Independent Learning PackageAcute2005

ACUTE STREAM Independent Learning Package © Division of Physiotherapy The University of Queensland 2005 This manual has been compiled by Ms Marie Steer Updated 2005 by Robyn Cupit © -Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005

TABLE OF CONTENTS Acute Stream Programme ................... ................................ .....................................3 Study Timetable .................................. ................................ .....................................4 Start Up Test ....................................... ................................ .....................................5 Common Term and Abbreviations...... ................................ .....................................14 Normal Values .................................... ................................ .....................................19 Common Drugs ................................... ................................ .....................................20 Respiratory Assessment ...................... ................................ .....................................25 Auscultation ........................................ ................................ .....................................37 Chest X Ray ........................................ ................................ .....................................39 Arterial Blood Gases........................... ................................ .....................................42 Respiratory Conditions - Chronic ....... ................................ .....................................46 Chest Trauma ...................................... ................................ .....................................57 Cardiac Conditions.............................. ................................ .....................................60 Surgical Pre-operative Assessment .... ................................ .....................................67 Surgical Post-operative Assessment ... ................................ .....................................69 Abdominal Surgery............................. ................................ .....................................78 Vascular Surgery................................. ................................ .....................................105 Cardiac Surgery .................................. ................................ .....................................112 Thoracic Surgery................................. ................................ .....................................121 Head and Neck Surgery ...................... ................................ .....................................126 Mastectomy......................................... ................................ .....................................132 ICU...................................................... ................................ .....................................137 Medications......................................... ................................ .....................................148 Semi / Unconscious Patient ................ ................................ .....................................178 Case Management............................... ................................ .....................................185 Burns ................................................... ................................ .....................................188 Diabetes............................................... ................................ .....................................193 Renal Failure....................................... ................................ .....................................197 Amputees ............................................ ................................ .....................................202 © - Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005 2

ACUTE STREAM PROGRAMME : This Independent Learning Package (ILP) has been designed to be completed over the four (4) weeks of your Acute Placement. With the variety of settings in which the Acute experience is offered, this ILP aims to provide guidelines for the medical and surgical management. It is important to understand the rationale for the guidelines and to appreciate the reasons for any differences should they occur. If, having reflected on the differences, you are not clear as to the rationale, it would be appropriate to discuss the information with your supervisor. The programme needs to be completed at the end of the four (4) week experience. There is a suggested study outline provided to ensure that you complete the programme. With the number of topics to be covered it is essential that you are disciplined and allocate time to cover the material. If you are having difficulty understanding a section, ensure you have reviewed the relevant lectures before asking your supervisor for some assistance. They are aware of the material that has been covered in the pre-clinical training. Although the Study Programme Guidelines are provided, you need to remain flexible, dependent upon the mix of your caseload. Relevant material needs to be prepared in advance. You already have your pre-clinical information and therefore should be able to apply your knowledge and principles even if you have not covered a topic in your study programme. The Case Management exercise is one that requires you to use your problem solving skills and be able to provide a rationale for your priority decisions. In view of the various settings this is one exercise that will need to be discussed with your supervisor who will be able to provide you with relevant feedback regarding the decisions you have made ACKNOWLEDGEMENTS This Independent Learning Package is the the result of the teaching and experience of a number of past and present Acute staff. I wish to acknowledge the contribution of Mrs Bernadette Pozzi, Ms Julie Adsett, Dr Jennifer Paratz and Mrs Robyn Cupit. © - Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005 3

STUDY TIMETABLE WEEK 1 Monday Respiratory Assessment Auscultation Chest X Ray Tuesday Arterial Blood Gases Surgical Pre and PostOperative Assessment Wednesday Acute Respiratory Conditions Chronic Respiratory Conditions Chest Trauma Thursday Abdominal Surgery Friday Vascular Surgery Amputees WEEK 2 Monday Cardiac Surgery Thoracic Surgery Tuesday Catch up Day Wednesday Medications Cases 1 – 3 Thursday Head and Neck Surgery Mastectomy Friday ICU WEEK 3 Monday Semi / Unconscious Patient Tuesday Case Management Wednesday Medications Cases 4 – 6 Thursday Burns Friday Diabetes Renal Failure WEEK 4 REVISION © - Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005 4

START UP TEST The aim is for you to work through the following situations and cases to demonstrate how your pre-clinical training is a basis for your successful performance in Clinic. It is vital that you understand the information tested here. This information is considered essential for you to be adequately prepared for your first day in the Acute Unit. If you are unable to answer the questions in the appropriate detail, you will need to revise your pre- clinical lectures and attempt the question again. It is appropriate for Clinical Supervisors to expect that having completed this material prior to commencing the Unit, that this knowledge has been gained. Having completed the cases, review the checklist provided by the profession at the end of the start up section, and be sure you are adequately prepared to undertake the start up exam on day one of your unit and to perform at a basic level of competence. Revision: Review your PHTY 3250 /7825 notes on: • Respiratory Assessment and Assessment of the Surgical Patient • Chest Xray • Auscultation • Interpretation of Blood Gases Complete the following case presentations and check your answers at the end of the section. PRESENTATION 1 You are reviewing the chart of a bronchiectatic patient who has been referred to physiotherapy for treatment of her chest infection. ¾ Discuss the key points or information you would look to obtain from the patient’s medical chart. ¾ Indicate why this information is important © - Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005 5

PRESENTATION 2 Your CAL patient is admitted with ↑↑ SOB and an inability to cope at home alone. His ABG’s are as outlined : FIO2 - 0.30 via a multi-vent mask pH - 7.31 59 pCO2 - 30 HCO3 - 60 pO2 - ¾ Interpret the ABG’s ¾ Discuss the breathing pattern that your patient may be demonstrating ¾ Outline the signs and symptoms of Type I and Type II Respiratory Failure PRESENTATION 3 Mrs Brown is a 76 year old CAL patient admitted with a ( R ) ML bronchopneumonia. As part of your assessment you are reviewing her chest X Ray. ¾ Outline using headings the steps you would take in this review. ¾ What classical sign would demonstrate the involvement of the ( R ) ML. PRESENTATION 4 Mr Jones has returned to the Ward from the High Dependency Unit (HDU) Day 1 post AAA Repair. He received initial post op physiotherapy in the Unit. He had poor pain control with pain at rest 6/10 and with movement 8/10. His BP had been in the range 140 – 175 75 – 90 . The APS (Acute Pain Service) reviewed his pain relief and increased the range he was able to receive via the epidural. He had an episode of chest pain this am and an ECG and serial cardiac enzymes were ordered ¾ Discuss any results or information you would wish to know prior to treating this patient and the reasons this information is needed ¾ Provide the range of normal values for these results ¾ Explain the precautions you would take prior to and during mobilisation of this patient ¾ Outline the signs that you would monitor that may indicate the patient was having difficulty during the walk © - Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005 6

ANSWERS TO PRESENTATIONS PRESENTATION 1 INFORMATION IMPORTANCE History of the presenting complaint Indication of the severity of the infection Cough ↑ or ↓ or normal SOB ↑ or normal Indication of the course of the disease Sputum Change in colour process quantity or quality Current status compared to usual baseline Exercise Tolerance and an indication of the aim for discharge regarding mobility Medications Regular medications used and any changes with this admission Chest X Ray + / - Report The need to co-ordinate treatment with use of bronchodilators ABG result Steroid use and the potential for Respiratory or Lung Function tests contraindications to physiotherapy techniques Sputum Culture Specific lung segments involved Lung changes as a result of the disease process Indication of the patient’s current level of function Indication of either the obstruction or restriction the patient experiences. If a post bronchodilator test is performed there is an indication of the reversibility of the obstruction. The organism that has caused the infection and the need for any additional precautions Plan of Medical Management Indication of patient’s LOS PRESENTATION 2 Interpretation of ABG’s pH 7.35 – 7.45 ↓ acidosis PaCO2 35 – 45 mm Hg ↑ acidosis HCO3 PaO2 22 –28 ↑ alkalosis 80 – 100 ↓ severe hypoxaemia Partially Compensated Respiratory Acidosis with severe hypoxaemia © - Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005 7

PRESENTATION 2 (Continued) Breathing Pattern The patient would be demonstrating an ↑ in the work of breathing (WOB) with a utilisation of accessory muscles, with elevation of the shoulders and potentially stabilisation of the upper limb to provide fixation for reversed origin and insertion. In view of his chronic respiratory condition, the lower chest wall movement is likely to be minimal or nil with vertical or piston movement most obvious – demonstrating rigidity RESPIRATORY FAILURE TYPE I TYPE II Agitated Vasodilation Confusion Bounding peripheral pulses Plucking at the air or sheets Flushed appearance ↓ PaO2 ↑ RR, PR, BP ↑ PaCO2 Late sign – drowsy (with ↑ PaCO2) coma PRESENTATION 3 Review of Chest Xray ¾ Patient Information ¾ Type of film and position ¾ Exposure ¾ Centering or rotation ¾ Soft tissue structures ¾ Bony structures and outline ¾ Trachea, mediastinum and hilar region ¾ Heart size, heart borders and cardiophrenic angles ¾ Diaphragm border and levels and costophrenic angles ¾ Lung fields Involvement of the ( R ) ML is demonstrated When there is loss of the ( R ) heart border such that the margin is not clearly differentiated. If you were unable to answer this question or need to clarify the aspects being considered in more detail, review the section on Chest X Rays in this ILP before commencing clinic as this information will be needed DAY 1. Review 3rd year chest x ray tutorial notes. © - Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005 8

PRESENTATION 4 Result or information required prior to treatment - Hb level Reason the information is needed - ¾ Surgery directly to the vascular system - ↑ potential for blood loss ¾ If Hb is ↓ - activity requiring effort may → ↑ breathlessness - patient may be lethargic - may feel light-headed on standing or faint during the walk - a blood transfusion may be planned ¾ If Hb < 8 gm / 100 ml patient will not be mobilised due to the reasons outlined above Normal Range Males - 14 - 16 gm / 100 mls Females - 12 - 15 gm / 100 mls Result or information required prior to treatment - regarding chest pain ¾ the interpretation of the ECG by medical officer ¾ serial cardiac enzymes Reason the information is needed - ¾ ECG interpretation - ensure patient has not had an MI ¾ Serial cardiac enzymes - will reveal changes in enzyme levels over time if the patient has had an MI Normal Range ¾ ECG - no ST elevation; no T wave changes; no Q waves ¾ Cardiac enzymes : SCPK - serum creatine phophokinase LDH - lactic dehydrogenase SGOT - serum glutamic-oxaloacetic transaminase ADDITIONAL INFORMATION Enzyme Appearance Peak Return In Serum Activity to normal SCPK 4 - 8 hrs 18 – 24 hrs 3 – 4 days Released with muscle injury or necrosis not specific for MI CK - Males - 30 - 250 U / l - Females - 30 - 180 U / l LDH 8 - 24 hrs 2 - 3 days 7 - 10 days Normal values for absolute amounts vary by laboratory and technique utilised so look for the normal ranges for the institution. © - Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005 9

Result or information required prior to treatment - Check BP Reason the information is needed - ¾ may be ↓ with blood loss intra-operatively ¾ influenced by epidural that can cause vasodilation Normal Range ¾ Need to know normal range for the patient, look at the measure obtained on admission or at pre-admission clinic Precautions prior to and during mobilisation of this patient ¾ Subjectively ask about pins and needles , tingling, numbness or heaviness of their legs - MANDATORY FOR SAFETY ¾ Objectively • if needed assess sensation – checking light touch in a dermatomal distribution • assess muscle strength – repeated inner range quads contraction and hip and knee flexion look at the quality, range and eccentric control of the movement • vitals signs should have been checked at the beginning of Rx . If indicated BP can be checked prior to transferring the patient Patient transfer and mobilisation • Organise the equipment so all attachments are on the one side of the bed • Organise chair prior to moving the patient if the patient is to sit out of bed and have a forearm support frame (FSF) ready • First walk have a second person present in view of the large surgery and aiming to minimise patient’s discomfort • Ensure you are close to the patient to control or facilitate the movement • Clear instructions to the patient and assistant regarding movement • Sit the patient on the side of the bed for a few moments to allow BP to settle • Question the patient regarding light-headedness and encouage the patient to move his ankles to assist the blood return to the head and some slow deep breaths • When shoes are being put on ensure one person is responsible for the patient • Remain close to the patient at all times particularly on standing the patient • Ensure the patient is stable before organising the FSF into position • Remain close to the patient and utilise the sacrum as a key point of control • Talk to the patient while mobilising to monitor their level of awareness These steps will ensure safety with mobilisation. You must follow them through for safe handling to be demonstrated © - Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005 10

Signs that indicate the patient may be having difficulty during the walk ¾ ↑ sweating ¾ Change in colour - patient becomes pale ¾ ↓ or slowing of verbal response ¾ Staring or fixed gaze prior to rolling eyes back ¾ ↓ SpO2 Check list for Further Preparation Required by Facilities for Day 1 11 © - Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005

Background Theory The student should know; • definitions of FEV1 , FVC, FEV1 /FVC and differentiation of obstructive and restrictive Volume –Time curves • Normal values Hb, WBC, Platelets • Normal values T,BP, P, RR, Sats and BSL.’s • Names of major abdominal surgeries and respective incision lines • Gravity Assisted Drainage Positions (PD) Assessment The student should be able to : • List respiratory symptoms eg SOB, wheeze, pain, cough, sputum and haemoptysis • List accessory muscles of ventilation • Describe and palpate for a ventilatory pattern • Understand the questions to ask about a patient’s home situation • Understand the effects of body position on assessment findings • Observe an ICC for swinging, bubbling, draining • Auscultate using surface anatomy landmarks • Describe a calf check and the signs of a DVT • conduct a 6 minute walk test (6MWT) and should know: • flow rates achievable through various oxygen delivery devices • to run nebuliser masks on 6L/min • why low FiO2 < 28% is used in COAD patients • the definitions of acute coronary syndromes Interpretation The student should know: • Signs of left vs right sided heart failure • Basic groups of medications - beta 2 agonists - steroids- inhaled,oral,IV - analgaesics - diuretics - antibiotics - anti hypertensives - digoxin, amiodarone © - Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005 12

• oxygen sats to be kept above 85% during mobilisation to avoid PA vasocinstriction causing pulmonary hypertension • the relationship between long term steroid use and osteoporaosis • contrindications for percs and vibs - especially osteoporosis Treatment Planning The student should be able to discuss • deep breathing exercises suitable for a range of patients including post op with atelectasis • ACBT • circulatory exercises • indications for incentive spirometry • the component parts of a home exercise program for a patient with chronic respiratory disease • a safety check list prior to mobilising a patient for the first time. • The use of PCA analgesia Safety The student should know: • to always mobilise patients with epidural in situ with 2 people • not to disconnect an ICC on wall suction without prior permission from the medical team • the ideal pressure ranges for PEP therapy. • contraindications for TENS to the chest wall • precautions for handling ICC’s Common Terms and Abbreviations used in Medical/Surgical Wards 13 © - Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005

Common Prefixes and Suffixes angio- artery/blood vessel brachio- arm cardio- heart chole- gall bladder colo - colon cranio- skull cysto/vesico- bladder entero- intestine gastro- stomach haemo- blood hepato- liver hystero- uterus lap- abdomen lith- stone e.g. cholelithiasis mast- breast myo- muscle nephro- kidney orchido- testicle pneumo- lung/air procto- anus pyelo- pelvis of kidney pyloro- pylorus pyo- pus thoraco- thorax -aemia condition of the blood e.g.. septicaemia -ectomy cutting out e.g. cholecystectomy -gram the resultant x-ray picture e.g. arteriogram -ography graphic description by injecting organ with radio-opaque dye and then taking x rays eg arteriography. -oma tumour e.g. sarcoma -orraphy suturing or stitching e.g. herniorraphy -oscopy to look or inspect using a special instrument e.g. bronchoscopy. -ostomy to make an opening e.g. colostomy -otomy to cut or make an incision e.g. laparotomy -plasty remodelling or refashioning e.g. pyloroplasty -resection cutting out of a part e.g. bowel resection. Common Abbreviations used in Charts. General Information BNO bowels not open DOA date of admission/ dead on arrival E/O excision of FFFT fits, faints, funny turns FH family history HNPF has not passed flatus LMO local medical officer NBM nil by mouth OT operating theatre, occupational therapy. OCP oral contraceptive pill © - Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005 14

PreAC pre admission clinic PH past history PMH past medical history PSH past surgical/social history R/O removal of S/A same address SPA surgical preparation area SW social worker TPR temperature, pulse, respiration Symptoms AJ/KJ ankle/knee jerk AO BP ankle oedema CVP DTR blood pressure HS ICC central venous pressure IDC IgG deep tendon reflexes JJ JVP heart sound LIF RIF intercostal catheter LUQ RUQ indwelling catheter PERLA PND immunoglobulin G PR RR jaw jerk SAR SJ jugular venous pressure SO SOA left iliac fossa ) referring to SOB SOBOE right iliac fossa ) localisation of SPPS TML left upper quadrant ) abdominal pain right upper quadrant ) pupils equal, round, react to light, accommodate paroxysmal nocturnal dyspnoea, post nasal drip pulse rate respiratory rate superficial abdominal reflex supinator jerk sacral oedema swelling of ankles shortness of breath shortness of breath on exertion stable plasma protein solution trachea midline Investigations ABG arterial blood gases AFB acid fast bacilli APTT activated prothrombin time test (activated partial thromboplastin time) BSL blood sugar level BUSE blood urea and serum electrolyte CAT computerised axial tomography CE cardiac enzymes CXR chest X-ray C/S culture and sensitivity © - Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005 15

ECG electrocardiogram EEG electroencephalogram ELFTS electrolyte & liver function tests EMG electromyogram ESR erythrocyte sedimentation rate FBC full blood count FBS fasting blood sugar FRC functional residual capacity GTT glucose tolerance test Hb haemoglobin INR international normalized ratio LFT liver function test LP lumbar puncture MBC maximum breathing capacity MRI magnetic resonance imaging MV minute volume NMR nuclear magnetic resonance PCV packed cell volume, haematocrit PTT prothrombin time test RBC red blood cell RFT respiratory function test RV residual volume S/M/C/S sputum microbiology culture and sensitivity TV tidal volume VC vital capacity WBC white blood cell Diagnosis D diagnosis DD differential diagnosis PD provisional diagnosis Frequency of Treatment bd x2 daily tds x3 daily qid x4 daily mane morning nocte night prn as required Q2h, Q3h, every two hours, 3 hours © - Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005 16

Conditions abdominal aortic aneurysm acute bacterial endocarditis AAA atrial fibrillation ABE aotic incompetence AF aortic stenosis AI atrial septal defect AS aortic valve regurgitation / repair / replacement ASD brachial artery graft AVR bundle branch block (R or L) BAG basal cell carcinoma BBB bronchiectasis BCC bilateral salpingo-oophorectomy BrX coronary artery bypass graft BSO coronary artery disease CABG chronic airflow limitation CAD congestive cardiac failure CAL cystic fibrosis CCF chronic obstructive airways disease CF cerebrovascular accident COAD disseminated intravascular coagulation / coagulopathy CVA end stage renal failure DIC fever of unknown origin ESRF gastro-intestinal tract FUO heart failure GIT hypertension HF ischaemic heart disease HT internal mammary artery IHD left femoral arteriogram IMA left heart/ventricular failure LFA left inguinal hernia LHF/LVF lumbar sympathectomy LIH left ventricular hypertrophy LS myocardial infact LVH mitral stenosis / multiple sclerosis MI mitral valve regurgitation / repair / replacement MS premature atrial contraction MVR paroxysmal atrial tachycardia PAC pulmonary embolism PAT pulmonary hypertension PE pelvic inflammatory disease/prolapsed intervertebral disc PHT pyloric stenosis PID pulmonary thrombo- embolism PS peptic ulcer disease PTE pyrexia of unknown origin PUD premature ventricular contraction PUO peripheral vascular disease PVC radial artery graft PVD RAG © - Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005 17

RF renal failure RHF right heart failure RIH right inguinal hernia SBE subacute bacterial endocarditis SCC squamous cell carcinoma SOL space occupying lesion SR sinus rhythm SVG saphenous vein graft SVT supra ventricular tachycardia T&A tonsillectomy and adenoidectomy TAH total abdominal hysterectomy TCC transitional cell carcinoma TEA thrombo-endarterectomy TLA trans lumbar aortogram TUR trans urethral resection TUR (P) trans-urethral resection of the prostate URTI upper respiratory tract infection UTI urinary tract infection VEB ventricular ectopic beat VF ventricular fibrillation VPB ventricular premature beat VSD ventricular septal defect VT ventricular tachycardia VV varicose veins Intensive Care ARDS adult respiratory distress syndrome CPAP continuous positive airways pressure IMV intermittent mandatory ventilation IPPV intermittent positive pressure ventilation IRV inverse ratio ventilation MOSD multi-organ system dysfunction PCV pressure controlled ventilation PEEP positive end expiratory pressure PS pressure support SIMV synchronized intermittent mandatory ventilation SIRS systemic inflammatory response syndrome Hospital Departments CCU coronary care unit CSD central sterilising department CSSD central sterilising supply department ICU intensive care unit ICW intensive care ward RIU respiratory investigation unit © - Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005 18

NORMAL VALUES Blood Gases Pa 02 85 - 100 mm Hg (11-13 kpa) Pa C02 35 - 45 mm Hg (4.5 - 6.0 Kpa) pH 7.35 - 7.45 HC03- 22 - 28 meq/l Serum Electrolytes Na+ 140 - 145 mlq/l K+ 4.0 - 4.5 mlq/l Cl- 105 meq/l Urea 20 - 40 mgm % (3.0-7.5) Creatinine .06 - 0.12 HC03- 24 - 27 mlq/l Blood Values Male Female Hb 14 - 16 gm / lOO ml 12 - 15 gm / lOO ml PCV 40 - 54 % 36 - 47 % RBC 5 - 6 mill / c. mm. 4 5 - 5.5 mill / c. mm. WBC 4000 - lOOOO / c.mm. ( 4 - 10 ) Platelets 150,000 - 400,000 / c.mm ( 150 - 400 ) Bleeding Time 2 - 5 mins. Whole blood clotting time 4 - 10 mins ESR 15 min in 1 hour. INR 2.0 - 3.0 for treatment of DVT APTT 22 - 38 secs 60 - 100 secs if heparinized © - Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005 19

COMMON DRUGS - REFERENCE GUIDE Groups Product Name Generic Name Analgesics Pethidine Methodone Narcotics Fentanyl Oxycodone Morphine Morphine Mixed Analgesics Omnopon Codeine / Paracetamol Simple Analgesics Physeptone Local Analgesics Endone Paracetamol MS Contin Asprin Anti-inflammatory Codeine Phosphate Asprin Non Steroidal Anti- Doloxene Bupivacaine Inflammatories Digesic Capadex Lignocaine NSAID’s Panadeine For OA, RA, SLE, Steroids Panadol CollagenDisorders, Aspirin allergic states (asthma Solprin dermatitis) Marcain Naproxen Lignocaine Piroxicam Xylocaine Ibuprofen Naprosyn Diclofenac Feldene Sulindac Brufen Indomethacin Toradol Voltaren Hydrocortisone Clinoril Dexamethasone Indocid Dexamethasone Orudis Methylprednisolone Asprin Hydrocortisone Decadron Dexmethsone Depo-medrol Prednisone / Prednisolone © - Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005 20

Anti-ulceratives Tagamet Cimetidine Zantac Ranitidine H2 Receptor Antagonist Pepcidine / Pepcid Famotidine & S/T Rx , maintenance & prevention duodenal & Losec Omeprazole gastric ulcers Zoton Iansoprazole Proton pump inhibitors, Prepulsid Cisapride Reflux oesophagitis & Mylanta ulcers May be used in conjunction with oral or Gastroparesis / Reflux IV steroids ( anti- inflammatories ) Antacid Salbutamol Respiratory Salbutamol Terbutaline β2 Agonists Ventolin Fenoterol Short-acting Respolin Bricanyl Ipratropium Bromide Anticholinergic Berotec Long-acting β2 Agonist Salmeterol Symptom Controller Atrovent Eformoterol Xanthine Derivatives Serevent Theophylline Mast Cell Stabiliser Oxis, Foradile Theophylline Inhaled Corticosteroids Theo-Dur Sodium Cromoglycate Combination Medications Nuelin Nedocromil sodium Aminophylline Rheumatoid Drugs Beclomethasone Intal Beclomethasone Slow Acting Anti Tilade Budesonide Rheumatoid Drugs Fluticasone Becotide / Becloforte ( SAARDS ) Aldecin Atrovent + salbutamol Pulmicort Flixotide + serevent Anti-emetics Flixotide Used with analgesics, anti- Combivent inflammatory & cytotoxics Seretide Penicillamine Gold 50 / Gold Salts D- Penamine Hydroxychloroquine Bisulquin sulphate Plaquenil Chloroquine Nausea & Vomiting Maxalon Metoclopramide Stemetil Prochlorperazine Zofran Ondansetron © - Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005 21

Cardio-vascular drugs Rx angina, arrythmias, cardiac failure, HT Diuretic Non K+ sparing lasix K+ sparing moduretic frusemide (Thiazide) midamor / amizide amiloride hyrochlorothiazide Glyceryltrinitrate anginine tridil (S/L) Liquid anginine (infusion) Nitrates transiderm nitradisc (Topical) nitrobid /nitrolate ointment imdur isosorbide mononitrate –O isordil isosorbide dinitrate (S/L) Calcium Channel Blockers isopten (arrhythmia) verapamil HT, Angina cardizem diltiazem plendil felodipine norvasc amlodipine adalet nifedipine ACE Inhibitors capoten captopril HT, CHF with diuretic renitec enalapril accupril quinipril monopril fosinopril coversyl perindopril zestril / prinivil lisinopril β Blockers inderal propranolol HT betaloc / lopressor metoprolol tenormin atenolol α adrenergic visken pindolol Cardiac Glycosides minipress / pressin prazosin (AF & rapid vent. rate) digoxin / lanoxin adrenaline β stimulants dobutrex dopamine isuprel dobutamine Anti-arrhythmics alphapress / apresoline isoprenaline AngiotensinII Receptor catapres hydralazine antagonist aldomet clonidine methyldopa cordarone xylocard amiodarone lignocaine avapro irbesarten © - Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005 22

Anticonvulsants Epilim Sodium Valproate Dilantin Phenytoin Diabetic Drugs Tegretol Carbamazepine Phenobarbitone Clonazepam IDDM Rivotril Insulin Preparations Oral Hypoglycaemics Insulin 2 Neutral NIDDM Humulin Chloropropamide Actrapid Metformin Antibiotics Monotard Mixtard Glibenclamide Penicillins Glipizide Diabenese Cephalosporins Diabex Amoxil, Moxacin Diaformin Tetracyclines Glucophage Cephalexin Aminoglycosides Daonil Cefotaxime Minidiab Ceftazidime Cephalothin Flucloxicillin Cefoxitin Ticarcillin Ceftriaxone Amoxycilline Ampicillin Doxycycline Gentamicin Keflex Tobramycin Amikacin Keflin Amphotericin Mefoxin Nystatin Rocephin Nystatin Mysteclin Erythromycin Vibramycin Vancomycin Metronidazole Anti fungal Nilstat Other Mycostatin Sulphadiazine Bactrim Flagyl © - Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005 23

Cytotoxics cycloblastin cyclo-phosphamide endoxan-asta cyclo-phosphamide ( Immunosuppressive methotrexate tamoxifen Therapy ) nolvadex temazepam Sedatives normison flunitrazepam rohypnol nitrazepam May be anti-anxiety, mogadon chlormethiazole sedative, hemineurin muscle relaxant, anti- diazepam LMW heparin convulsant,hypnotic valium ducen streptokinase Anti-coagulant urokinase heparin simvastatin calcium / sodium heparin fluvastatin sodium calciparine pravastatin fragmin gemfibrozil warfarin clexane doxepen hydrochloride dothiepin hydrochloride ↓ Hypercholestraemia zocor / lipex fluoxefine hydrochloride vastin / lescol imipramine hydrochloride Severe pravachol amitriptyline hydrochloride Hypertriglyceridaemia lopid / jezil sertraline hydrochloride Depression sinequin / deptran allopurinol dothep / prothiaden colchicine Tricyclic anti-depressant prozac spironolactone tofranil tryptanol Major depression zoloft General span K, slow K chlorvescent, kay ciel Potassium Chloride Gout zyloprim colgout Aldosterone antagonist, K aldactone sparing diuretic - used in 10 hyperaldosteronism , HT, CCF © - Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005 24

RESPIRATORY ASSESSMENT Revision Lectures and practicals with a focus on ¾ Respiratory Assessment ¾ Lung Function Testing An area of confusion in first reading the medical chart is the abbreviations utilised. It is vital that you become familiar with them as the conditions they signify may influence your patient management. Revise abbreviations at the beginning of the ILP before answering the following or alternatively, try to answer them independently and outline how they influence your treatment. Abbreviations Definition Influence patient management IHD HT PND SOBOE JVP CCF SOA Which of the abbreviations go together? Drugs are another area where a lot of information can be deduced about the patient. They indicate the precautions that need to be considered in treatment planning. For the following medications outline their effects, the conditions for which they may be prescribed and special precautions with physiotherapy treatment DRUG EFFECT CONDITIONS PRECAUTIONS Lasix / Frusemide Digoxin / Lanoxin Isordil Nitrolate Paste Anginine Hydrallazine Prednisone The gathering of data involves not only reading the medical chart but also the bed chart. What information do you specifically look to gain from this chart? © - Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005 25

A further important part of a respiratory assessment is the subjective questioning of the patient. What questions do you need to ask in your subjective assessment? What will the responses tell you about your treatment planning? The objective assessment involves Observation Palpation Auscultation During your observation what do you need to note about your patient? Can you think of how you might make these observations unobtrusively? What signs would you be looking for that would indicate that your patient was in respiratory distress? Observation of the patient’s breathing pattern forms part of your objective assessment. To ensure you are aware of the “what is normal”, revise the order of recruitment of respiratory muscles with increasingly deeper breathing. If your patient is noted to have costal margin paradox what will you see? Another aspect evaluated during observation of the patient is the shape of the chest. Outline the abnormalities of chest shape which you would note. After having made your observations you now need to place your hands on the patient and palpate. 1. Where should your hands be placed? 2. What instructions would you give to your patient? 3. What will you be noting? 4. Why is it important to palpate before auscultating? Prior to auscultating what instructions would you give to your patient? During auscultation you note your patient is becoming breathless, what would you do? After a thorough assessment, treatment planning and application of techniques, the management is not complete. Reassessment is an integral part of patient management. What would you note when reassessing a patient during treatment? What would be included in reassessing the patient at the completion of your treatment? The following exercise aims to assist you in gaining appropriate information from the medical chart. From the following examples outline: 1. the presenting condition 2. list the relevant PMHx / PSHx 3. areas requiring further questioning in the subjective assessment 4. relate the list of medications to PMHx / PSHx or the presenting condition © - Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005 26

Patient 1 A 68 year old man admitted for an aorto- bifemoral bypass. He suffers from IHD, AMI 3 years ago with ongoing angina and IDDM. He has a 45 pack year history of smoking. His medications include angina, transiderm, isordil, ventolin and atrovent via MA and actrapid. Epidural T 8-9 fentanyl and marcaine. Patient 2 A 75 year old bronchiectatic admitted with increased SOB and increased cough productive of a large amount of purulent sputum. He has (R)HF and HT. Medications on admission included - norvasc, lasix, span K, lanoxin, ventolin, atrovent, pulmicort. Consider the tests or investigations these patients may undergo that would enhance your knowledge of them. RESPIRATORY ASSESSMENT Answers ƒ Abbreviations Table on the following pages ƒ Abbreviations that go together ¾ HT PND SOBOE CCF / (L)VF ¾ SOBOE inc. JVP SOA CCF / (R)HF ¾ IHD can exist on its own - patients may be SOBOE when severe ƒ Medications - Effects Conditions treated and Precautions for physiotherapy treatment Outlined in a table on the following pages © - Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005 27





Abbreviations Definition IHD Ischaemic Heart Disease - Impairment of cardiac HT muscle due to imbalance between coronary blood flow and myocardial needs caused by a change in coronary circulation. Includes angina, myocardial infarct and myocardial ischaemia Hypertension - Normal 95/60 to 140/90 Common in elderly controlled with medication PND Paroxysmal nocturnal dyspnoea - breathlessness that wakes the patient at night SOBOE Short of breath on exertion JVP Jugular Venous Pressure normal 0 - 2 cm Assesses CCF volume of blood in great vessels entering the heart. SOA Congestive Cardiac Failure - used as a collective term for (L)VF and (R)HF Swelling of ankles - peripheral oedema © - Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005

Influence on patient management Questions in subjective re: Angina - establish history - stable / unstable . Time of last episode, location of pain, quality, duration, intensity, precipitating factors. Expectation re exercise tolerance. Technique selection Medications - indication of severity Need to know the baseline BP . HT => inc. risk CVA, MI Influence technique selection - HDT cautious (not if unstable) relax the patient, short inspiratory holds not contraindicated check BP Think of factors that inc. BP - pain, isometric exercise. Causes - Cardiac suggests (L)VF - inc. venous return from LL ==> pooling of blood in lungs ==> breathlessness - Resp - severe asthma - nocturnal b’spasm Implications - no HDT, dec. ex. tolerance, care with demand, avoid supine position Be specific - ex. tolerance- distance + on flat, stairs, hills /inclines. Aware of cause of SOB =>implication - Cardiac - treat with medication to control (L)VF look at demand or Resp - aim to increase demand - gain control of SOB Increased in (R)HF , 20 to (L)VF / CAL (Cor Pulmonale) Establish from the chart if symptoms reflect more (R)HF or (L)VF. Establish cardiac or respiratory involvement Need to establish cause as will influence treatment 1) Cardiac - reflect (R)HF 2) Impaired lymphatic or venous drainage -legs elevated for venous + support bandaging /stockings) 3) Other - steroids, low albumen 29

ƒ Bed chart information Vital signs ¾ Temperature > 375 ? source of temperature ¾ PR - normal for patient check for trends - > 100 tachycardia < 60 bradycardia - ? cause - tachy ? septic brady ? medication ¾ BP - baseline for patient - varies with age, fitness, HT - ? controlled ¾ SpO2 - > 95% normal unless respiratory impairment Other observations - as indicated ¾ Fluid balance - important post op, CRF, CCF and acute HI / neurosurgery ¾ BSL - Normal 5 - 10 No exercise if <5 or >20 ¾ Peak flow readings ¾ Pain scales ¾ HI / Vascular / Neuro observations Medications ¾ relate to PMH or presenting condition , note times of relevant medications ƒ Subjective questioning Subject to SOB + implications from the chart Aim to establish normal vs. present status ⇒ aiming for at D/C What is the main problem or what brought them into hospital? SOB/ cough / pain • Cough - how much, when , what colour • SOB ⇒ ? cause • Pain - area / type / relate to presenting condition • Exercise tolerance - distance + on flat, impact of hills / inclines, stairs - + / - aid, + / - O2 • Smoking history • Sleeping positions / Recovery positions • Home programme - e.g. airway clearance techniques used, peak flows, medications, walking programme © - Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005 30

DRUG EFFECT CONDIT Lasix / Frusemide Quick acting non K+ sparing loop (L)VF, HT diuretic Digoxin / Lanoxin + ive Inotrope - short/long acting CCF, Arrhyth Isordil Inc. contractility of heart without Fibrilla Nitrolate Paste inc. O2 demand Anginine Long acting Coronary Art. IHD, moderate vasodilator Cor. Art. Disea Hydrallazine Long acting systemic dilation IHD, severe C ==>dec.(L) Vent. O2 demand Prednisone Short acting Coronary Art. IHD, CAD vasodilator HT, dec. perip Powerful anti-hypertensive vascular resista Corticosteroid, anti- COAD, Asthm inflammatory, anti auto-immune Ulcerative Col Crohn’s Disea combine with NSAID’s © - Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005

TIONS PRECAUTIONS T, CRF Inc. excretion of fluid and electrolytes often K+ added - slow / span K hmia, Atrial Hypo / Hyper kalaemic ==> cardiac ation arrhythmia If for AF acutely - do not treat until effect of e - severe medication assessed ase (CAD) CCF - aware of demand CAD Care with demand , HDT pheral Consider the demand, able to cover silent ance ischaemia If stable no limitations - if inc. demand e.g. ma, stairs - take anginine. Care if unstable - inc litis, frequency of pain and inc. use of medication Signify significant problem with control of ase, RA - HT. Can ==> hypotension ==> care with SAARD / mobilising. BP closely monitored Side effects possible after 3/12 months use S/E : fragile skin, capillary fragility, osteoporosis, infection control, electrolyte disturbance, Cushingoid - moon shaped, fluid retention Aim for reducing dose - slow decrease to enable Adrenal Cortex to switch back on 31

ƒ Observation Whilst looking at the bed chart ¾ (P) appearance /posture /position in bed (orthopnoea) ¾ Effect on SOB of moving about the bed ¾ Breathing pattern - RR, resp. muscle use, accessory muscle use, pursed lip breathing ¾ Colour, cyanosis ¾ Signs of distress ¾ Audible wheezing ¾ Note attachments - IV drips, catheter, oxygen mask ¾ Chest shape Calf Check ¾ Observe SOA ¾ Clubbing of toes ¾ Peripheral perfusion Subjective questioning ¾ SOB - ability to talk in sentences Sputum Mug at bedside - observe colour, quality and quantity of sputum ƒ Signs of respiratory distress Tachypnoea - difficulty talking in sentences, use of accessory muscles, inc. RR ⇓ ↑work of breathing ⇓ Sweaty ↑PR Extreme - Hypoxia with confusion, agitation, twitching, plucking Respiratory Failure - Type I and Type II ƒ Muscles of Respiration - Order of Recruitment Inspiratory Expiratory Diaphragm Abdominals Intercostals (IC) Intercostal Sternocleidomastoid (SCM) Latissimus Dorsi Scalenes (SC) Quadratus Lumborun Upper Trapezius (UT) Pectoralis Major and Minor Serratus Anterior (SA) © - Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005 32

The diaphragm, intercostals (IC) and scalenes (SC) are recruited during quiet inspiration with activity increasing in IC and SC muscles as the depth of breathing increases. Towards the end of normal deep inspiration there is recruitment of the SCM and UT. With a further increase in the work of breathing there is a greater level of activity in the IC, SC, SCM, UT with SA and pectoral muscles being recruited. Expiration is usually passive after a quiet inspiration with the suggestion of eccentric work in the diaphragm and IC to slow the muscle and ribs recoil. An active expiration may be evident with forced expiration or obstructive lung disease and involve the recruitment of the abdominals, latissimus dorsi and quadratus lumborum. ƒ Costal Margin Paradox ¾ Paradoxical movement of the lower chest on inspiration i.e. due to the flattened diaphragm the lower ribs are drawninwards at the margins instead of being pulled outwards ƒ Abnormalities of chest shape • Kyphosis - Inc. flexion of thoracic spine • Kyphoscoliosis - Kyphosis + lateral curvature of the spine with vertical rotation - Restrictive lung defect • Congenital and relate to the central tendon of the diaphragm - rarely alters lung function significantly Funnel Chest - Pectus Excavatum - sternum depressed in - shortens the pull of the diaphragm Pigeon Chest - Pectus Carinatum - sternum protrudes anteriorly, lengthens the diaphragm • Barrel shaped - Hyperinflated, air trapping - loss of normal 450 rib to thoracic spine - AP diameter increased almost = transverse • Ankolysing Spondylitis - No rib cage movement - abdominal movement only ƒ Palpation Hand Placement ¾ Laterally over Ribs 7 - 10 or anteriorly over the lower ribs Feel ¾ Chest wall movement compare - sides - range of movement for patient to individual of same age ¾ Fremitus ¾ Tempersature ¾ Sweating ¾ Subcutaneous emphysema © - Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005 33

ƒ Auscultation Instructions ¾ Explanation of what you are going to do ¾ Take slightly deeper breaths than normal and breathe in and out through your mouth slowly and gently in your own time ¾ Request the patient not to talk whilst auscultating the chest ¾ Ask the patient to turn his head away Patient becomes SOB during auscultation ⇓ 1) stop auscultation 2) position patient 3) commence relaxed deep breathing ƒ Reassessment • Reassessment during treatment should note 1. response to technique 2. tolerance for treatment 3. change to objective signs • Include in reassessment at the end of treatment 1. re-auscultation of involved lung segments 2. question patient re subjectively how they feel PATIENT 1 Presenting Condition - Aorto-bifemoral bypass Relevant PMHx /PSHx - IHD - Ischaemic Heart Diseas - MI - Myocardial Infarct - IDDM - Insulin Dependent Diabetes Mellitus - Smoking History Subjective questioning IHD - Angina - Establish baseline for patient : any recent pain – how long it lasted and the medications that were required IDDM - Check stability of BSL”s Smoking Hx - Current - how many per day; if ceased - when and how long did they smoke Post-op - Pain - at rest and with movement - Cough - effective, productive or non productive © - Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005 34

Medication Anginine - for angina - short acting Coronary Artery vasodilator Transiderm - Nitrate for systemic vasodilation } Moderate to Severe Isordil - Long acting Coronary Artery vasodilator } CAD Ventolin - β2agonist - short acting bronchodilator } May have lung changes Atrovent - Anticholinergic agent } due to smoking or } given pre-op - potentiates the effect of ventolin Actrapid - Insulin for IDDM - post-op a sliding scale may be used i.e. dose of insulin altered according to BSL Epidural - Short acting narcotic with less respiratory depression Fentanyl - Local anaesthetic - Bupivicaine - concentration may vary Marcaine Tests ¾ RFT’s ¾ Chest X Ray ¾ ABG’s pre-op ¾ BSL’s ¾ CT Scan - to assess the extent of the aneurysm ¾ Pulse Oximetry - post-op PATIENT 2 Presenting Condition - Infective exacerbation of Bronchiectasis Relevant PMHx / PSHx - RHF - HT Subjective questioning ¾ Extent depends on SOB ¾ Determine the current situation vs. normal for patient ¾ HT - check stability with patient and check bed chart ¾ RHF - influence on symptoms - e.g. peripheral oedema, SOB ¾ Level of SOB - activity level ¾ Exercise tolerance - walking distance, effect of stairs, slopes, inclines or hills ¾ Home programme - drainage programme or self- management regime, walking programme © - Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005 35

Medication Norvasc - Amlodipine Besylate - Calcium Channel Blocker - For HT or angina Lasix - Frusemide - Non K+ sparing loop diuretic - For RHF Span K - K+ supplement to replace K+ lost with diuretic Lanoxin - Digoxin - + ive Inotrope - For RHF - ↑ contractility of ventricle without ↑ O2 demand Ventolin - β2agonist - short acting bronchodilator } For obstructive Atrovent Pulmicort - Anticholinergic - potentiates the effect of ventolin } component - Budesonide - Inhaled corticosteroid - ↓ inflammtory component Tests ¾ Chest X Ray ¾ Electrolyte levels ¾ Digoxin levels ¾ Sputum M / C / S - micro / culture / sensitivity ¾ Pulse oximetry © - Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005 36

AUSCULTATION 1. Review Surface Anatomy ¾ diaphragm levels on full inspiration post - ( R ) rib 9-10 ; (L) rib 10-11 ant - rib 6 ¾ fissures - oblique - T3 → rib 6 at ant. axillary line - horizontal - (R) - 4th intercostal space ¾ segments - for auscultation and techniques of percussion and or vibration 2. Sound Generation Anatomy Cause Treatment Normal/Vesicular Airflow through Breath Sounds airways + transmitted Transmitted 0-6 Trachea through lung Cough or suction sounds Main tissue Rattle audible w/o Bronchus stethoscope Secretions (Bronchitis) Coarse crackles 12-17 Small Secretions Postural drainage Rumbling 24 Bronchi (Pneumonia) Percussion or Vary with cough vibration I or E Alveoli a) L.V.F. a) usually Fine Crackles Fluid overload untreatable by Rustling physiotherapist Late I alveoli Wheeze Any level Alveoli b)early pneumonia b) humidification varying pitch E>I Trachea collapsed Alveoli relaxed deep Length, not 24 re-expanding post breathing intensity (3.5s) 0-2 treatment Bronchospasm Relaxation Bronchial breath narrowing Medical treatment sounds foreign body tumour Percussion not Stridor indicated Consolidation Untreatable by Pleural rub Pleura physiotherapy Upper airway Pain relief Obstruction Inflammation Fibrosis © - Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005 37

3. Indicate where you would place the stethoscope to auscultate the following areas and identify the surface anatomy markings for each. LOBE SEGMENT AREA PLACEMENT (R)&(L) Apical Not routinely assessed – Above the Clavicle Upper Lobe - anterior only if Upper Lobe anteriorly involved Above the spine of the - posterior scapula posteriorly Anterior Ribs 2 – 4 anteriorly Just below the clavicle in the mid-clavicular line Posterior At the level of T3 posteriorly Opposite the spine of the ( R ) Middle scapula Lobe Ribs 4 – 6 on ( R ) ( R ) Mid-Axillary Line ( L ) Upper Lingula Ribs 4 – 6 ( L ) approximately level of the Lobe nipple Anterior Ribs 6- 8 anteriorly ( L ) Mid-Axillary Line Ribs 6 – 8 laterally approximately level of the ( R ) & ( L ) Lateral T3 – T7 posteriorly nipple Lower Lobe T8 – T10 posteriorly 450 down from the nipple Apical Mid-Axillary Line Posterior At the level of T7 – inferior angle of the scapula At the level of T10 posteriorly © - Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005 38

CHEST XRAY VIEWING P-A or A-P CHEST X-RAYS - be systematic and view from 1.2m / 4 ft away then close up 1. PATIENT INFORMATION a) Patient’s name b) Identification number c) Age d) Date and time of film 2. TECHNICAL DETAILS a) Type of film - PA, AP, Lat b) Patient position – erect or supine c) Exposure – barely able to see the IV disc space / see spinous processes to T4 not T5 important for interpretation of thoracic structures - over - increased penetration – increased blackness of film - under - decreased penetration –increased whiteness of film d) Rotation of film – look at the medial ends of the clavicle to the spinous process of the vertebral body at the same level. Centred they should be equidistant 3. SOFT TISSUE a) Breast tissue b) Air in the tissues – surgical emphysema c) Air under the diaphragm d) Gastric Bubble 4. BONY STRUCTURES a) Posture / alignment b) Chest wall shape c) Ribs - # (loss of continuity), decalcification (less white), angle off the sternum d) Sternum e) Spine - # 5. MEDIASTINUM – trachea and hilar region Mediastinum – consists of the organs and soft tissue in the central part of the chest Forms an inverted Y - i.e. trachea, aortic arch, great vessels, superior vena cava and oesophagus a) trachea - midline (TML) or slight deviation to ( R ) above the carina due to displacement by the aortic arch b) aortic arch – may have some calcification c) hilar shadows – composed of pulmonary arteries and veins, bronchi and lymph nodes - ( L ) & ( R ) hilum – of equal density, the same size (related to blood flow) - ( L ) hilum 0.5 – 1.5 cm higher than the ( R ) - ↑ density or abnormal configuration – result of lymph node or pulmonary artery enlargement © - Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005 39

6. HEART a) 1 / 3 to the ( R ) of the spine, 2 / 3 on the ( L ) b) Cardiothoracic Ratio – CTR – 1 / 3 to 1 / 2 - i.e. the maximum transverse diameter of the heart should be less than half the maximum transverse diameter of the thorax c) Heart borders should be clear – - on ( R ) loss of the heart border shows ( R ) ML involvement - ( L ) - ( L ) UL lingula involvement 7. DIAPHRAGM a) Check contour of the diaphragm – dome shaped, smooth b) ( R ) higher than ( L ) by 1-3 cms c) Level – anteriorly – ( R ) - Rib 6 ( L ) – Rib 7 - posteriorly – ( R ) - 9th – 10th Rib - ( L ) - 10th – 11th Rib d) Cardiophrenic angle – angle between the heart and diaphragm – should be clear e) Costophrenic angle – acute angle of diaphragm and chest wall at the outer or lateral margins ‰ filling or blunting reflects pleural disease – fluid or thickening 8. LUNG FIELDS a) Compare each lung they should be of equal transradiency b) Pulmonary blood vessels → the branching and linear structures within the lung and should be perceptible to 2 cm from the lung /costal margin c) Vessels are more prominent at the bases compared to apically - ( R ) more obvious than ( L ) d) Identify the horizontal fissure – hilum to the 6th rib in the axillary line - the oblique fissure seen on Lat film e) Bronchi not seen at > 2-3 cm from the hilum f) Identify the area of lung pathology 9. EXTRATHORACIC STRUCTURES a) Identify leads, wires, staples b) Note tube levels – ETT or tracheostomy LATERAL X-RAY Regardless of the way in which the film was taken (L or R side against the plate) always view the film in the same way. Look at the film with the vertebral column on ( R ) and the front of the chest on ( L ). 1. PATIENT INFORMATION and TECHNICAL DETAILS -As for the PA film 2. RETROSTERNAL SPACE - Black if obliterated → white indicates anterior mass. 3. POSITION OF FISSURES a) Horizontal Fissure - passes horizontally from the midpoint of the hilum to the anterior chest wall. - if not horizontal the fissure is displaced. b) Oblique Fissure – passes obliquely downwards from the T2 vertebrae, through the hilum, ending at the anterior third of the diaphragm. © - Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005 40

4. DENSITY OF HILA A hilar mass causes increased whiteness compared to normal 5. DIAPHRAGMS a) ( R ) hemidiaphragm stretches across the whole thorax clearly passing through the heart border b) ( L ) hemidiaphragm disappears when it reaches posterior border of the heart c) Pleural effusion → blunting of the costophrenic angle either anteriorly or posteriorly 6. LUNG FIELDS a) Compare the appearance of the lung fields in front of and above the heart to behind - equal density b) Check no discrete lesions in either field 7. VERTEBRAL BODIES a) More translucent (darker) as moves caudally. b) All the same shape, size and density c) Look for collapse of vertebra or vertebrae significantly lighter or darker © - Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2005 41

CHEST X-RAY Positions occupied by the Bronchopulmonary segments on Posterioanterior Projection 1. Upper Lobe R) & (L)UL apical (R) & (L)UL posterior (R) & (L)UL anterior Segments Segments Segments 2. Middle/Lingula 3. Lower Lobe Lateral Superior Medial Inferior (R)& (L)LL apical Segment Segment Segment Segment Segments 3. Lower Lobe (continued) (R)&(L)LL anterior (R)&(L)LL lateral (R)&(L)LL posterior (R)LL medial Segments Segments Segments Segment 39 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

Posterioanterior View SVC - superior vena cava MPA - main pulmonary artery RPA - right pulmonary artery RA- right atrium RV - right ventricle LAA - left atrial appendage LA-left atrium LV-left ventricle AA-Aortic Arch DA-Descending Aorta Lateral View 40 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

Movement of Fissures with Lung Collapse Lateral Posterioanterior 1. Upper Lobe 2. Middle/Lingula 3. Lower Lobe 41 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

ARTERIAL BLOOD GAS ANALYSIS 1. Revise Normal Values of Arterial Blood Gases pH - 7.35 - 7.45 PaO2 - 80 - 100 mm Hg Age lowers PaO2 = 103.7 - (1/4 x age) Steps in Analysis PaCO2 - 35 - 45 mm Hg HCO3 - 22 - 28 meq / l SECTION A – BASIC QUESTIONS 1. Look at pH – acidotic < 7.35 or alkalotic > 7.45 2. Look at PaCO2 – abnormal or normal? < 35 Respiratory Alkalosis > 45 Respiratory Acidosis 3. Look at HCO3 – abnormal or normal ? < 22 Metabolic Acidosis > 28 Metabolic Alkalosis 4. Identify primary problem - which of the PaCO2 or HCO3 agrees with the pH 5. Has compensation occurred or not? When pH deviates from normal the body will attempt to compensate by adjusting the concentrations of H+ and HCO3 in the blood Compensation may be Complete Partial Absent Complete - occurs when one system is able to offset a change in the other and returns the pH to within normal limits Partial - exists when one system has begun to offset the change in the other but not sufficient to return the pH to the normal range Look at the second component ( i.e. either the PaCO2 or HCO3 ) is this outside its normal range (some compensation has occurred) or within normal range (no compensation) The next decision if there has been some compensation is it partial or complete Partial compensation the pH will be outside its normal range i.e. below 7.35 or above 7.45 Complete compensation the pH will be back within its normal range i.e. between 7.35 and 7.45 42 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

Patterns of ABG’s Respiratory pH Pa CO2 PaO2 HCO3 Condition Acidosis Decreased Increased Decreased Normal CAL Respiratory Decreased Normal or Normal Pneumonia Alkalosis Increased Normal Decreased Decreased Anxiety, Metabolic Normal Pain, PE Acidosis Decreased Normal Increased Diabetes, Normal Toxicicty, Metabolic Increased Renal Alkalosis Failure NG suction Vomiting Before attempting some interpretations let’s work through an example. EXAMPLE 1 7.23 ↓ Acidosis (Step 1) pH PaCO2 50 mm Hg ↑ Acidosis (Step 2) HCO3 24 Normal (Step 3) PaO2 60 mm Hg Severe hypoxaemia Primary problem Respiratory Acidosis (PaCO2 agrees with the pH) (Step 4) Compensation HCO3 within normal range and therefore no compensation has occurred (Step 5) Interpretation Uncompensated Respiratory Acidosis with severe hypoxaemia EXAMPLE 2 pH 7.49 ↑ Alkalosis (Step 1) PaCO2 27 mm Hg ↓ Alkalosis (Step 2) HCO3 21 ↓ Acidosis (Step 3) PaO2 80 mm Hg Within normal range Primary problem Respiratory Alkalosis (PaCO2 agrees with the pH) (Step 4) Compensation HCO3 outside normal range and therefore some compensation but only partial as the pH remains outside normal range (Step 5) Interpretation Partially compensated Respiratory Alkalosis with oxygenation within normal range 43 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

Interpret the following blood gas results HCO3 Interpretation 30 PH PaCO2 18 7.21 60 44 7.45 26 24 7.55 52 15 7.10 95 38 7.39 25 20 7.56 44 15 7.48 28 34 7.20 40 12 7.39 56 7.24 28 44 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003