mobilise and
restore independent

functional mobility and reduce the risk of a pulmonary complications and
thromboembolic disease.
After upper abdominal surgery, vital capacity and diaphragmatic motion have been
demonstrated to
be markedly reduced for 1 week. Abdominal muscle activity is impaired, particularly on
the ‫ﻐ‬irst postoperative
day.
After having a colectomy, most patients will lead normal lives. This is because the small
intestine
performs most of the bowel’s vital functions and the large intestine primarily absorbs
water from the
stool.

Q :4 What does indicate that respiratory function is worsening?

‐ purulent sputum
‐ Decreased coughing
‐ Drowsiness
‐ Hypertension

ANS: A

Case 8

50YO patient having thoracic surgery for cholesystectomy following cancer. Has a
drainage system connected and PCA. Chronic past 4 days and totally dehydrated.post
operatively had copd.

Q 1 What is the risk factor of pulmonary complications

a) Age
b) Pca
c) Copd
d) Cancer

ANS; C

Q 2 What side effect can we expect from oxycodone?

a) Dif‫ﻐ‬iculty to be awake

b) Increase respiratory rate
c) Dryness of mouth
d) Urinary urgency

ANS: C
Oxycodone side effects
Get emergency medical help if you have any signs of an allergic reaction to
oxycodone: hives; difficult breathing; swelling of your face, lips, tongue, or throat.
Call your doctor at once if you have:
● shallow breathing, slow heartbeat, cold, clammy skin;
● seizure (convulsions);
● confusion, severe d rowsiness ;
● infertility, missed menstrual periods;
● impotence, sexual problems, loss of interest in sex;
● a lightheaded feeling, like you might pass out; or
● low cortisol levels nausea, vomiting, loss of appetite, dizziness, worsening
tiredness or weakness.
Oxycodone is more likely to cause breathing problems in older adults and people
who are severely ill, malnourished, or otherwise debilitated.
Seek medical attention right away if you have symptoms of serotonin syndrome,
such as: agitation, hallucinations, fever, sweating, shivering, fast heart rate, muscle
stiffness, twitching, loss of coordination, nausea, vomiting, or diarrhea.
Common oxycodone side effects m
ay include:
● drowsiness, headache, dizziness, tired feeling;
● stomach pain, nausea, vomiting, constipation, loss of appetite;
● dry mouth; or
● mild itching.

Q 3 which other professional do you refer him to

a) Dietician
b) Speech pathologist
c) Exercise physiologist
d) Occupational therapy

ANS; A
As pat is dehydrated

Case 9
Hemicolectomy, patient has low temperature

Q1 what would be the most likely complication after surgery?

a) Hypertension
b) Chest infection
c) COPD

ANS – B

Q2 You checked the pulse oxymetry before mobilizing your patient. The reading is 49%,
what do you do?

a) Tell the nursing staff
b) Ignore the reading and mobilize the patient anyway
c) Give the patient some oxygen.
d) Delay

ANS – A
But AAPTA gave C.

Q3 which of the following can change the Pulse oximetery reading:

a) Shivering of patient
b) Low light in the room
c) Peripheral dilation !

ANS – A
Movement artifact
C‐ instead vasoconstriction do

Case 10
Post hemicolectomy 54 year old lady day 1 drowsy oxygen saturation with tumor in
colon ON PCA high morphin. Patient responds on command well. ABG {DONT
REMEMBER},bp stable,every thing was normal. ON VENTURI MASK of 2lt o2.

Q1 Risk factor for Patient

a) Age
b) Copd
c) Opiods
d) Malignancy

ANS: C

Q2 Physio notice that patient can’t do effective coughing how physio will help to remove
secretion?

a) Do nasopharyngeal suction
b) Give breathing exs and ask to do coughing remaining clear with oral suction
c) Do mini tracheostomy

ANS: B

Q 3 How would physio know pt is independent in her exercise?

a) ability of pt to use PCA
b) Uses her PCA for pain control before moving the wound
c) Dosage of PCA
d) Frequency of usage of PCA

ANS: D

Case 11
65 YEAR OLD FEMALE WHO HAD UPPER LEFT LOBE RESECTION 1 DAY AGO. CHEST
DRAIN IN SITU.

Question 1: How would you assess this pt?

a. Sitting on side of bed
b. High supported sitting
c. Right side lying
d. Supine

ANS – B
Bad lung up. Ventilation perfusion ratio increases. In Australian culture.
Reference: Effect of positioning and mobilazation in P n P
CROP file 105 pg

Question 2: How would you modify your assessment for this patient?

a. avoid palpation and auscultation around drain site
b. advise to take shallow breaths on auscultation
c. do not move patient
d. monitor pain on movement
Ans D

Question 3: You have mobilised the patient 20 meters and have returned her to her
chair. What would you advise to her?

a. Sit there and wait for nursing staff to return you to bed
b. Walk again in 1 hour and double your distance
c. Wait for a few mins and then practice your leg exercises
d. Support cough

ANS D
(doubts posted)

Question 3 : You teach her secretions removal techniques> When do you consider she
will be independent ? When she is able to do

a. shallow breathing with moist cough
b. shallow breathing with ???

c. deep relaxed breathing with loose huff
d. deep relaxed breathing with strong huff

ANS – changes with lobectomy are different. Post op phase – disruption is large.
Contusion of lung is large.
P n webber – PT for respiratory and cardiac problems. Cardio pulmonary function
testing. Pg 62.
Answer D.

Question 4 regarding pain while breathing or regarding breathing assessment?

a. avoid the area of the surgery
b. assess within the limit of pain or something similar ??
c. ???
d. ????

ANS B

Case 12
A 64year old female has had an abdominal surgery for removal of her pancreatic cyst.
On observation she is of thin built. She is complaining of shortness of breath at rest and
is in considerable pain besides being on analgesics. Her chest X ray has revealed minor
bilateral in‫ﻐ‬iltrations. Her ABG ‫ﻐ‬indings are:
pH 7.48,
PaCO2 28mmHg,
HCO3 26,
PaO2 87mmHg,
SaO2 90%.
On her observation charts her vital signs are recorded as follows: SpO2 96%, HR
110bpm, RR 22, Temperature 37° c& BP 137/80.

Q1: What do the ABG ‫ﻐ‬indings indicate?

1: Compensated respiratory acidosis
2: Uncompensated respiratory alkalosis
3: Uncompensated metabolic alkalosis
4: Uncompensated respiratory acidosis

Ans‐ 2

Q2: What could be the cause of her tachycardia?
1: Pain
2: Hypertension

3: Post‐operative complications
4: Anxiety

Ans 1
P N P 4ed pg 398

Q3: Her Physio has taught her to do forced expiratory technique.
What is the purpose of this technique?
1: to correct breathing pattern
2: to improve lung volume
3: to clear secretions from peripheral airways
4: to clear secretions from central airways

Ans ‐ 3 refer Crop ‫ﻐ‬ile

Q4: What is risk factor for post op pulmonary complication in this patient’s case?
1. Age
2. COPD
3. Metastasis
4. Opioid use

Ans: 4

case 13
55 year old female, hemicholectomy cancer removal. Had a vertical midline
incision done.
Every thing is normal. PCA present.

ABG – PH 7.33, Pco2 – 49, HCO3 – 25, Spo2 – 96%, Respiratory rate 10. Temp –
38.7

1. What are the factors for post pulmonary complications
a. age
b. opiods
c. Cancer History
d. Vertical incision.

2. Which of the following can change the Pulse oximetry reading?
1: Shivering of patient
2: Low light in the room
3: Peripheral vasodilatation
4: Cold weather

Ans: 1

3. The patient feels dizzy what will you do ?

a: Tell the nursing staff
b: Ignore the reading and mobilize the patient anyway
c: Give the patient some oxygen.
d: Delay the treatment

Ans A

4.How would you improve …

a. give her incentive spirometer
b
c
d

Case 14
53 year old woman (Mrs F)
‐ has six adult children
‐ had a bladder neck elevation, vaginal hysterectomy and anterior colporrhaphy three
days ago.
‐ lives at home with her 59 year old husband who is mostly wheelchair bound due to
chronic low back pain.
‐ focus is on the home and the care of her husband
‐ has few outside activities.
‐ to be discharged home tomorrow once her physiotherapist has given her a program to
follow for her post surgical rehabilitation. !

colporrhaphy vagianal repair

1. Mrs D should be encouraged to avoid activities that raise her intra abdominal
pressure. Such activities include

a) standing up from the floor
b) diaphragmatic breathing
c) standing for long periods
d) lifting
e) all of the above !

ANS APC D
Lifting will increase intraabdominal pressure because the walls of the abdomen
will
contract
and the diaphragm will be isometrically contracted. The other activities will not
necessarily

increase intraabdominal pressure because other parts of the abdominal wall can
relax
when one
part is contracting so there is no net pressure increase.

2. Because Mrs D has had a bladder neck elevation, she should be encouraged to

a) rely on the fascia of the pelvic floor to support her abdominal organs, at least
for the first 6 weeks post operatively
b) regain good bowel and bladder habits
c) do maximum pelvic floor contractions immediately
d) wear absorbent pads in her pants
e) establish a routine for voiding urine !

ANS: B
It will be important that Mrs F does not strain this area so good bowel as well as
bladder
habits
will need to be regained to decrease stress.

3. In view of Mrs D’s care of her husband, it would be essential to

a) assess Mrs D’s home environment and the tasks she needs to perform for her
husband
b) have Mr D placed in respite care for six weeks
c) assist Mrs D to engage nursing care for the first six weeks post operatively
d) ensure that Mrs D returns for weekly outpatient physiotherapy visits
e) a) and c) !

ANS: A
A home assessment would be required prior to deciding on an appropriate
management
plan
such as nursing or respite care.

4. Mrs D is MOST likely to have poor abdominal muscle recruitment because

a) she is more than 40 years of age
b) she has had multiple pregnancies

c) she has a pelvic floor problem
d) b) and c)
e) a), b) and c) !

ANS; D
Multiple pregnancies and pelvic floor weakness are associated with poor
abdominal
muscle
recruitment.

5. In suggesting exercises for Mrs D’s abdominal musculature in the early stages
postoperatively, which would be MOST appropriate?

a) pelvic tilting in lying
b) abdominal muscle contractions in standing
c) contraction of transversus abdominis in a variety of positions
d) pelvic rotation in lying
e) modified sit ups !

ANS: C
Contraction of TA will encourage contraction of the pelvic floor. It is also least
likely to
increase intraabdominal pressure

6. Mrs D is probably at risk of development of deep vein thrombosis because

a) of the use of the lithotomy position during surgery
b) she is likely to be severely dehydrated
c) of the amount of blood loss with this type of surgery
d) her movement in bed is likely to be restricted post operatively
e) all of the above are correct.

ANS: A
Complications of the lithotomy position are well‐known and include lower extremity
compartment syndrome, peroneal nerve dysfunction, femoral neuropathy, and deep vein
thrombosis. These complications may be explained by direct nervous or muscular
compression
or by decreased arterial and venous blood ‫ﻐ‬low in the lower extremities.

A bladder neck elevation is not associated with high blood loss and her movement in
bed
should not have been severely restricted to the extent that a DVT would occur. In light of
the
operations, ‫ﻐ‬luids would have been encouraged so dehydration is unlikely.

Case 15
&q16= After mastectomy, a patient receiving home care, cannot accept the loss of
her breast. She reports being weepy all the time with loss of sleep. She is constantly
tired and has no energy to do anything. The BEST action the therapist can take is:

16a= contact her primary physician and request a psychological consult.
16b= tell the nurse case manager to monitor the patient closely.
16c= tell her depression is common at ‫ﻐ‬irst, but will resolve with time.
16d= have her spouse observe her closely for possible suicidal tendencies.

ANS: A

case 16
Surgery thoroscopy. Rtrib resection

Q.which of the following can change the Pulse oximetery reading:

1.Shivering of patient
2 Low light in the room
3.peripheral dilation
4. cold weather

ANS ‐ A

Q: When mobilizing the patient, what would you do manage the drain?

1: measure the length of tubes and moblise within the reach
2: Ask a physio assistant to carry intercostal catheter
3: Fix it to the frame
4: Remove the suction

ANS ‐ 3

Q: After mobilizing him what would you do?

1: Make him sit on the chair and say the nurses will take you to the bed.

2: Ask him to stay in the chair and after resting for few min practice breathing exercises
3: Ask to Huff strongly with pillow support.
4: Put him back in bed

ANS ‐ C

Pulmonary Equipments
UWSD
Case 1
72 year old male ‐ rib removal because of mass in lung, seeing patient next day. UWSD in
place.

Q : 1 What do you expect in UWSD if it is managing normalized air leak?

‐ intemittent bubbling in under water seal
‐ contineous bubbling in under water seal drainage
‐ intermttent bubling in Suction chamber
‐ Contineous bubling in suction chamber

ANS: A
intemittent bubbling in under water seal: pg 420 p np 4 ed
Inspiration and expiration will increase and decrease the ‫ﻐ‬luid.
UWSD has 3 chambers.
1. UWSD / chest canister collects ‫ﻐ‬luid
2. Water seal ‐ shows intermittent bubbling on expiration and coughing. if there is
continuous bubbling, there is an airleak
3. Suction control chamber: bubbling in suction chamber is of no importance as it will
occur only when suction is applied.

‐ contineous bubbling in under water seal drainage: large air leak

Q : 2 How will you prepare the patient for mobilization ?

‐ ask nurse or AHA to carry catheters
‐ put the bottles in the walker that patient gonna use to walk
‐ switch off the suction and open the suction cap
‐ clamp the suction

ANS: B
C (According to March 2015 document).

POE
A‐ not ethical
C‐ correct procedure to switch off the suction
D ‐ U don’t clamp the suction unless there is an emergency. Like UWSD is broken.
Reference Pryor and Prasad
Underwater seal drain
Clamp will cause tension pneumothorax.

similar Q
Question 2 : You want to mobilise him What would you do ?

a. turn off the suction chamber, remove it from the wall and then open the vent
b. turn off the suction chamber and drain the suction chamber
c. ???
d. ?????

ANS – A
B‐ can’t Drain suction chamber.
CROP ‫ﻐ‬ile – you never clamp this.
An air leak will be characterised by intermittent bubbling in the water seal chamber
when the patient with a pneumothorax exhales or coughs.
The severity of the leak will be indicated by numerical grading on the UWSD (1‐small
leak 5‐large leak)
Continuous bubbling of this chamber indicates large air leak between the drain & the
patient. Check drain for disconnection, dislodgement and loose connection, and assess
patient condition. Notify medical staff immediately if problem cannot be remedied.
Document on Fluid Balance Chart

Patient Transport
If the patient needs to be transferred to another department or is ambulant, the suction
should be disconnected and left open to air.
DO NOT CLAMP THE TUBE
Clamps must not be used on the patient for transport because of the risk of tension
pneumothorax
Ensure the chamber is below the patients chest level during transport
Flutter Valve systems (pneumostat, Heimlich) may be used for patient interhospital
transfers (e.g. NETS and PETS

ANS A
If UWSD chamber is broken, then we can clamp otherwise you don’t clamp.

Leona – youtube clips. Guidelines of nurses how to do it and how it actually works. If the
tubing disconnects from the bottle. Then air can get into the patient. This would be an
emergency situation
http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Chest_Drain_Manage
ment/
UWSD – 3 bottles.
2 bottles if they have a lot of passive stuff coming out.
CROP ‫ﻐ‬ile ‐ Pg 95. Very well explained.

ON youtube – check UWSD.

Additional question on pulse oximetry –( another question)

If oxygen saturation is 48 and it is accurate, then what would be symptoms?

a. Normal skin color
b. Loss of skin color
c. regular breathing
D. purse lip breathing

ANS B.
Reference cyanosis.

D‐ common in chronic respi disease or severe airways restriction.

Can’t recall the other

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
(Normal Questions continued)

Q : 3 You are mobilizing the patient and checking O2 saturation‐ which is 49. what will
you do?

‐ Assist him to go back to bed and consult nurse immediately
‐ Mobilize him anyway
‐ Check the radial pulse and continue mobilizing
‐ Delay the treatment untill organizing another pulse oxymeter

ANS; A
(According to March 2015 document group discussion ‐ answer is D).

Pg 66 Pn P 4ed ‐ below 50 % =pulse oximeter is unreliable
Movement artifact can affect Spo2

CROP ‫ﻐ‬ile‐52
PaO2 is a more sensitive measure of respiratory function than
SpO2
> 95%
> 90% in elderly and COPD

Q : 4 How will you know she is independent with ACBT ?

‐ spontaneous coughing and productive secretions
‐ moderate huff with less sputum
‐ no secreatins

ANS: A

Case 2
62 year old male ‐ R) upper lobectomy ‐ posterio lateral upper lobectomy
Intercostal drain in situ, UWSD
Smoking 50 pack per year
h/o copd, HTN
Brown sputum ( 20 ml )
On PECA
Vital signs normal

Q : 1 Side effects of PECA

‐ Back pain
‐ HTN
‐ Hyperthermia
‐ Drowsiness

ANS – D
Epidurals do pose a risk ‐ epidural haematoma formation can lead to paralysis.
This may present as visible haematoma at site of insertion,
backache ,

Hypothermia due to peripheral vasodilation, neurological signs. The epidural site
should be inspected prior to mobilisation.

PCA bolus dose demands versus actual bolus doses are recorded:
low bolus dose demands may indicate poor use or well controlled pain. High bolus
dose
demands may indicate inadequate pain relief, poor education re PCA button use,
or anxiety.
Demand not dosage of PCA used.

Q : 2 Patient is on PECA. What would you explain?

‐ It is continuous administration of drug so you do not need to buzz to increase dosage
‐ If you will buzz, your dosage of drug will be increased
‐ We will not increase after cut off ( ? ) level
‐

ANS – C
Self administration of drug
OA: C as per ILP surgical and AAPTA moderator.

But March 2015 document has answer as A.

Q: 3 You have to teach him airway clearance technique. What will be best suitable
technique for him?

‐ Autogenic drainage + coughing with pillow
‐ Autogenic drainage + nasopharyngeal suction
‐ Pursed lip breathing + nasopharyngeal suction
‐ Pursed lip breathing + coughing with pillow support

ANS A
ACBT technique as the 1st goal and choice.
Immediately post op they dont do autogenic drainage.
Autogenic case in a bit of chronic
OA: A
Pursed lip breathing for improving

Pain is a big issue as he has Thoracic surgery. Reduced airway clearance is an issue. In post
op do as much as active technique. Autogenic draining involves breathing at different
volumes. And small amount of sputum so not first thing to go to.
No need suction as he is alert and can cough.
Pursed lip breathing is a technique to manage shortness of breath not to remove sputum.
If you Have ACBT with supported cough then that is the best option.

Q : 4 How will you prepare with suction before mobilizing?

‐ Clamp the suction
‐ Clamp the ICC close to chest and disconnect suction
‐ Disconnect ICC and drain the ‫ﻐ‬luid in the suction chamber

ANS – B
Not sure.
March 2015 ‐ a bubbling chest cannot be clamped.
Group discussion ‐ We never clamp it. generally u want to mobilize ‐ call the nurse.
nurse dicconect the wall suction
the patient will march at the spot
mobilize the patient then.

Case 3
Surgery thoracotomy. Thoracotomy for wedge resection right upper lobe. Patient has
under water seal drainage with suction.post op day 1. DR refers the patient to the PT for
assessment and mobilization.

Q1 what is normal about underwater seal drainage for the normalized air leak.

a) Bubbling intermittently in under water seal drainage
b) Bubbling continuously in under water seal drainage
c) Bubbling in the suction chamber
d) No bubbling in suction chamber

ANS: A

Q2 When mobilizing the patient, what would you do manage the drain?

a) Clamp the UWSD
b) Ask a physio assistant to carry intercostals catheter
c) Fix it to the frame

d) Remove the suction

ANS: C

Q3 After mobilizing him what would you do?

a) Make him sit on the chair and say the nurses will take you to the bed.
b) Ask him to stay in the chair and after resting for few min practice breathing exercises
c) Ask to Huff strongly with pillow support.
d) Put him back in bed

ANS: B

case 4
21 Years old Aboriginal man had a motor vehicle accident was thrown away 20
30 m from car. Acquired clavicle fracture, right chest pain. Is on USWD, with a two
bottle system draining pneumothorax and hemothorax.

1. What is not true for USWD?

a. Bubbling on inspiration and expiration indicates large air leak.
b. Distal end of tube under water surface.
c. During inspiration the swing goes down due to negative pleural pressure.
d. Drain should be below chest level.

ANS C
During inspiration the swinging should rise and during expiration the swinging should
fall.

2. Chest xray shows increased opacity on right side. what will u see in an Xray?

a. Diminished costophrenic angle
b. Diminished heart border.
c. Diminished apex
d. Diminished middle diaphragm.
e. Diminished costophrenic and right heart border(not sure}.

ANS – E?

3. Reason for Hypoxemia

a. Fracture of clavicle
b. v/q mismatch due to intrapulmonary shunt
c: ……something related to other shunt..
d:

ANS

4. What will not improve the Ventilation ( something related to it), choice was
mainly between these two options (mobilization or sit out of bed), the other two
options definitely were true
A: mobilisation
B: s it out of bed(not sure)
c: Thoracic expansion exes
d. CPAP

ANS C
Pnp 4ed 421
Pain from chest drains could limit cheat active movement, CPAP can be applied
with conti monitoring of air leak.

Question about UWD:
Q: What the physio does before mobilizing:
A: clamp the suction chamber

Techniques
Case 1
88 year‐old male (Mr M)
‐ admitted to a medical ward following a history of feeling unwell for three days.
‐ thinks he has a fever
‐ has been experiencing increasing breathlessness.
‐ moist cough
‐ dif‫ﻐ‬iculty clearing sputum.
Past medical history
• chronic obstructive pulmonary disease (COPD)
• chronic atrial ‫ﻐ‬ibrillation
• ischaemic heart disease (IHD) ‐ with moderate impairment of left ventricular function

• re‫ﻐ‬lux oesophagitis and prostatism
• medications include ‐ Prednisolone; Atrovent via metered dose inhaler with spacer;
Flixotide; Perindopril; Prazosin; Frusemide; Ranitidine; Aspirin
Arterial blood gas (ABG) on admission on 28% O2
• pH ‐ 7.32
• PaO2 ‐ 60mmHg
• PaCO2 ‐ 75 mmHg
• HCO3
‐ ‐34mlEq/L
• SaO2 90% on 28% oxygen via Venturi mask
Other ‫ﻐ‬indings on admission
• heart rate (HR) ‐ 85 beats/min
• blood pressure (BP) 100/60 mmHg
• respiration rate (RR) ‐ 30/min
• auscultation ‐ decreased breath sounds throughout, widespread polyphonic wheeze
and
bibasal inspiratory crackles
• cough is weak and moist sounding
• he is sweaty, short of breath during conversation and orthopnoeic
• he is very thin and extremely frail and has signi‫ﻐ‬icant bruising on his arms and legs
Immediate medical management
• intravenous hydrocortisone and antibiotics
• Ventolin / Atrovent / saline given four hourly via a nebuliser
• Digoxin and increased levels of Perindopril and Frusemide
• Oxygen therapy !

49. Which of the following is an indication of Mr M’s acid‐base disorder?

a) respiratory alkalosis with partial compensatory metabolic acidosis
b) metabolic alkalosis with partial compensatory respiratory acidosis
c) respiratory acidosis with partial compensatory metabolic alkalosis
d) metabolic acidosis with partial compensatory respiratory alkalosis
e) respiratory alkalosis with compensatory metabolic acidosis !

ANS: C
In acute respiratory acidosis, the PaCO2 is elevated above the upper limit of the
reference
range
(ie, >45 mm Hg) with an accompanying acidemia (ie, pH <7.35). In chronic respiratory
Page 20 of 25
acidosis, the PaCO2 is elevated above the upper limit of the reference range, with a
normal or

near‐normal pH secondary to renal compensation and an elevated serum bicarbonate
(ie,
HCO3
‐
>30 mm Hg). These are consistent with Mr M’s gases.

Chart in CROP ‫ﻐ‬ile – pg 54‐ 55 for this.

50. Which of the following statement(s) about the mechanism of Mr M’s orthopnoea is/
are FALSE?

a) orthopnoea is due to an increase in pulmonary venous congestion
b) abdominal contents cause an increased mechanical load on the diaphragm
c) reduced closing capacity results in V/Q mismatching
d) orthopnoea is often associated with haemoptysis
e) all of the above are false !

ANS: D
Orthopnoea occurs when right atrial and right ventricular function is relatively normal
but
there is impaired function on the left side of the heart. This will cause pulmonary
venous
Congestion. In crdiac patients ,lying ‫ﻐ‬lat increases venous return from legs causes
pooling of blood in the lungs, causing bresthlessness.

Abdominal contents can increase intraabdominal pressure and there fore
increase the
mechanical resistance against which the diaphragm must work.
Ventilation/perfusion mismatching will arise because of increased closing volume and
therefore reduced closing capacity.
The only incorrect option is the association with haemoptysis.

51. The physiotherapist ‫ﻐ‬inds that when Mr M moves quickly from a standing to
a supine position he experiences breathlessness. Which of the following
statements about possible causes of the breathlessness are TRUE?

• I the effect of increased preload on the heart
• II the effect of decreased preload on the heart
• III the effect of increased right ventricular end diastolic volume
• IV the effect of ‫ﻐ‬luid backing up in the lungs
• V the effect of increased ejection fraction

a) I, III and IV

b) I, II and V
c) III, IV and V
d) II and IV
e) I and III !

ANS: A
When supine there is an increase in venous return to the right atrium and the right
ventricle, and
hence an increase in blood ‫ﻐ‬low to the lungs. In the presence of conditions such as mitral
stenosis or left ventricular failure, there is an increase in left atrial and pulmonary
venous
pressure. If the pulmonary venous pressure is raised above approximately 25 mm Hg (ie
the
oncotic pressure of the plasma proteins) there is transudation of ‫ﻐ‬luid from the
capillaries
into
the interstitial tissues of the lungs which become stiff. The result of the above process is
the
development of interstitial oedema and dyspnoea.

Good explanation is given in cardiac rehab and chapter – effect of positiong and
rehabilitation

52. Which of the following would be the MOST appropriate management strategies to
assist airway clearance for Mr M?
Page 21 of 25

a) pursed lip breathing, thoracic expansion exercises
b) active cycle of breathing techniques (ACBT), modi‫ﻐ‬ied gravity‐assisted drainage
positioning (GADP)
c) sustained maximal inspirations (SMI), percussion
d) gravity‐assisted drainage positioning (GADP), shaking
e) positive expiratory pressure (PEP) mask, breathing control !

ANS: B
The breaching techniques and gravity assisted drainage will be most bene‫ﻐ‬icial to
Mr M in clearing his airways.

They ‫ﻐ‬irst rule in Oz is tht they go with ACBT.

53. Which of the following statements about a Venturi mask is TRUE?

a) it is used for the delivery of oxygen for patients with a hypercapnic respiratory drive
b) the high ‫ﻐ‬low of oxygen entrains a small volume of ambient air
c) a ‫ﻐ‬ixed FiO2 can be delivered to the patient
d) it can be used for the delivery of the patient’s inhaled medications
e) CO2 accumulation in the mask is prevented by periodically removing the mask
!

ANS: C
The primary purpose of the Venturi mask is to deliver strict FiO2s.
Reference 2005 and in CROP ‫ﻐ‬ile.

54. Which of the following represents the LOWEST risk factor for IHD?

a) cigarette smoking
b) stress
c) family history of IHD
d) hypertension
e) diabetes mellitus

ANS: B
The three highest risk factors are smoking, diabetes mellitus and cholesterol levels.
Hypertension is a risk factor in the development of IHD, Genetic and hereditary factors
may also be responsible for the disease. Stress is the lowest risk factor of those listed.

additional Q 4m cardio 2009 to 2005

2. For what is intercostal drainage used,
a. pneumothorax
b. surgical emphysema
c. subcutaneous empyema
d. contusion

ANS – Surgical emphysema, empyema is in the skin. Contusion is coz its already
bleeding. So choose A
surgical emphysema: S ubcutaneous emphysema is when gas or air is in the layer under
the skin. subcutaneous emphysema usually occurs on the chest, neck and face, where it is
able to travel from the chest cavity along the fascia

Pg 13 pnp 4ed

Empyema is a condition in which pus accumul ates in the area
between the lungs and the inner surface of the chest wall. This area
is known as the pleural space. Empyema, also called pyothorax or
purulent pleuritis, usually develops after pneumonia, which is an
infection of the lung tissue. Pus in the pleural space can’t be
coughed out. Instead, it needs to be drained by a needle or surgery.

tidy
Antibiotics are given to combat infection.
Aspiration through a needle inserted into the cavity
may remove sufficient pus to relieve the condition, but
continuous underwater drainage may be necessary. Rib
resection may be indicated if the effusion is very thick
or loculated.
If the condition results in fibrosis of the pleura
which severely limits lung expansion, then a rib resection
may be performed and the pleura stripped off the
lung (decortication).

Contusion: Pulmonary contusion is an injury to lung parenchyma, leading to oedema and blood
collecting in alveolar spaces and loss of n ormal lung structure & function The classic management of
pulmonary contusion includes fluid restriction

Indications for Insertion of a Chest Drain
● Post operatively e.g. cardiac surgery, thoracotomy
● Pneumothorax
● Haemothorax
● Chylothorax
● Pleural effusions
http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Chest_Drain_Management/

Flutter valve (e.g. pneumostat, Heimlich valve): One way valve system that is small & portable for
transport or ambulant patients. Allows air or fluid to drain, but not to backflow into pleural cavity.

3. what is the treatment
a. autogenic drainage …
b. ACBT, assisted coughing
ANS B

5. What is abnormal in underwater seal?
a. water level moving up during inspiration
b. no movement in water at all
ANS ‐ B

Case 2
&q123= The recommended time duration for endotracheal suctioning is:
123a= 10 to 15 seconds.
123b= 1 to 5 seconds.
123c= 5 to 10 seconds.
123d= 15 to 20 seconds.

ANS: A
A recent SR and an LR consistently found that suction time should be limited to a
maximum of 10‐15 seconds in order to minimise the risk of hypoxia, atelectasis and
trauma (9, 13). It was also recommended that suction should be performed in a
continuous manner only as the suction catheter is being removed. N 3 attempts should
be made.

https://www.aci.health.nsw.gov.au/__data/assets/pdf_‫ﻐ‬ile/0010/239554/ACI14_Suctio
n_2‐2.pdf

Case 3
ANS:

EXTRAS
Case 1
&q24= A 14 year‐old boy with advanced Duchenne muscular dystrophy is
administered a pulmonary function test. The value that is UNLIKELY to show any
deviation from normal is:
24a= vital capacity.
24b= FEV1.
24c= functional residual capacity.
24d= total lung capacity.

ANS: C

Muscle weakness produces restrictive pattern on spirometry with FEV 1 being reduced to
similar extent to VC therefore the ratio is high or normal.Tlc will be low as a consequences of
weak inspiratory ms n stiff ness that develops due to long standing weakness.
FRC IS unlikely to change
FEV1 = forced expiratory volume in 1 second.

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Best answer - refer him back to the Dr.

Q: What does the ABG results imply?

. Allergic Asthma‐ atopic

d. Non‐Allergic Asthma‐ non atopic

3: She can check with the doctors if they can be removed

volume (RV) a nd a n ormaltoincreased functional residual capacity (FRC). The RV

As a result o f these p rocesses, tidal b reathing may take p lace a t lung volumes a s h igh

Most of the studies that have shown a n improvement in e xercise capacity have used

2: to improve lung volume

2: Low light in the room

You might also like

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Uploaded by

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Original Title

Copyright

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Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Cardio Pulmonary Master Document Google Docs

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Copyright:

Available Formats

Best answer - refer him back to the Dr.

Q: What does the ABG results imply?

. Allergic Asthma‐ atopic

d. Non‐Allergic Asthma‐ non atopic

3: She can check with the doctors if they can be removed

volume (RV) a nd a n ormal­to­increased functional residual capacity (FRC). The RV

As a result o f these p rocesses, tidal b reathing may take p lace a t lung volumes a s h igh

Most of the studies that have shown a n improvement in e xercise capacity have used

2: to improve lung volume

2: Low light in the room

You might also like

volume (RV) a nd a n ormaltoincreased functional residual capacity (FRC). The RV