1. Pulmonary System

2. Pulmonary Anatomy UPPER AIRWAYS : A. Nose/Mouth B. Pharynx C. Larynx
2. LOWER AIRWAYS
A. Conducting Airways:
Trachea to terminal
bronchioles
B. Respiratory Unit:
bronchioles, alveolar ducts,sacs & alveoli
3. LUNG STRUCTURES
R & L lungs
4. Pleura
Parietal, Visceral

3. Segmental bronchi -18
R- 10
L- 8 L:
Upper Lobe
Apical/Posterior/Anterior
Lingula
Superior/Inferior Lingula
Lower Lobe
Apical/Anterior/ Posterior
Medial/lateral R:
Middle Lobe
Medial/Lateral

4. Muscles of Inspiration

5. INSPIRATION
Diaphragm ( C3-C5)
External Intercostals ( T1-T12)
Accessory Muscles:
SCM
Upper Trapezius
Scalenes
Serratus Anterior
Pectoralis major & minor
ACTIVE EXPIRATION
Rectus Abdominis ( T10-T12)
Internal Intercostals ( T1-T12)

6. Mechanics of Respiration
Inspiration:
Bony thorax pulls the pleura and lungs outward; diaphragm descends (contracts)
Expiration
Elastic recoil of lung parenchyma pulls the pleura and lungs inward; diaphragm relaxes (ascends)
Resting End Expiratory Pressure (REEP)
pt of equilibrium between the 2 forces; at the end of tidal expiration
Mechanics of Respiration

7. Pulmonary Physiology
Ventilation – movement of gas in and out of the pulmonary system
Respiration – diffusion of gas across the alveolar-capillary membrane

8. Lung Volumes and Capacities

10. OBSTRUCTIVE LUNG DISORDERS- characterized by progressive airflow limitation associated with inflammation of lungs
Example : Chronic bronchitis, Emphysema
Asthma, Cystic Fibrosis, Bronchiectasis
RESTRICTIVE LUNG DISORDERS- characterized by difficulty expanding the lungs causing reduction inlung volumes
Example : idiopathic pulmonary fibrosis,asbestosis, pneumonitis, ankylosing spondylitis

11. GI Motility online (May 2006) | doi:10.1038/gimo73
Figure 4 Comparison of Lung Volumes/Capacities for Restrictive & Obstructive Lung Disorders
GI Motility online (May 2006) | doi: /gimo73

12. Flow Rates
Forced Expiratory Volume ( FEV1):the volume of air expired in the first second of FVC.
Normal : 75% of FVC is exhaled in 1st second
( FEV1/FVC x 100 = 75%)

13. Flow Rates
Forced Expiratory Flow Rate ( FEF) :slope of a line drawn between 2 points ( 25 % and 75%) of exhaled volume on forced vital capacity exhalation curve.
Diminished in persons with obstructive disorder

14. Comparison of Volumes and Flow Rates: Obstructive and Restrictive Lung Disorders

15. RESPIRATION Alveolar Oxygenation :ability of arterial blood to carry
Normal PaO2 = mm Hg
Alveolar Ventilation : ability to remove carbon dioxide
from pulmonary circulation and maintain pH
Normal pH:
PaCo2 : mm Hg
HCo3- : meq/mL

16. Ventilation and Perfusion
Optimal respiration occurs when ventilation and perfusion are matched.
Dead Space: space that is well-ventilated but no respiration ( gas exchange)
Ex. airways, pulmonary embolism
Shunt: there is good perfusion but no gas exchange
Ex. atelectasis

17. Ventilation and Perfusion
Effects of body position in Ventilation and Perfusion
A. Upright
1. Perfusion – gravity dependent , greater at BASE of
lungs
2. Ventilation – apical alveoli fuller than at the base
3. Ventilation – Perfusion ratio ( V/Q)
Apex of lungs : High V/Q
Middle lungfield: Matched V/Q
Base of lungs : Low V/Q

18. Ventilation and Perfusion
Effects of body position in Ventilation and Perfusion
A. Upright
1. Perfusion – gravity dependent , greater at BASE of
lungs
2. Ventilation – apical alveoli fuller than at the base
3. Ventilation – Perfusion ratio ( V/Q)
Apex of lungs : High V/Q
Middle lungfield: Matched V/Q
Base of lungs : Low V/Q

19. Pulmonary Examination
Vital Signs :
Observation:
Peripheral edema and jugular vein distention : Heart failure
Cyanosis
Digital clubbing: chronic hypoxemia
Inspection/Palpation:
- Trachea, accessory ms of ventilation
- Anterior-posterior: lateral dimension : 1:2 ratio
COPD: barreled chest and increased AP dimension
- Thoracic excursion ( base of lungs) from full
inspiration to full expiration : Normal ( 2-3 in)

20. Pulmonary Examination
VOCAL SOUNDS:
Normal transmission of vocal sounds :
* loudest near trachea and mainstem bronchi
* words intelligible but less clear at more distal areas of the lungs
Abnormal transmission of vocal sounds:
- usually heard in fluid-filled areas of consolidation,cavitation or pleural effusion
* Egophony : “E” sounds like “A”
* bronchophony: intense clear sound even at the base
* Whispered Pectoriloquy: whispered sounds heard clearly

21. Pulmonary Examination
PERCUSSION
dull and flat : increased amount of solid matter ( consolidation/tumor)
Hyperresonant – increased amount of air
TACTILE FREMITUS:
VIBRATION FELT AT the chest wall when patient speaks :
Increased – with high amounts of secretions
Decreased – with high amounts of air in the lungs

22. Pulmonary Examination
LABORATORY TESTS
TYPE pH
PaCo2
HCO3-
Causes
Signs & Symptoms
Respiratory Alkalosis
WNL
Alveolar hyperventilation
Dizziness, syncope,tingling,numbness, early tetany
Respiratory Acidosis
Alveolar hypoventilation
Anxiety,restlessness,dyspnea,headache, confusion, somnolence, coma
Metabolic Alkalosis
Bicarbonate ingestion,vomiting,diuretics,steroids,adrenal disease
Weakness, mental dullness,possibly early tetany
Metabolic acidosis
Diabetic, lactic acid,uremic acidosis,prolonged diarrhea
Secondary hyperventilation: Kussmaul breathing,nausea, lethargy, coma

23. Pulmonary Examination
EXERCISE TOLERANCE TEST:
Purposes:
Analysis of arterial blood gas values to gradually increasing exercise
Determination of exercise-induced bronchospasm
Determines need for supplemental oxygen during exercise

24. Pulmonary Examination
EXERCISE TOLERANCE TEST:
GRADED EXERCISE TEST TERMINATION CRITERIA
Maximal SOB
Fall in PaO2 > 20 mmHg or PaO2 < 55 mmHg
Rise in PaCo2 > 10 mm Hg or > 65 mm Hg
Cardiac Ischemia or arrhythmia
Fatigue
Increase in diastolic BP of 20 mmHg; systolic HPN > 250 mmHg; decrease in BP with increasing workloads
Leg pain
Total fatigue
Signs of insufficient cardiac output
Reaching ventilatory maximum

25. Pulmonary Diseases Acute Diseases Bronchogenic Carcinoma
Bacterial / Viral /Aspiration Pneumonia)
Tuberculosis
Pneumocystis Carinii pneumonia
SARS
Chronic Obstructive Diseases
Chronic Bronchitis
Hyaline Membrane Disease
Emphysema
Asthma
Cystic Fibrosis
Bronchiectasis
Chronic Restrictive Disease
Due to alterations in lung parenchyma and pleura
( pulmonary fibrosis, asbestosis, radiation pneumonitis, oxygen toxicity)
Due to alterations in chest wall
( ankylosing spondylitis, scoliosis, pectus excavatum, etc.)
Bronchogenic Carcinoma
Trauma
Rib fracture
Pneumothorax
Hemothorax
Lung contusion
Pulmonary Edema
Pulmonary Embolus
Pleural Effusion
Atelectasis

26. Pulmonary Tuberculosis
Mycobacterium tuberculum infection
Sx/Sy:
Fever
Weight loss
Cough
Hilar adenopathy – enlargement of lymph nodes surrounding the hilum
Night sweats
Crackles
Hemoptysis: blood streaked sputum
Increased WBC : lymphocytes
CXR : Upper Lobe involvement

27. Chronic Obstructive Pulmonary Disease
Airflow limitation due to inflammation of lungs
Sx/Sy:
Cough/hemoptysis
Dyspnea on exertion
Increased RR
Weight loss/anorexia
Increased AP of chest wall
Cyanosis
Posture : elevated shoulder
Adventitious sounds
ABG : hypoxemia, hypercapnea
PFT: decreased FEV1, FVC, FEV1/FVC ratio; Increased FRC and RV,

28. Asthma Increased reactivity of trachea and bronchi to various stimuli
Sx/Sy:
Wheezing, crackles, decreased BS
Increased secretions’
Anxiety
Tachycardia
Tachypnea
Hypoxemia
Hypocapnea
Cyanosis
PFT: impaired flow rates

29. Cystic Fibrosis
Genetically inherited disease caused by thickening of secretions of all excorine glands
Sx/Sy:
Meconium ileus
Frequent respiratory infections ( Staph Aureus/ Pseudomonas)
Inability to gain weight
Positive sweat caloric test
Dyspnea on exertion
Productive cough
Hypoxemia
Hypercapnea
Cyanosis
Digital clubbing
Tachypnea
Use of accessory ms
Crackles, wheezes, decreased BS

30. Bronchogenic Carcinoma
Tumor arising in bronchial mucosa
Sx/Sy:
Unexplained weight loss
Hemoptysis
Dyspnea
Weakness
Fatigue
Wheezing
Pneumonia with productive cough
Hoarseness with compression of laryngeal nerve
Atelectasis or bacterial pneumonia with nonproductive cough

31. Rib Fracture, Flail Chest
Fracture of ribs due to blunt trauma
Sx/Sy:
Shallow breathing
Splinting due to pain ( esp. with deep inspiration or cough)
Crepitation during breathing
Paradoxical movement of flail section

32. Pneumothorax
Air in the pleural space , usually due to lacerated visceral pleura from a rib fracture or bullae
Sx/Sy:
Chest pain
Dyspnea
Tracheal and mediatisnal shift away from injured side
Absent or decreased breath sounds
Hyperresonant with percussion
Cyanosis
Respiratory distress
Confirmed by CXR

33. Pulmonary Edema
Excessive seepage of the fluid from the pulmonary vascular system into the interstitial space
Sx/Sy:
Crackles
Tachypnea
Dyspnea
Hypoxemia
Peripheral edema
Cough with pink frothy sputum
CXR:

34. Pulmonary Embolus:
Thrombus from peripheral venous circulation becomes embolic and lodges in pulmonary circulation
Sx/Sy:
History of DVT, oral contraceptives, recent abdominal/hip surgery, polycythemia,prolonged bed rest
Sudden onset of dyspnea
Tachycardia
Cyanosis
Crackles, decreased BS
Chest pain
Hemoptysis

35. Pleural Effusion:
Excessive fluid between the visceral and parietal pleura
Sx/Sy:
Decreased breath sounds,
Pleural friction rub
-mediastinal shift away from large effusion
Breathlessness
CXR: fuid in gravity-dependent areas

36. Atelectasis: Collapsed, airless alveolar unit Sx/Sy:
Decreased breath sounds
Dyspnea
Tachycardia
Increased temperature
CXR with platelike streaks

37. Chest Physical Therapy
Secretion Removal techniques
Postural drainage
Percussion
Shaking
Cough/Huffing
Tracheal Stimulation
Endotracheal suctioning
Active Cycle of Breathing
Autogenic Drainage
Low Pressure and High
Pressure Expiratory Pressure
Breathing Exercises
DDBE
Segmental BE
Sustained Maximal Inspiration
Pursed Lip Breathing
Functional Training Activities
Aerobic Exercises
Inspiratory Muscle Trainers
Energy Conservation

38. Postural Drainage Positioning for optimal secretion drainage
Indications :
Increased pulmonary secretions
Aspiration
Atelectasis
Duration: 20 min

39. Considerations Prior to Use of Postural Drainage
Precautions to Trendelenburg Positions:
Circulatory :pulmonary edema, CHF, HPN
Abdominal Problems:obesity, ascites,pregnancy,
hiatal hernia, nausea and vomitting,
recent food consumption
Neurologic System : recent neurosurgery,increased
intracranial pressure, aneurysm,
precautions
Pulmonary System : SOB

40. Considerations Prior to Use of Postural Drainage
Precautions to Sidelying Positions:
Circulatory :axillo-femoral bypass graft
Musculoskeletal : humeral fractures,need for hip abduction brace, other situations that make sidelying uncomfortable ( arthritis, bursitis)

41. Percussion Force rhythmically applied with PT’s cupped hands
Indications :
Increased pulmonary secretions
Aspiration
Atelectasis
Duration: 3-5 min

42. Considerations to Use of Percussion and Shaking
Pain made worse by the technique
Aneurysm precautions, hemoptysis
Increased Partial Thromboplastin Time, increased Prothrombin Time, decreased platelet count ( below 50,000) or medications that interfere with coagulation
Fractured rib,flail chest,degenerative bone disease, bone metastases

43. Shaking Bouncing maneuver applied to the ribcage throughout EXHALATION
Indications :
Increased pulmonary secretions
Aspiration
Atelectasis
Duration:5-10 deep inhalations ( > 10 risks hyperventilation)

44. Coughing and Huff
COUGH: must be done in upright position, effective for major central airways
HUFF : effective in patients with collapsible airways ( COPD); prevents high intrathoracic pressure causing premature airway closure

45. Assisted Cough
Used when patient’s abdominal ms cannot generate effective cough (SCI)
PT’s hand below the subcostal angle; pushes inward and upward as patient attempts to cough

46. Endotracheal Suctioning
14 French gauge – Adult
10 Fr for older children
5-6 Fr for younger children and infants
Force: 120 mmHg
Procedure: when resistance is felt at carina,catheter is rotated and withdrawn
Time : 10-15s
Complications:
Hypoxemia
Bradycardia
Tachycardia
Hypotension or HPN
Increased intracranial P
Atelectasis
Tracheal damage
infection

47. Active Cycle of Breathing
The ACBT is an airway clearance technique , using different types of breaths to shift secretions from peripheral to central airways.
RELAXED BREATHING
HUFF 2- 3 X
(+ OR – COUGH)
DEEP BREATHING 3s hold, 3-5X
( Thoracic expansion)
RELAXED BREATHING

48. Autogenic Drainage Used to clear peripheral secretions
Time spent in each phase is based on where the patient feels the secretions
Phases:
The Unstick Phase : quiet breathing at low lung volumes (for peripheral airways)
The Collect Phase: breathing at low to mid lung volumes ( for middle airways)
The Evacuation Phase: breathing at mid to high lung volumes ( to clear central airways).

49. Positive Expiratory Pressure
Low Pressure PEP: uses expiratory resistance via face mask to assist in removal of airway secretions
Uses mm HG
Sitting, patient breathes at TV with mask for 10x, then coughs
High Pressure PEP uses mm Hg
For patients with unstable airways,who can exhale more with the mask
After breathing 10x with mask, huff with mask in place

50. Breathing Exercises DDBE ( semifowler’s position) Segmental Breathing
Sustained Maximal Inspiration(SMI)
For acute situations, posttrauma pian, acute lobar collapse, post-operative pain
Procedure: Inspire thru pursed lips, hold for 3s
Pursed Lip Breathing
Decreases RR, dyspnea
Increases TV , relaxation, gas exchange
For patients with COPD
DDBE ( semifowler’s position)
Segmental Breathing
For hypoventilated areas
For pleuritic, incisional or posttrauma pain
Procedure: apply gentle pressure before inhalation, pt breathes against resistance

51. Aerobic /Conditioning Exs
Same guidelines as in Cardiovascular Aerobic Exercises
Intensity : 40-85% ( MHR-RR)+ RR
Frequency: min, 3-5x/wk

52. Inspiratory Muscle Training ( IMT)
Used to increase strength and endurance of diaphragm
Loads the ms by breathing through series of grades aperture openings
Use Aperture opening with 30-40% Maximum Inspiratory Pressure ( MIP)
Patient breathes into the device for 15 minutes

53. Pacing/Energy Conservation
Pacing – spread out the metabolic demands of activity over time ( ex. paced breathing)
Energy conservation – careful planning of activities

54. SURGICAL MX OF LUNG CONDITIONS
Pneumonectomy: removal of lung
Lobectomy : removal of lobe
Segmental resection: removal of a segment
Wedge resection: removal of a portion of segment of the lobe
Lung Volume Reduction Surgery: removal of large emphysematous areas of the lung

55. SURGICAL MX OF LUNG CONDITIONS
Pertinent Post-operative complications:
Increased temperature
Increased WBC
Change in breath sounds
Abnormal CXR
Decreased expansion of thorax
SOB
Change in cough and sputum production

56. ICU EQUIPMENT MECHANICAL VENTILATION CHEST TUBES IVs Arterial Lines
NO contraindications to PT
CHEST TUBES
If dislodged, cover defect and seek assistance
IVs
No contraindications to PT
Arterial Lines
If dislodges, apply pressure to or above the arterial insertion
Supplemental Oxygen
Indicated if SaO2 is less than 88% or PaO2 is less than 55 mmHg
Must be prescribed by the doctor

57. BRONCHODILATOR AGENTS
MEDICAL MX
Drug
Effects
SideEffects
BRONCHODILATOR AGENTS
Beta-2 agonists ( sympathomimetics)
Ex. ventolin, Alupent, Maxair,Albuterol
Bronchodilation
Increased HR & BP
Anticholinergics
(ex. Atrovent)
Bronchodilation by inhibiting the parasympathetic NS
Increased BP and HR
Methylxanthines
(Aminophylline , Theophylline)
Muscle relaxation
Increased BP,H
Arrhthmias
GI distress
Nervousness
Headaches, seizures
* Monitor for toxicity by frequent blood sampling

58. MEDICAL MX Drug Effects SideEffects ANTI-INFLAMMATORY STEROIDS
Vanceril,Azmacort, prednisone, Solumedral
Decreased inflammation
Decreased mucosal edema
Reduce Airway activity
Increased BP, sodium retention, ms wasting, osteoporosis, GI irritation, hypercholesterolemia
Leukotriene –receptor Antagonist
Ex. Montelukast-Singulair
Blocks leukotrienes relased suring an allergic reaction
Inhibits airway edema and smooth ms contractions
-----
Cromolyn Sodium
Prevents release of mast cells
Prevents exercise-induced bronchospasm
Hoarseness, cough
Dry mouth, bronchial irritation