Pulmonary System

Chapter 4
Mayis Aldughmi, PT, PhD
In courtesy of Nihad Almasri, PT, PhD
Objectives
1. Provide a brief review of the structure and function of the pulmonary
system
2. Give an overview of pulmonary evaluation, including physical
examination and diagnostic testing
3. Describe pulmonary diseases and disorders, including clinical
findings, medical-surgical management, and
physical therapy intervention
Overview of body structure and function
• Revise the body structure and function of the pulmonary system from
pages 53-57 in chapter 4
Evaluation- history
• History of smoking, including packs per day or pack
years
(packs per day × number of years smoked) and the
amount of time that smoking has been discontinued
(if applicable)
• Presence, history, and amount of O2 therapy at
rest, with activity and at night
• Exposure to environmental or occupational toxins
(e.g., asbestos)
• History of pneumonia, thoracic procedures, or
surgery
• History of assisted ventilation or intubation with
mechanical Ventilation
• Level of activity before admittance
• History or current reports of dyspnea either at rest or with
exertion. Dyspnea is the subjective complaint of difficulty
with respiration, also known as shortness of breath. A visual
analog scale or ratio scale (Modified Borg scale) can be used
to obtain a measurement of dyspnea. The American
Thoracic Society Dyspnea Scale can be found in Table 4-3.
Note: The abbreviation DOE represents “dyspnea on
exertion”
• Sleeping position and number of pillows used
• History of baseline sputum production, including color
(e.g., yellow, green), consistency (e.g., thick, thin), and
amount. Familiar or broad terms can be applied as units of
measure for sputum (e.g., quarter-sized, tablespoon)
Dyspnea
Physical Examination- Inspection
• General appearance and level of alertness
• Ease of phonation
• Skin color
• Posture and chest shape
• Ventilatory or breathing pattern
• Presence of digital clubbing
• Presence of supplemental O2 and other medical equipment
• Presence and location of surgical incisions
Physical Examination- Observation of
Breathing Patterns
Physical Examination- Auscultation
Breath sounds (normal and abnormal)
https://www.youtube.com/watch?v=TlgP8MzlMaw

https://www.bing.com/videos/search?q=lung+auscultation+sounds&&v
iew=detail&mid=E7CCF2827471CE8F7BCDE7CCF2827471CE8F7BCD&rv
smid=2826716718BFA2FE3EB42826716718BFA2FE3EB4&FORM=VDRV
RV
Physical Examination- Palpation
Diagnostic testing
• Oximetry
• Blood Gas Analysis
• Chest x-rays
• Sputum Analysis
• Flexible Bronchoscopy
• Ventilation-Perfusion Scan
• Computed Tomographic Pulmonary Angiography
• Pulmonary Function Tests
Health conditions
• Please revise the common pulmonary health conditions from page
68-78

• Read the boxes in these pages named “Clinical Tip”

Management
• Pharmacological agents
• Thoracic procedures
• Physical Therapy
Physical Therapy Intervention

• Promoting independence in functional mobility

• Maximizing gas exchange (by improving ventilation and airway

clearance)

• Increasing aerobic capacity

• Respiratory muscle endurance, and the patient’s knowledge of his or

her condition
General intervention techniques

• Breathing retraining exercises

• Secretion clearance techniques

• Positioning

• Functional activity

• Exercise with vital sign monitoring

• Patient education
Dean’s Hierarchy for Treatment of Patients
with Impaired Oxygen Transport
Management Concepts for Patients with
Respiratory Impairments
Bronchopulmonary Hygiene. The following are basic concepts for
implementing a bronchopulmonary hygiene, also known as airway clearance
techniques (ACT), program for patients with respiratory dysfunction:
• A basic understanding of respiratory pathophysiology is necessary
because bronchopulmonary hygiene is not indicated
for certain conditions, such as a pleural effusion or pulmonary
edema.
To develop a proper plan of care, the physical therapist also
must understand whether the respiratory pathology is acute
or chronic, reversible or irreversible, or stable or progressive,
in addition to the potential for alterations in other body systems.
The bronchopulmonary hygiene treatment plan will vary in
direct correlation to the patient’s respiratory or medical
status. The physical therapist must be cognizant of the
potential for rapid decline in patient status and modify treatment
accordingly.
Bronchopulmonary hygiene requires constant reassessment
before, during, and after physical therapy intervention and
on a daily basis.
Bronchopulmonary hygiene may be enhanced by the use of
supplemental O2 and medication such as bronchodilators.
Both O2 and bronchodilators are medications that require a
physician’s order. Additionally, a combination of ACT may
produce a more effective intervention (e.g., breathing assist
techniques with inhaled hypertonic saline).
Tolerance to bronchopulmonary hygiene can be monitored
by pulse oximetry and can help determine the need for
supplemental O2 during therapy sessions.
Cough effectiveness can be enhanced with pain medication
before therapy, splinting (in cases of incision or rib fracture),
positioning, and proper hydration.
Patients with an ineffective cough for secretion removal may
require nasotracheal suctioning. This technique should be
performed only by well-trained therapists.
Devices that provide oscillatory positive expiratory pressure,
such as the Flutter device, can be a good adjunct to manual
vibration/shaking in patients with large amounts of secretions
(e.g., CF, bronchiectasis)
https://youtu.be/K0-AHtJHzw4
Patients with chronic respiratory diseases, such as CF or
bronchiectasis, usually have an established routine for their
bronchopulmonary hygiene. Although this routine may
require modification in the hospital, maintaining this routine
as much as possible optimizes the continuity of care. Be
aware of the usual order of postural drainage positions and
whether certain positions are uncomfortable.
Document baseline sputum production, including certain
times of the day when the patient is most productive.

• Patients with an obstructive pulmonary disorder generally

do well with slow, prolonged exhalations, such as in pursed
lip breathing. A patient may perform this maneuver naturally.
Frequent rest breaks between coughs are also helpful
to prevent air trapping and improve secretion clearance.
• Patients with a restrictive pulmonary disorder generally do
well with therapeutic activities to improve inspiration, such as
diaphragmatic breathing, breathing assist techniques,
and chest wall stretching.
• Many hospitals (especially in the ICU
setting) have incorporated rotational
beds to facilitate frequent changes in
patient positioning.
• Some beds also have modules for
percussion/vibration.
• They should not replace standard
bronchopulmonary hygiene by physical
therapists; they should supplement it.
Activity Progression
• The following concepts should be considered when progressing activity
in patients with respiratory dysfunction:
• Rating of perceived exertion or the dyspnea scale are better indicators
of exercise intensity than heart rate because a patient’s respiratory
limitations, such as dyspnea supersede cardiac limitations. Monitoring O2
saturation also can assist in determining the intensity of the activity.
• Shorter, more frequent sessions of activity are often better tolerated
than are longer treatment sessions. Patient education regarding energy
conservation and paced breathing contributes to increased activity
tolerance.
• A treatment session may be scheduled according to the patient’s other
hospital activities to ensure that the patient is not over fatigued for
therapy.
• Document the need and duration of seated or standing rest periods
during a treatment session to help measure functional activity progression
or regression.
• Although O2 may not be needed at rest, supplemental O2 with exercise
may decrease dyspnea and prolong exercise duration and intensity.
• Bronchopulmonary hygiene before an exercise session may optimize
activity tolerance.