Module 5-Acute Care Pulmonary System-revMay 2015 final change

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The Pulmonary System:

The Pulmonary System Dr. Elisabeth McGee, DPT, MOT, CHT, MTC Dr. Karen Rathgeber, PhD, OTR/L Maureen Johnson, MS, OT/L University of St. Augustine

Pulmonary Defense System:

Lungs are constantly exposed to microorganisms but the lower airways are protected by several defense mechanisms The upper respiratory tract warms, filters, and humidifies inhaled air Air that is breathed in is composed of 78% nitrogen, 21% oxygen, .9% argon, and a smaller % of other elements and compounds Defense mechanisms: cough, secretions (eg. mucous and surfactant), and natural antibodies University of St. Augustine Pulmonary Defense System

Pulmonary Disorder:

Symptoms of pulmonary disorder include: Dyspnea-subjective experience of SOB It is one of the most important symptoms affecting engagement in daily activities, occupational performance, and quality-of-life issues (Most of the time our clients don’t realize that they are SOB) Rapid, forceful, or shallow breathing and use of the accessory breathing muscles Cough-productive or nonproductive Mucous secretions Wheezing University of St. Augustine Pulmonary Disorder

Pulmonary Diseases and Disorders:

Categorized as obstructive or restrictive See Appendix 5.B for a list of common symptoms and terms associated with respiratory disorders University of St. Augustine Pulmonary Diseases and Disorders wikimediacommons

Obstructive Pulmonary Conditions:

COPD -umbrella term for a group of diseases 4 most common forms Emphysema Chronic Bronchitis Asthma Cystic Fibrosis University of St. Augustine Obstructive Pulmonary Conditions

Chronic Obstructive Pulmonary Disorder (COPD):

4 th leading cause of death in the US Progressive disorder defined by chronic airflow limitation that is not fully reversible Inflammatory response results in loss of elastic recoil, increased airway resistance, and reduced expiratory airflow, with a deterioration of pulmonary function A client may have the disease for many years and be asymptomatic, until as much as 50-75% of lung function is lost University of St. Augustine Chronic Obstructive Pulmonary Disorder (COPD) www.ksi.com wikimediacommons

COPD:

Characteristics : tobacco use leading to chronic cough and sputum production hx of exposure to environmental conditions onset in middle age rapid and shallow breathing, dyspnea, anxiety , and deconditioning University of St. Augustine COPD

COPD:

Treatment for COPD : symptom management, prevention of exacerbations, slowing disease progression, smoking cessation, long-term O2 use, meds, prophylactic immunizations, airway clearance techniques, and limiting exposure to communicable diseases, environmental pollution, irritants, and allergens. Exercise can help improve physical activity, increasing exercise tolerance, improving oxygenation, and reducing CO2 retention University of St. Augustine COPD

COPD:

Problems associated with COPD: decreased endurance, limited ability to work, decreased participation in family and social activities, and difficulty sleeping OTs can modify and grade activities and environments to increase independence, education to utilize strategies to conserve energy and breathe more efficiently, as well as coping strategies to deal with anxiety and depression As a last resort, COPD can be treated surgically through lung volume reduction surgery (LVRS), bullectomy , or lung transplantation for end-stage disease University of St. Augustine COPD

Emphysema:

Common type of COPD Recurrent inflammation destroyed walls of alveoli causing large bullae (air sacs) leading to air trapping, loss of elastic recoil, hyperinflation, and decreased O2 exchange Smoking and alpha 1 antitrypsin deficiency are primary risk factors “Pink Puffers”- a redder complexion than those with chronic bronchitis or another type of COPD University of St. Augustine Emphysema wikimediacommons

Emphysema:

Symptoms include: dyspnea on exertion, malnutrition, weight loss, muscle wasting, clubbing digits, decreased chest expansion, wheezing, and rapid shallow breathing with use of hypertrophied accessory muscles “Barrel chest”- lungs hyperinflate and partially expand the rib cage University of St. Augustine Emphysema www.thefreedictionary.com

Emphysema Treatment:

Smoking cessation to protect remaining alveoli Symptom management and slowing disease progression Dietary changes (ie. small but frequent high calorie and high protein meals), adequate hydration to mobilize secretions, O2 therapy, medication (eg. bronchodilators, steroids, antibiotics, mucolytics), immunizations for influenza and pneumonia, and pulmonary rehabilitation Avoid cold, windy weather that may trigger broncospasms Avoid inhaled irritants Avoid public places/people with possible respiratory infections University of St. Augustine Emphysema Treatment

OT Intervention: Pursed Lip Breathing:

OTs can educate on controlled breathing techniques ( eg . pursed lip and diaphragmatic breathing), energy conservation strategies 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 What does pursed lip breathing do 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 When should I use this technique? Use this technique during the difficult part of any activity, such as bending, lifting or stair climbing Practice this technique 4-5 times a day at first so you can get the correct breathing pattern Watch video titled: COPDTV-Pursed lip breathing . https :// www.youtube.com/watch?v=RxPRng3FRD4 University of St. Augustine OT Intervention: Pursed Lip Breathing

Chronic Bronchitis:

One of the most common forms of COPD Airway resistance due to inflammation and edema Like other forms of COPD, it is linked to cigarette smoking Defined as chronic productive cough that lasts for more than 3 months in a year, during 2 consecutive years, that is not caused by another respiratory disorder Mucous hypersecretion, prolonged expiration, and periods of exacerbation that result in lung function deterioration “Blue Bloaters”- Their lips and skin may have a bluish tone due to poor oxygenation (CO2 retention) with presence of edema *“Pink Puffer” on LEFT and “Blue Bloater” on RIGHT University of St. Augustine Chronic Bronchitis wikimediacommons

Asthma:

Reversible or reactive airway disease Increased airway resistance results from obstruction from mucous, smooth muscle constriction, inflammation and bronchial edema Symptoms: wheezing, dyspnea, early morning or nighttime coughing, and SOB with activity Etiology is unknown but may be linked maternal or second-hand smoking, heredity, gender (more common in females), and occupational/environmental exposure Treatment: O2 therapy during acute attacks, warm-up and cool-down during exercise since asthma may be induced by exercise University of St. Augustine Asthma

Asthma: OT Intervention:

M: Practice breathing exs to include whole body stretching P: Wellness education and life style modifications, such as avoidance of triggers ( eg . smoke, pollen, cold air, flowers, stress, sick people), self-management plan for symptom control, medication management, and nutrition counseling S: Social activities, anxiety reduction when symptoms occur University of St. Augustine Asthma: OT Intervention

Cystic Fibrosis (CF):

Chronic disease affecting endocrine glands Thick mucous adheres to airway surfaces that is difficult to clear Diagnosis is usually made in childhood Most die from respiratory failure with an avg life expectancy of 32 y/o By the age of 21, half of clients with CF are hospitalized annually for pulmonary exacerbations University of St. Augustine Cystic Fibrosis (CF)

Cystic Fibrosis: OT Treatment:

M: Daily schedule/routine of ADLs, find interests and keep engaged for motor/sensory development throughout the lifespan, eg . g entle sports, focus on EC/WS P: Cognitive focus on education of disease at age appropriate level S: Typically teens or young adult-age appropriate social media, self-identify/awareness/body image, preparation for worsening of disease process Focus of OT tx : Encourage engagement in routine occupations and lifestyle modifications to increase quality of life and functional capacity and infection control to avoid transmission of organisms University of St. Augustine Cystic Fibrosis: OT Treatment

Restrictive Pulmonary Conditions:

Atelectasis Idiopathic Pulmonary Fibrosis Adult Respiratory Distress Syndrome (ARDS) Pneumonia Pulmonary Edema University of St. Augustine Restrictive Pulmonary Conditions

Atelectasis:

Partial or complete collapse of a lung, usually caused by lung compression or obstruction of a bronchus ( eg . mucous plug, infection, or cancer) Causes include: prolonged bed rest, heavy sedation, obesity, smoking, lung compression by fluid ( ie . pleural effusion) or air in the pleural space ( ie . pneumothorax), or foreign objects obstructing the airway ( eg . swallowing small toys or tumors) that obstruct the airway University of St. Augustine Atelectasis Symptoms: tachypnea, shallow respirations, and SOB Treatment: removing obstructions, ensuring airways remain open, deep breathing with incentive spirometry , supplemental O2, functional mobilization, and bronchopulmonary hygiene www.wikipedia.org

Idiopathic Pulmonary Fibrosis (IPF):

Progressive lung disease with poor prognosis with no cure- life expectancy is 3-5 years after diagnosis Lungs become inflamed, fibrotic, and stiff making ventilation difficult leading to hypoxia and decreased lung function Linked to a hx of smoking S/S include: chest pain, cyanosis, cough, severe dyspnea, pulmonary hypertension (PH), and clubbed fingers and toes Treatment includes: Supplemental O2 therapy, activity tolerance and O2 saturation levels should be closely monitored OT should focus on increasing activity tolerance and EC/WS University of St. Augustine Idiopathic Pulmonary Fibrosis (IPF)

Pneumonia (PNA):

Inflammation of lung tissue Different types of PNA are classified according to their cause (eg. bacterial, viral, fungal) or location (eg. lobes, bronchioles) Two main types of PNA are seen in acute care Community-acquired PNA (CAP) Hospital-acquired PNA (HAP) See Table 5.6 for Comparison of CAP and HAP Supplemental O2 therapy Activity tolerance and O2 saturation levels should be closely monitored Medications include corticosteroids and cholchicine Surgery for a lung transplantation is often indicated Therapist should always use good hand hygiene Keep the client’s HOB at a 30-45 degrees angle to minimize aspiration Ensure that client performs good oral hygiene Increase activity tolerance and functional endurance, strengthening and education on energy conservation strategies University of St. Augustine Pneumonia (PNA)

PNA:

S/S: cough, malaise, dyspnea, tachypnea, fever and chills Treatment: rest, antibiotics, O2 therapy, fluids, mechanical ventilation It may take up to 6 weeks for PNA to clear the lungs University of St. Augustine PNA www.wikipedia.org

Diseases of the Pulmonary Vasculature:

Pulmonary Hypertension (PH) Progressive disease characterized by elevation in pulmonary artery pressure AKA “pulmonary arterial hypertension” due to effects on pulmonary arteries Symptoms: dyspnea, angina, LE edema, heart palpitations, syncope, cyanosis, and fatigue Treatment: lifestyle modifications Low-level aerobic exercise ( eg . walking ) Low-sodium diet Avoidance of high altitudes Flu and PNA immunization Avoidance of pregnancy University of St. Augustine Diseases of the Pulmonary Vasculature

Diseases of the Pulmonary Vasculature:

Pulmonary Embolism Clot, air bubble, or fat particle travels through the venous system into the right side of the heart and out to the pulmonary vessels causing obstruction 90% of PE are due to DVTs of the LEs; may be undetected Three categories of risk factors for PE Hypercoaguability : malignancies , pregnancy, oral contraceptives Stasis : Immobility -prolonged bedrest , long airplane or car trips, casts or external fixators Venous injury : from surgeries or trauma, especially in the LEs ( fxs , THA, TKA) or damage from a previous DVT Symptoms : sudden tachypnea, dyspnea, pleuritic chest pain, syncope, tachycardia, anxiety, restlessness and cyanosis. If treated early, the prognosis is good, but can be fatal if left untreated Prevention is key Early ambulation after surgery, anticoagulation medication, use of antiembolitic stockings or use of LE sequential compression devices Treatment includes: Anticoagulation therapy with heparin and warfarin to prevent LE clots from reaching lungs Thombolytics ( ie . “clot busting” agents ) or embolectomy ( ie . surgical removal of a clot or embolism) University of St. Augustine Diseases of the Pulmonary Vasculature

Pneumothorax:

Air gets between the lungs and chest wall causing a change in intrapleural pressure Air that leaks into the pleural space can cause the lungs to collapse Usually caused by trauma or injury to the chest wall (eg. stab, GSW), broken rib, or surgical procedure that involved the chest wall or lung University of St. Augustine Pneumothorax wikimediacommons Symptoms: chest pain, SOB, tachypnea, fatigue, tachycardia Parenchymal air leak closure is done by suture, staple, ligature, or chemical pleurodesis A chest tube may be inserted to evacuate air

Hemothorax and Pleural Effusion:

Hemothorax Bleeding into the pleural cavity Treatment f ocus is determined by the source of the bleeding A drain may be placed to assess the rate of blood loss An explorative thoracotomy is done if bleeding persists Pleural Effusion Buildup of fluid within the pleural space Related to conditions such as PNA, lung CA, chest trauma, sarcoidosis, PE, TB, CHF, liver disease, or pancreatitis Pleuritic chest pain, cough, SOB, fever, malaise Draining fluid through thoracentesis, placement of a chest tube O2 therapy and meds (diuretics, antibiotics) University of St. Augustine Hemothorax and Pleural Effusion

Empyema:

Collection of pus (containing bacteria, fibrin, and debris) caused by infection in pleural cavity Often associated with bacterial PNA but may be caused by bacteria entering the pleural space from trauma sx, or aspiration PNA Risk of spreading to airway or heart Treated with antibiotics, chest tube to drain pus University of St. Augustine Empyema

Pectus Excavatum:

Congenital and possibly genetic chest wall deformity where anterior chest wall has a sucken-in or concave appearance May compromise cardiac function, lung function, or both Symptoms often do not appear until adolescence during growth spurts Treated surgically unless mild case University of St. Augustine Pectus Excavatum Client wears orthoplastic chest shield to be worn during the daytime to protect the chest after surgical repair Postural training while the client heals Lifting restrictions and avoidance of contact sports are in place for 4 weeks after sx wikimediacommons

Tuberculosis (TB):

Infectious disease spreads by the inhalation of droplets from a cough or sneeze of someone infected Individuals living in poor condition or those with a weak immune system are a greater risk for developing the active form of TB Symptoms: cough, fatigue, weight loss, malaise, and night sweats, and if untreated, can lead to destruction of lung tissue Treatment: antibiotics , chemotherapy, and bed rest OT Treatment Considerations: Precautions: use of an air droplet mask and isolation in a negative pressure room Health care workers are screened annually to monitor exposure University of St. Augustine Tuberculosis (TB)

Sarcoidosis:

Symptoms: fever, cough, dyspnea, fatigue, glaucoma, and weight loss Acute sarcoidosis usually resolves on its own The chronic form is treated with steroids or immunosuppressants University of St. Augustine Sarcoidosis wikimediacommons

Obstructive Sleep Apnea (OSA):

Marked by recurrent periods of breathing cessation for at least 10 seconds, resulting in sleep fragmentation, hypoxia, and hypercapnia, and may lead to cardiovascular disease Treatment includes sleeping with a CPAP machine lowering the danger of CV complications and improvement of quality of life Maintains an open airway Compliance is a concern because many clients cannot tolerate the mask, noise form air, nasal dryness, conjunctivitis, or fascial abrasions OT Interventions: M: Teach proper positioning ( sidelying with HOB elevated 30-45 degrees), walking program P: Educate client regarding lifestyle modifications: losing weight, avoidance of alcohol or sedatives S: Social supports for weight reduction and exercise programs University of St. Augustine Obstructive Sleep Apnea (OSA)

Lung Cancer:

Most common cause of death from CA, one of the leading causes of preventable death Cigarette smoking is responsible for about 90% of all lung cancers Also linked to environmental and occupational carcinogen exposure Air pollution, radon, arsenic, asbestos, polycyclic aromatic hydrocarbon (combustion of fossil fuels), nickel, and exposure to chromates Symptoms: cough, chest pain, dyspnea, weakness and weight loss Client may also have anxiety, depression and decreased endurance for ADLs University of St. Augustine Lung Cancer

Lung Cancer & OT:

M (Motor/Sensory): Walking program, continuation of daily routines P (Process): Education regarding EC/WS, breathing techniques, diets high in antioxidants ( eg . fruits and vegetables) can neutralize free radicals and protect cells from damage associated with CA S (Social/Emotional): Social supports to prepare for changes in medical condition, anxiety control techniques due to ongoing restricted pulmonary function, smoking cessation support groups and programs University of St. Augustine Lung Cancer & OT wikimediacommons

Medical and Surgical Treatment of Pulmonary Conditions:

University of St. Augustine Medical and Surgical Treatment of Pulmonary Conditions wikimediacommons

Medical and Surgical Treatment of Pulmonary Conditions:

Incentive Spirometry Provides visual feedback and encourages long, slow, deep breaths to improve inspiration, lung expansion, respiratory muscle function and prevention of atelectasis Provided after sx to help clear the lungs Clients breaths in as much as possible and holds it before letting it out Piston measures progress (goal marker) Used frequently throughout day University of St. Augustine Medical and Surgical Treatment of Pulmonary Conditions wikimediacommons

Medical and Surgical Treatment of Pulmonary Conditions:

Flutter valve Handheld device used for airway clearance of mucous A small metal ball in the device causes vibrations with exhalations Helps loosen mucous from the lungs so it can be coughed out Good for clients with COPDs such as bronchitis, asthma, or CF University of St. Augustine Medical and Surgical Treatment of Pulmonary Conditions wikimediacommons

Oxygen Therapy for Pulmonary Conditions:

Oxygen Therapy Supplemental O2 used when concentrations of inspired O2 in room air is insufficient for respiration O2<88%-90% Arterial partial pressure of O2<55mmHg C heck with medical staff before adjusting flow rates Cushion with gauze or foam if skin irritation behind ears from 02 tubing Make sure tubing is long enough for functional mobility Avoid combustible material Discourage use of electrical devices (eg. electric shaver) that can spark University of St. Augustine Oxygen Therapy for Pulmonary Conditions

Modes of Oxygen Delivery:

Nasal Cannula : most commonly used; plastic tubing with prongs that are inserted into client’s nostrils; O2 is mixed with room air Face Mask : placed over nose and mouth with ventilation holes on sides; O2 is mixed with room air; limits ability to talk, cough, eat, perform ADLs Nonrebreather Mask : placed over nose and mouth; provides high concentrations of O2; Client breathes in O2 from the attached reservoir bag but exhales through valves, preventing inhalation ( ie . rebreathing) of expired air; limits ability to talk, cough, eat, perform ADLs University of St. Augustine Modes of Oxygen Delivery

Other Modes of O2 Delivery:

Venturi Mask : placed over nose and mouth; provides fixed-concentration of O2 using a high-flow system; limits ability to talk, cough, eat, perform ADLs Tracheostomy collar : O2 delivered through tube inserted into trachea; humidification usually required; adapted tubing may be applied to O2 tank for functional mobility CPAP : Ventilation system that maintains an open airway; often used with clients that have OSA; a mask is attached to a machine that blows air at a prescribed rate BiPAP : Decreased work of breathing by providing positive inspiratory pressure and PEEP via a face mask; check with staff to see if client can be taken off for functional intervention Hyperbaric Chamber : Client receives O2 therapy by entering a specialized chamber; indicated for clients with decompression sickness, embolism, or carbon monoxide poisoning University of St. Augustine Other Modes of O2 Delivery

Ventilation for Pulmonary Conditions:

Mechanical Ventilation Noninvasive Positive-Pressure Ventilation University of St. Augustine Ventilation for Pulmonary Conditions

Pulmonary Rehabilitation:

Multidisciplinary approach Address fatigue, anxiety, breathing, activity tolerance, and confidence to engage in occupations Focuses on increasing functional capacity, client-family education, and psychosocial support to improve quality of life Includes a CV exercise program Flexibility Endurance Strengthening Educating the client about their disease, medication use, lifestyle modification, energy conservation strategies, breathing retraining, stress management, coping strategies, and nutritional counseling University of St. Augustine Pulmonary Rehabilitation

OT Intervention-Pulmonary Rehab:

OT is crucial for designing a self-management program that is appropriately challenging and purposeful to maximize client’s functional capacity Motor/Sensory Graded strengthening and activity tolerance via everyday occupations such as ironing, reaching into cabinets, etc., home modifications, adaptive equipment Process Inco rporate breathing exs into daily activities, client to prioritize and plan daily schedule to incorporate pacing, EC/WS strategies, verbalize understanding of their disease and disease process, instruct in problem-solving strategies, educate on avoiding environmental toxins and minimizing risk of infection ( eg . avoiding crowds or people with respiratory infections ) Social/emotional Support groups via social connections, church groups, Meals-on-Wheels, anxiety reduction techniques and coping skill strategies, engagement in leisure skills, relaxation and stress management techniques (guided imagery, progressive muscle relaxation) University of St. Augustine OT Intervention-Pulmonary Rehab

OT Interventions: Breathing:

Abdominal or diaphragmatic breathing : cue to increase diaphragm motion and decrease use of accessory breathing muscle recruitment This deep breathing decreases dyspnea by ensuring more efficient gas exchange at the alveolar level Exhale during strenuous part of activity Pursed-lip breathing : By pursing the lips, the airway is narrowed, which increases resistance to airflow, increasing positive pressure generated by the airways and lengthening expiration time, which helps the lungs empty Reduces respiration rate and improves quiet breathing University of St. Augustine OT Interventions: Breathing

OT Interventions: Lifestyle Modifications:

Dressing Avoid tight clothing that restricts trunk-chest expansion Use abdominal and pursed-lip breathing into dressing routines Sit to dress and avoid unnecessary steps (eg. don underwear and pants at the same time before standing up to pull them both up) Use adaptive equipment (eg. long-handled reacher, long handled shoe horn, elastic laces, sock aid, or dressing stick) Bathing Sit to bathe Use adaptive equipment ( eg . long-handled sponge, bath chair, hand-help shower) Dry self by donning a terry cloth robe or draping a large towel around body to pat self dry Avoid hot water for bathing and showering because steam and humidity may make it more difficult to breathe; steam can be decreased by leaving the door open or using a ventilation fan University of St. Augustine OT Interventions: Lifestyle Modifications

OT Interventions: Lifestyle Modifications:

Meal Preparation Sit when possible Use an exhaust fan for fumes, which can interfere with breathing Organize materials ahead of time University of St. Augustine OT Interventions: Lifestyle Modifications wikimediacommons

What else….?:

University of St. Augustine What else….?

References:

Salhut , M. (2012). Link found between pneumonia and oral hygiene. Yale Daily News, January 25, 2012 edition. Retrieved from http :// yaledailynews.com/blog/2012/01/25/link-found-between-pneumonia- and-oral-hygiene / YouTube. (2011). COPDTV-Pursed lip breathing . Retrieved from https :// www.youtube.com/watch?v=RxPRng3FRD4. University of St. Augustine References

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