Respiratory Physiotherapy An On Call Survival Guide Physiotherapy pocketbooks Second Edition, jennifer pryor

Case studies 289 20 Questions 1. What are the key elements of your assessment and why? 2. What are your treatment options? Answers 1. Key assessment elements include the following: General ● Sudden deterioration ● Recent oesophageal surgery – note altered anatomy and contraindications/ cautions to treatment ● Long history of swallowing difficulties. CVS ● Signs of infection – tachycardia with raised WCC and CRP. CNS ● Signs of confusion, could be due to: ● hypoxia ● neurological event ● brain metastases. Respiratory ● Single pulmonary metastasis (be aware of). 2. Treatment options: ● Ascertain if appropriate for critical care and resus status. She is acutely unwell and needs immediate action to avoid further deterioration. ● Liaise with medical team regarding suction and IPPB. Needs to be documented before undertaking these treatments due to altered anatomy and risk of damage to anastomosis. ● May be too fatigued and confused for ACBT and has an ineffective cough due to vocal cord palsy. Therefore positioning, manual techniques and suction (if team consent) may be only options. CASE STUDY 10: PAEDIATRIC WARD Paul Ritson You are called to see a 5-year-old girl with cerebral palsy on the paediatric ward. Admitted with increased seizures.

20 290 Case studies Telephone history ● Severe developmental delay and spasticity ● Possible aspiration 1 hour ago ● SpO2 88% in 15 litres oxygen via mask ● Suction – copious thick green secretions ● ABGs: pH 7.25, pCO2 10 kPa (75 mmHg), pO2 8 kPa (60 mmHg), BE +1 ● Recent CXR (Fig. 20.1) – not reported ● Auscultation: Reduced breath sounds bibasally, crackles right > left. Questions 1. What further information do you require? Can you offer any advice? 2. How would you plan your assessment? 3. Analyse ABGs and CXR. 4. Devise a treatment plan; justify your answers. Answers 1. Further information required: ● Response to handling ● Position of patient ● Clinical details, e.g. CVS Figure 20.1 Patient CXR.

Case studies 291 ● Suction frequency/type (NP/OP) ● Nebulizers. Which ones? ● Relevant PMH. Advice: ● Increase FiO2, keeping SpO2 above 93%, humidify via face mask ● Reposition to supported side-lying with ‘head up’ ● Bronchodilator (if prescribed)/saline nebulizer. 2. Assessment: ● ABC (see Chapter 4). 3. Interpretation: CXR: ● Thoracic scoliosis ● Small volume lungs ● No major consolidation/collapse ● Mild right lower zone changes, ?infection. ABG: ● Hypoxic ● Uncompensated respiratory acidosis. 4. Treatment plan: ● Consent! ● Maximize oxygen therapy – keep SpO2 >93% ● Humidification ● ?Saline/bronchodilator nebulizers ● Positioning (alternate side-lying, head up), modify if desaturates ● ?Manual techniques ● ?NP suction ● Regular repositioning/reassessment ● Never treat when fitting ● Communication with parents/team. 20



APPENDIX 1 Abbreviations A&E: Accident & Emergency BiPAP: bi-level positive airway pressure ABC: Airway, Breathing, Circulation BMI: body mass index ABG: arterial blood gas BOS: base of skull ACBT: active cycle of breathing BP: blood pressure (arterial) b.p.m./BPM: beats per minute (also techniques ACE: angiotensin converting enzyme used as breaths per minute) ACPRC: Association of Chartered BPD: bronchopulmonary dysplasia b.p.m.: beats per minute Physiotherapists in Respiratory Care BS: breath sounds AD: autogenic drainage BTS: British Thoracic Society AF: atrial fibrillation Ca: cancer ALI: acute lung injury CABG: coronary artery bypass graft AML: acute myeloid leukaemia CCF: congestive cardiac failure AP: anteroposterior CF: cystic fibrosis APTT: activated partial thromboplastin CFM: cerebral function monitor CMD: congenital muscular dystrophy time CMV: continuous mandatory ARDS: acute respiratory distress ventilation syndrome CMV: cytomegalovirus ASAP: as soon as possible CNS: central nervous system ASB: assisted spontaneous breathing CO2: carbon dioxide ASD: atrial septal defect COAD: chronic obstructive airway Ausc.: auscultation AV: arterioventricular disease AVPU: best patient response, Alert, COPD: chronic obstructive pulmonary responding to Voice, Pain or is disease Unresponsive CP: cerebral palsy AVSD: atrioventricular septal defect CPD: continuing professional AVR: aortic valve replacement BAL: bronchoalveolar lavage development BC: breathing control CPAP: continuous positive airway BE: base excess pressure

294 Abbreviations A1 CPP: cerebral perfusion pressure GTN: glyceryl trinitrate CRP: C-reactive protein Hb: haemoglobin CRT: capillary refill time HCO3: bicarbonate CSF: cerebrospinal fluid HDU: high dependency unit CSP: Chartered Society of HF: haemofiltration HFO: high-frequency oscillation Physiotherapy HFOV: high-frequency oscillatory CT: computed tomography CVA: cerebrovascular accident ventilation CVVHD: continuous veno-venous HME: heat and moisture exchanger HPC: history of present condition haemodialysis HR: heart rate CVVHF: continuous veno-venous IABP: intra-aortic balloon pump ICD: intercostal drain haemofiltration ICP: intracranial pressure CVP: central venous pressure ICU: intensive care unit CVS: cardiovascular system IHD: ischaemic heart disease CXR: chest X-ray i.m.: intramuscular DH: drug history INR: international normalized ratio DIC: disseminated intravascular IPPB: intermittent positive pressure coagulation breathing DMD: Duchenne muscular dystrophy IPPV: intermittent positive pressure DVT: deep vein thrombosis ECG: electrocardiogram ventilation ECMO: extracorporeal membrane IS: incentive spirometry i.v.: intravenous oxygenation JVP: jugular venous pressure ENT: Ear Nose & Throat K+: potassium ions EPAP: expiratory positive airway LFT: lung function test or liver function pressure test ET: endotracheal LLL: left lower lobe ETT: endotracheal tube LPA: lasting power of attorney EVD: external ventricular drain LTEE: lower thoracic expansion exercise Fen.: fenestrated LTOT: long-term oxygen therapy FET: forced expiration technique LUL: left upper lobe FEV1: forced vital capacity in first LVF: left ventricular failure LZ: lower zone second of expiration MAP: mean arterial pressure FiO2: fraction of inspired oxygen MDT: multidisciplinary team FRC: functional residual capacity MEWS: Modified Early Warning Score FVC: forced vital capacity MHI: manual hyperinflation GAP: gravity-assisted positioning MI: myocardial infarction GCS: Glasgow Coma Scale GI: gastrointestinal GOR: gastro-oesophageal reflux

Abbreviations 295 MT: manual techniques PEP: positive expiratory pressure A1 MRSA: methicillin-resistant pH: negative logarithm of hydrogen Staphylococcus aureus ion concentration in moles per litre MV: minute volume PICC: peripherally inserted central MVR: mitral valve replacement MZ: middle zone catheter Na+: sodium ions PICU: paediatric intensive care unit NaCl: sodium chloride PIP: positive inspiratory pressure NAI: non-accidental injury Plts: platelets NBM: nil by mouth PMH: past medical history NCA: nurse-controlled analgesia p.r.n.: ‘as required’ NEC: necrotizing enterocolitis PRVC: pressure-regulated volume NGT: nasogastric tube NIV: non-invasive ventilation control NO: nitric oxide PS: pressure support or pulmonary NP: nasopharyngeal NSAIDs: non-steroidal anti- stenosis PT: prothrombin time inflammatory drugs PVC: premature ventricular contraction O2: oxygen PVD: peripheral vascular disease OP: oropharyngeal RLL: right lower lobe PA: pulmonary artery RML: right middle lobe PA: posteroanterior RR: respiratory rate PaCO2: partial pressure of carbon RS: respiratory system RSV: respiratory syncytial virus dioxide in arterial blood RTA: road traffic accident PaO2: partial pressure of oxygen in RUL: right upper lobe SAH: subarachnoid haemorrhage arterial blood SaO2: saturation of oxygen in arterial PAP: peak airway pressure PAWP: pulmonary artery wedge blood (shown in ABGs) SB: spina bifida pressure s.c.: subcutaneous PCA: patient-controlled analgesia SNP: sodium nitroprusside PCEA: patient-controlled epidural SH: social history SIRS: systemic inflammatory response anaesthesia/analgesia PCP: Pneumocystis carinii pneumonia syndrome PCPAP: periodic CPAP SMA: spinal muscular atrophy PD: postural drainage SR: sinus rhythm PDP: personal development plan SSC: squamous cell carcinoma PE: pulmonary embolus ST: sinus tachycardia PEEP: positive end expiratory SOB: shortness of breath SOBAR: shortness of breath at rest pressure SOBOE: shortness of breath on exertion PEFR: peak expiratory flow rate

296 Abbreviations A1 SpO2: pulse oximetry arterial oxygen TOF: tetralogy of Fallot saturation TV: tidal volume UO: urinary output SVCO: superior vena cava obstruction URT: upper respiratory tract SWOT: strengths, weaknesses, UZ: upper zone VT: tidal volume opportunities, threats VAS: visual analogue scale TB: tuberculosis V/Q: ventilation/perfusion ratio TBI: total body irradiation VC: vital capacity TEE: thoracic expansion exercise VSD: ventricular septal defect TENS: transcutaneous electrical nerve WCC: white cell count WOB: work of breathing stimulation TGA: transposition of great arteries TMR: transmyocardial revascularization

APPENDIX 2 Normal values Table to show normal values. Reproduced from Pryor and Prasad (2008), with permission. Normal values for arterial blood gases pH: 7.35–7.45 PaO2: 10.7–13.3 kPa (80–100 mmHg) PaCO2: 4.7–6.0 kPa (35–45 mmHg) HCO3: 22–26 mmol/L Base excess: −2 to +2 From Pryor JA, Prasad SA (eds) (2008) Physiotherapy for respiratory and cardiac problems, 4th edn. London: Churchill Livingstone (Box 1.4). Normal values for blood pressure (BP) (adult) Normal value of systolic/diastolic pressure: 95/60 − 140/90 mmHg Normal value of mean arterial pressure = Diastolic + [(Systolic − Diastolic)/3] = 70–110 mmHg From Pryor JA, Prasad SA (eds) (2008) Physiotherapy for respiratory and cardiac problems, 4th edn. London: Churchill Livingstone (Box 8.2). Normal values for central venous pressure (CVP) Normal CVP: 3–15 cmH2O (2.2–11 mmHg) From Pryor JA, Prasad SA (eds) (2008) Physiotherapy for respiratory and cardiac problems, 4th edn. London: Churchill Livingstone (Box 8.3).

298 Normal values A2 Paediatric normal values Newborn Up to 3 years 3–6 years >6 years 7.30–7.40 7.30–7.40 7.35–7.45 7.35–7.45 Arterial blood pH PaCO2 (mmHg) 30–35 30–35 35–45 35–45 4.0–4.7 4.0–4.7 4.7–6.0 4.7–6.0 (kPa) PaO2 (mmHg) 60–90 80–100 80–100 80–100 (kPa) 8.0–12.0 10.7–13.3 10.7–13.3 10.7–13.3 Adapted from Pryor JA, Prasad SA (eds) (2008) Physiotherapy for respiratory and cardiac problems, 4th edn. London: Churchill Livingstone (Table 9.5). Paediatric normal values Respiratory rate – range Blood pressure – (breaths/min) systolic/diastolic Age group Heart rate – mean (mmHg) (range) (beats/min) 40–60 39–59/16–36 30–50 Preterm 150 (100–200) 20–40 50–70/25–45 Newborn 140 (80–200) 20–40 <2 years 130 (100–190) 15–30 87–105/53–66 >2 years 80 (60–140) >6 years 75 (60–90) 95–105/53–66 97–112/57–71 From Pryor JA, Prasad SA (eds) (2008) Physiotherapy for respiratory and cardiac problems, 4th edn. London: Churchill Livingstone (Table 13.1).

Normal values 299 Conversion tables 0.133 kPa = 5 1.0 mmHg mmHg pH = 9 - log [H+] where [H+] is in nmol/L A2 kPa 7.5 pH [H+] 1 7.52 30 2 15.0 7.45 35 4 30 7.40 40 6 45 7.35 45 8 60 7.30 50 10 75 7.26 55 12 90 7.22 60 14 105 7.19 65 From Pryor JA, Prasad SA (eds) (2002) Physiotherapy for respiratory and cardiac problems, 3rd edn. London: Churchill Livingstone. BLOOD CHEMISTRY Albumin 37–53 g/L Calcium (Ca2+) 2.25–2.65 mmol/L Creatinine 60–120 μmol/L Glucose 4–6 mmol/L Potassium (K+) 3.4–5.0 mmol/L Sodium (Na+) 134–140 mmol/L Urea 2.5–6.5 mmol/L Haemoglobin (Hb) 14.0–18.0 g/100 ml (men) 11.5–15.5 g/100 ml (women) Platelets 150–400 × 109/L White blood cell count (WCC) 4–11 × 109/L Urine output 1 ml/kg/h From Pryor JA, Prasad SA (eds) (2002) Physiotherapy for respiratory and cardiac problems, 3rd edn. London: Churchill Livingstone.



APPENDIX 3 Surgical incisions

A3 302 Surgical incisions Median Bilateral subcostal sternotomy with median extension (liver transplant) Right subcostal Left paramedian (open cholecystectomy) (laparotomy) Horizontal Lower midline transabdominal Appendicectomy Suprapubic Right inguinal (hernia repair) A Lateral Limited thoracotomy thoracotomy Thoracolaparotomy Left transverse lumbar B (nephrectomy) Figure showing common surgical incisions. Reproduced from Pryor and Prasad (2002), with kind permission.

APPENDIX 4 Common drugs used in critical care areas Angela Kell Group Effect Indications Examples Bronchodilators Mucolytics Relax smooth muscles Bronchospasm Salbutamol of the airways (Ventolin) Inotropes Bricanyl Glycosides Atrovent Diuretics Thiazides Reduce the viscosity Viscous sputum N-acetyl-cysteine of sputum to aid (Parvolex) airway clearance Carbocisteine (Mucodyne) Hypertonic saline DNase (Pulmozyme) Increase the force of Heart failure Enoximone myocardial Milrinone contraction increasing cardiac output Relax smooth muscle, increasing preload and afterload Slow electrical Heart failure Digoxin conduction through Supraventricular the AV node tachycardias Promote excretion of water and electrolytes by the renal system Inhibit sodium Chronic heart failure Bendroflumethiazide reabsorption Hypertension (low Indapamide Metolazone doses only)

304 Common drugs used in critical care areas Group Effect Indications Examples Loop diuretics Inhibit fluid Pulmonary oedema Furosemide reabsorption in the and left ventricular (frusemide) renal tubule failure Bumetanide They are the most Lasix powerful diuretics A4 Potassium sparing Increase water and Diuretic-induced Amiloride diuretics electrolyte excretion hypokalaemia Spironolactone but prevent loss of Co-amilofruse potassium and Oedema due to hydrogen ions chronic heart failure Hypertension Sympathomimetics Mimic sympathetic Hypotension Dobutamine nervous system – Dopamine constrict peripheral Noradrenaline blood vessels, Epinephrine increase heart rate Norepinephrine Anti-arrhythmics Different drugs will Ventricular Amiodarone target different arrhythmias by tachycardias, atrial Diltiazem either sodium channel blocking, flutter and Verapamil beta-adrenergic receptor blocking or fibrillation, Adenosine calcium channel blocking paroxysmal Flecainide tachycardias, Sotalol supraventricular Quinidine tachycardias, ventricular fibrillation Nitrates Coronary dilatation. Acute angina relief Isosorbide Reduces venous mononitrate (ISMN) return which reduces left Isosorbide dinitrate ventricular workload Glyceryl trinitrate (GTN) Beta-blockers Reduce blood Hypertension Propranolol pressure and slow Long-term prevention Atenolol heart rate, reducing Bisoprolol the force of of angina Metoprolol myocardial Labetalol contraction, thus reducing myocardial oxygen demand

Common drugs used in critical care areas 305 Group Effect Indications Examples Calcium channel Dilate coronary Angina Diltiazem blockers arteries by inhibiting Some calcium channel Nifedipine calcium ion blockers also have Amlodipine channels across the anti-arrhythmic Felodipine cell membrane, properties reducing the force of contraction and A4 thus workload of the heart Antihypertensives Work by inhibiting the Hypertension Sodium sympathetic nervous First treatment of nitroprusside system which choice is beta- (SNP) dilates peripheral blockers and See also beta- blood vessels, by diuretics, followed blockers, ACE blocking the calcium by sympatholytics, inhibitors and channels or by vasodilators and diuretics acting directly to ACE inhibitors dilate vessels SNP and GTN may be administered i.v. postoperatively to prevent spasm of grafted arteries, ensuring adequate myocardial perfusion ACE inhibitors Promote excretion of Heart failure Ramipril sodium and water; Hypertension Lisinopril this lowers BP by Prophylaxis of Captopril decreasing cardiac Enalapril output cardiovascular events Statins Inhibit enzymes Hypercholesterolaemia Atorvastatin involved in Secondary prevention Simvastatin cholesterol synthesis, reducing of coronary and arterial lipid cardiovascular deposition events Potassium channel Activate potassium Prophylaxis and Nicorandil activators channels, vasodilate treatment of angina vessels

306 Common drugs used in critical care areas Group Effect Indications Examples Anticoagulants Reduce the ability of DVT and PE prevention Heparin the blood to clot and treatment Enoxaparin Prophylaxis for Aspirin mechanical valve Warfarin patients DIC A4 Thrombolytics Dissolve pre-existing PE Streptokinase clots DVT MI Ischaemic stroke Sedatives and Depress CNS activity For intubated/ Propofol anaesthetic ventilated patients Midazolam agents Fentanyl Analgesics Depress pain Routinely administered Alfentanil pathways after surgery – Morphine Can be opiate based or non-opiate based initially should be Tramadol intravenous, via Paracetamol epidural or intramuscular, then progressed to oral where appropriate Paralysing agents Relaxation of Due to difficulties in Atracurium respiratory and achieving optimal Vecuronium skeletal muscles ventilation or to Pancuronium control neurological parameters, e.g. acute head injury Anti-emetics Block receptors in the Nausea and vomiting Cyclizine GI tract and CNS (often induced by Granisetron anaesthesia and Ondansetron analgesics). Often used prophylactically Insulin Regulates protein, fat Unstable/abnormal Actrapid and carbohydrate blood sugar levels metabolism Proven to improve wound healing in post-surgical population

INDEX A lobar collapse 134 assisted cough 245–7 location of critically ill Association of Physiotherapists ABC (Airway, Breathing, Circulation) assessment patients 123 in Respiratory Care 17–18 management of ICU (ACPRC), assessment tool 1 abdominal breathing technique problems 134 asthma, acute 147–8 237, 238, 239 pleural effusion 134 atelectasis/collapse pneumothorax 134 adult intensive care patient abdominal surgery patient pulmonary embolus 134 134 162–4 pulmonary oedema 134 chest X-ray interpretation sputum retention 134 54–9, 63 Acapella device 240–1 Adults with Incapacity lung volume loss 92, 97 active cycle of breathing auscultation (Scotland) Act (2000) 15 children 44, 47 techniques (ACBT) 237–40 advance decision (under the patient assessment, 32–4 acute cardiology patient 202–3 autogenic drainage 241 acute epiglottitis, children 48 Mental Capacity Act 2005) AVPU neurological assessment acute lobar pneumonia, 15 24 air bronchogram, chest X-ray axillo-femoral bypass 165 hypoxaemia 114 interpretation 60, 61 acute lung injury see ALI airway differences in children B acute respiratory distress 40, 41 airway resistance, effects of bagging technique 242–3 syndrome see ARDS 131 decreased FRC 87–8 basal metabolic rate in infants acute respiratory failure see ALI (acute lung injury) 131 lung volume loss 92, 96 38 respiratory failure alveolar pulmonary oedema, bradycardia response to adjuncts for respiratory chest X-ray interpretation 59, 61, 64–5 hypoxia in children 38 physiotherapy treatments alveolar ventilation, brain-injured patient 178–83 240–1 consequences of decreased breathing control technique adult intensive care unit (ICU) VT 89 calls 123–35 anaemic hypoxaemia 112 237–8, 239 alarm systems in the ICU aortic aneurysm 165 bronchiectasis, medical unit 127–30 ARDS (acute respiratory distress assessment of the ICU syndrome) 131 calls 157 patient 123–5 complication of pancreatitis bronchiolitis, children 48 bronchospasm 134 150 bronchopneumonia case study 273–4 lung volume loss 92, 96 common pathologies and arterial blood gas (ABG) hypoxaemia 114 conditions 131–3 tensions, in respiratory medical unit calls 152, 154 drugs encountered in failure 111 bronchospasm intensive care 131 arterial bypass graft 165 adult intensive care patient environment of the ICU aspiration, chest X-ray 125–30 interpretation 59, 60, 61 134 equipment in the ICU and increased work of 125–30 fatigue 134 breathing 101, 103–4 identifying the cause of an sputum retention alarm 127–30 management 83

308 Index Burkholderia cepacia 156 paediatric intensive care factors affecting X-ray quality burns, ICU calls 132–3 274–5 51 C paediatric ward 289–91 heart shadow 52 surgical unit 279–82 hemidiaphragm (left and CABG (coronary artery bypass thoracic unit 285–6 grafting) 190 cerebral perfusion pressure right) 52 hilum (left and right) 52 cancer see oncology unit calls (CPP) values 179, 181 horizontal fissure 51, 52, 53 capacity issues 14–16 Chartered Society of lingula 51 Carbocisteine 109 normal lobar anatomy 51–3 carbon dioxide retention Physiotherapy, standards oblique fissure 51, 53 for on call working 1 planes and zones of the acute-on-chronic respiratory/ chest X-ray interpretation ventilatory failure 120 28–30 lungs 52, 53 chest X-ray interpretation children see paediatric care causes of acute ventilatory (abnormalities) 52–70 chronic chest disease, failure 116–17 air bronchogram 60, 61 alveolar pulmonary oedema hypoxaemia 115 causes of chronic ventilatory 59, 61, 64–5 chronic obstructive pulmonary failure 119–20 atelectasis/collapse 54–9, 63 collapse/atelectasis 54–9, 63 disease see COPD consequence of decreased VT consolidation 59–63 clinical assessment see patient 89 COPD (chronic obstructive pulmonary disease) 69 assessment contraindication for CPAP 91 emphysema 69 clinical experience, preparation hypoxaemia 115 fields which are too white medications for chronic 54–67 for on call working 8–9 fields which are too black 54, clinical reasoning process 5 ventilatory failure 120 66–9 clinicians, disagreement among signs and symptoms 113, fluid in the lung 59–63 heart failure and pulmonary 13–14 116 oedema 64–5 closing volume (lung) 85, 87 treatment of hypercapnia infected fluid in the lung 59, clotting disorders, ICU calls 63 117–19 interstitial pulmonary 133 see also hypercapnia oedema 66–7 collapse (lobar) cardiac surgery patient 189–91, Kerley B lines 66, 67 lobular collapse 54–7, 59 adult intensive care patient 192–3, 194–5 loss of lung volume 54–9, 63 134 cardiology patient 202–3 lung collapse 54, 58–9 cardiothoracic trauma patient pleural effusion 63–4, 65, 66 lung volume loss 92, 97 pneumonectomy 54, 58 collapse/atelectasis, chest X-ray 198, 200, 201–2 pneumonia 59, 63 cardiothoracic unit calls pneumothorax 66–8, 69 interpretation 54–9, 63 positioning of endotracheal communication 189–203 tube 59 cardiac surgery patient pulmonary oedema 59, 61, disagreement among 64–6, 67 clinicians 13–14 189–91, 192–3, 194–5 results of aspiration 59, 60, cardiology patient 202–3 61 when to seek help 14 cardiothoracic trauma patient round pneumonia 63 with a child 38 tension pneumothorax 66–8 with parents 38 198, 200, 201–2 thoracotomy 54 with the medical/nursing case study 284–5 traumatic lung contusion 59, lung contusions 200, 201, 60, 61–2 staff 13 chest X-ray interpretation with the patient/relatives 13 202 (normal) 51–2 consent issues 14–16 rib fractures 198, 201, 202 aortic arch 52 paediatric care 37 stab injuries 200, 201, 202 costophrenic angle 52 consolidation thoracic surgery patient 191, chest X-ray interpretation 196–98, 199, 200–1 59–63 cardiovascular observations, lung volume loss 92, 96 continuous positive airway patient assessment 22–3 case studies 273–91 pressure see CPAP contractual issues, on call adult intensive care 273–4 cardiothoracic unit 284–5 policy/procedures 8 haematology patient 286–7 COPD (chronic obstructive learning from on call events pulmonary disease) 5 care of patient with end-stage medical unit 276–9 neurological unit 282–4 COPD 146–7 oncology patient 288–9 causes of hypoxaemia 145

Index 309 causes of readmission 146, deep breathing exercises 237, fungal pneumonia, medical 147 238, 239 unit calls 152, 154–5 chest X-ray interpretation 69 dehydration, and sputum G controlled oxygen therapy retention 77, 82 GCS (Glasgow Coma Scale) 145–6 diaphragmatic breathing neurological observations hypoxic drive to stimulate 237–8, 239 24 breathing 146 documentation of on call Gillick Competence 37 increased work of breathing events 16 gravity-assisted positioning/ 109 drainage drainage 258, 260–2 medical unit calls 145–7 gravity-assisted 258, 260–2 Guillain-Barré syndrome 185–8 oxygen-induced respiratory postural 258, 260–2 H acidosis 146 E oxygen sensitive patients 146 haematology patient, case study risks of positive pressure early warning scores, patient 286–7 assessment 34–5 ventilation 69 head-injured patient 178–83 use of NIV in patients with ECG monitoring, patient health and safety issues, on call assessment 23–4 respiratory acidosis 146 policy/procedures 7 Cornet (R.C. Cornet®) device emphysema, chest X-ray heart failure and pulmonary interpretation 69 240–1 oedema, chest X-ray coronary artery bypass grafting endotracheal suction 267–9 interpretation 64–5 endotracheal tube positioning, Hickman catheter 212 (CABG) 190 high dependency unit (HDU) 3 coronavirus 155 chest X-ray interpretation hip fracture 165 cough 244 59 history see patient assessment ENT surgery patient 167 huffing technique 237, 238, assisted 245–7 Erdoseine 109 239–40 ineffective 77, 78–9 external fixators, surgical humidification 250–1 cough assist device 247 patients 166 hypercapnia cough stimulation/tracheal rub acute-on-chronic respiratory/ F ventilatory failure 120 248 and increased work of CPAP (continuous positive facial/intra-oral reconstruction breathing 105, 106 168 causes of acute ventilatory airway pressure) 248–9 failure 116–17 and carbon dioxide retention fatigue causes of chronic ventilatory adult intensive care patient failure 119–20 91 134 in Type II respiratory failure contraindication in hypoxaemic patients 115 111, 115, 116–19 medications for chronic pneumothorax 67 feedback ventilatory failure 120 risks with COPD 69 to other professionals 16 signs and symptoms of CO2 use in lung volume loss 91, to patient/relatives 16 retention 116 treatments 117–19 95–100 femoro-popliteal bypass 165 see also carbon dioxide CPP (cerebral perfusion flail chest, lung volume loss 93, retention hypoxaemia (Type I respiratory pressure) values 179, 181 98 failure) critical care, location of patients fluid in the lung, chest X-ray acute lobar pneumonia 114 aim of physiotherapy 113 123 see also intensive care interpretation 59–63 and increased work of unit (ICU); paediatric Flutter device 240–1 breathing 106, 107 intensive care unit (PICU) forced expiration technique bronchopneumonia 114 critical incident report (learning causes 112 context) 4, 5 (FET) 237, 238, 239–40 classification 112 croup (acute forced vital capacity (FVC) 85, clinical signs 113 laryngotracheobronchitis), common issues 113, 114–15 children 48 86, 89–90 cyanosis, in children 44 causes of decreased FVC 89 cystic fibrosis consequences of decreased medical unit calls 153, 155–6 FVC 90 sputum retention 74 functional residual capacity D (FRC) 85–9, 95 causes of decreased FRC 85, debrief after an on call event 3–4 87 consequences of decreased FRC 87–9

310 Index definition 111, 112 K lung contusions 200, 201, 202 treatment of hypoxia 113, chest X-ray interpretation 59, Kerley B lines, chest X-ray 60, 61–2 114–15 interpretation 66, 67 use of NIV 91 lung pathology, common ICU hypoxia L conditions 131–2 and increased work of laryngectomy patient 167–8 lung volume loss 85–100 breathing 106, 107 Lasting Power of Attorney and increased work of consequence of decreased VT breathing 106, 107 (LPA) 15–16 ARDS/acute lung injury 92, 89 lateral costal breathing 96 response in children 38, 44 assessment 90, 91–4 treatment for 113, 114–15 (thoracic expansion) 237, atelectasis 92, 97 238, 239 chest X-ray interpretation see also hypoxaemia learning contracts 2–3 54–9, 63 hypoxic hypoxaemia 112 learning diary/learning log 4–5 clinical diagnosis 90, 92–4 learning from on call events closing volume 85, 87 I 3–6 collapse 92, 96 case studies 5 collapse (lobar) 92, 97 IABP (intra-aortic balloon critical incident report 4, 5 consolidation 92, 96 pump) 190 debrief afterwards 3–4 effects of positioning 91 demonstration of what has flail chest 93, 98 ICP (intracranial pressure) been learned 4 forced vital capacity (FVC) values 179, 181 learning diary/learning log 85, 86, 89–90 4–5 functional residual capacity incentive spirometer 251–2 mentoring 5 (FRC) 85–9, 95 induced sputum 267 peer review 5 management by diagnosis induction, preparation for on portfolio of evidence 4–5 90, 96–100 recording your thoughts pain as cause 93, 98 call working 8–9 afterwards 3 patient assessment 18, 19, 36 infected fluid in the lung, reflection on action 4 pleural effusion 93, 99 reflective diary 3 pneumonia 96 chest X-ray interpretation learning needs assessment (for pneumothorax 93, 99 59, 63 on call working) 1, 2, 8 principles of treatment 90, infection, SIRS (systemic lobar collapse 95 inflammatory response to adult intensive care patient pulmonary oedema 94, 99 infection) 131 134 respiratory muscle weakness/ infection control, on call chest X-ray interpretation fatigue 94, 99 policy/procedures 7, 8 54–7, 59 signs and symptoms 90, inhaled foreign body, children management of volume loss 92–4 48 97 tidal volume (VT) 85, 86, 87, intensive care unit (ICU) 3 see signs and symptoms of 89, 90, 95 also adult intensive care volume loss 92 underlying unit (ICU); paediatric lobar/multilobar pneumonia, pathophysiological intensive care unit (PICU) medical unit calls 152, mechanisms 90, 91 intermittent positive pressure 154 use of CPAP 91, 95–100 breathing see IPPB lung abnormalities see chest X- use of NIV 91, 95–100 interstitial lung disease, ray interpretation medical unit calls 149, (abnormalities) lung volumes 153 lung anatomy see chest X-ray closing volume 85, 87 interstitial pneumonia 152, interpretation (normal) expiratory reserve volume 154 lung collapse (ERV) 85, 86 interstitial pulmonary oedema, chest X-ray interpretation 54, forced vital capacity (FVC) chest X-ray interpretation 58–9 85, 86, 89–90 66–7 management of volume loss functional residual capacity intra-aortic balloon pump 96 (FRC) 85–9, 95 (IABP) 190 signs and symptoms of inspiratory capacity (IC) 86 intracranial pressure (ICP) volume loss 92 inspiratory reserve volume values 179, 181 lung compliance, effects of (IRV) 86 IPPB (intermittent positive decreased FRC 87–8 pressure breathing) 252–4 contraindication in pneumothorax 67 risks with COPD 69 ischaemic hypoxaemia 112

Index 311 residual volume (RV) 85, 86 common respiratory spinal-injured patient 178, tidal volume (VT) 85, 86, 87, problems 229 183–5 89, 90, 95 consent 232 neuromedical patient 185–8 total lung capacity (TLC) 86 decision to treat or not 227 neuromuscular disorders 178, vital capacity (VC) 86 see also definition of a neonate 227 definition of a premature 185–8 forced vital capacity (FVC) neurophysiological facilitation baby 227 M definition of a term baby of respiration 254 NIV (non-invasive ventilation) manual hyperinflation 242–3 227 manual insufflation exsufflation normal values for neonatal 255–7 contraindication in 247 vital signs 228 maxillofacial surgery patient 168 risk factors in treating these pneumothorax 67 mean arterial pressure (MAP) risks with COPD 69 infants 227–8, 233 use in lung volume loss 91, values 179 techniques contraindicated in medical staff communication 95–100 neonates 234 nursing staff, communication with 13 treatment contraindications medical unit calls 145–57 with 13 232 acute asthma 147–8 treatment precautions 232 O bronchiectasis 157 treatment risks to be case study 276–9 oesophageal varices 115, 149, COPD 145–7 considered 227–8, 233 152 cystic fibrosis (adult) 153, treatment techniques and on call competency check list 155–6 modifications 233–4 2 interstitial lung disease 149, what to ask at the call out on call event 153 231 capacity issues 14–16 oesophageal varices 149, 152 neurological observations, communication issues 13–14 pancreatitis 149–50 communication with the pneumonia 152, 154–5 patient assessment 24–5 medical/nursing staff 13 pulmonary fibrosis 149, 153 neurological/neurosurgical unit communication with the renal failure 149, 151–2 patient/relatives 13 Mental Capacity Act (2005) calls 177–88 consent issues 14–16 airway protection 177–8 disagreement among (England and Wales) brain-injured patient 178–83 clinicians 13–14 15–16 case study 282–4 documentation 16 Mental Health Act (1983) 14 causes of respiratory failure patients without capacity (to mentoring, learning from on make decisions) 14–16 call events 5 177 things to consider and mobilization of patients 254, cerebral perfusion pressure prepare 13–16 255 when to seek help 14 MRSA 156 (CPP) values 179, 181 see also learning from on call mucociliary clearance, impaired features of a patent airway events; preparation for an 73–7 on call event mucolytic drugs 74, 109 177 musculoskeletal assessment 26 features of inadequate on call period, on call policy/ myasthenia gravis 185–6 procedures 7 ventilation 178 N Guillain-Barré syndrome on call policy/procedures 7–8 on call rota NAI (non-accidental injury) 44, 185–8 48 head-injured patient 178–83 appropriate and intracranial pressure (ICP) inappropriate calls 10, 12 needlestick injury 8 neonatal unit calls 227–35 values 179, 181 arrangements on the day of mean arterial pressure (MAP) your on call 10 aims of treatment 228 assessment 232 values 179 management of the common conditions in myasthenia gravis 185–6 telephone call 10–12 neurological conditions neonates and term babies on call logistics 10 229 178–88 preparation for 9–12 common issues and advice neuromedical patient 185–8 on call working, quality 230–1 neuromuscular disorders standards 1 178, 185–8 oncology unit calls 205–14 peripheral neuropathies 178, anaemia 208 185–8 respiratory management of the neurological patient 177–8

312 Index anxiety of patients and anatomical and physiological supporting parents 137 relatives 205 differences to adults 37–49 treatment precautions 141 ventilation 139–40 ascites 212 assessing children 44–7 paediatric medical ward calls aspergillosis 209 auscultation 44, 47 assessing patients with an basal metabolic rate in see paediatric unit calls paediatric surgical ward calls oncology diagnosis 205–6 infants 38 bony metastatic disease bradycardia response to see paediatric unit calls paediatric unit calls 215–26 210–11 hypoxia 38 cancer treatment modalities child protection 37, 44, 48 aims of physiotherapy chronic respiratory problems treatment 218 205 case study 288–9 41 assessment 215, 217–18 causes of respiratory clinical implications of assessment (medical ward) compromise 205–6 anatomical and 221, 223 disseminated intravascular physiological differences assessment (surgical ward) 38–42 coagulation (DIC) 210 common conditions 44, 48 221–2 effects of acute oncology communicating with a child case study 289–91 38 common conditions 208–10 communicating with parents effects of bone marrow 38 (medical ward) 222, consent issues 37 225–6 depression 207–8 cyanosis 44 common conditions (surgical effects of metastatic oncology dealing with children 16 ward) 221–2 hypoxia response 38, 44 common issues and advice 210–12 information from medical (medical ward) 222, 224 equipment used in the cancer history 43 common issues and advice NAI (non-accidental injury) (surgical ward) 220–1 setting 212 44, 48 common problems (medical Hickman catheter 212 objective information 44, 46 ward) 223 hypercalcaemia 211 oxygen delivery devices 47 common problems (surgical lymphangitis carcinomatosa oxygen demand in infants ward) 219 38 conditions requiring extreme 212 parents’ reactions 38 caution 215, 216 mucositis 208–9 refusal of treatment 37 consent in paediatrics 215 neutropenia 207 signs of respiratory distress contraindications for PICC line 212 41–2, 44, 49 treatment 215, 216 pleural effusion 211 stridor 41 inappropriate calls 215, 216 Pneumocystis carinii subjective information 43, monitors and equipment 44, 45 (surgical ward) 222 pneumonia (PCP) 209 sudden infant death paediatric medical ward calls pneumonitis 209 syndrome risk 41 222–6 side effects of chemotherapy thoracic differences 38–9, paediatric surgical ward calls 41 218–22 207–8 paediatric intensive care unit see also paediatric intensive spinal cord compression 210 (PICU) calls 137–44 care unit (PICU) calls superior vena cava age range of patients 137 pain, as cause of lung volume aims of physiotherapy 138 loss 93, 98 obstruction (SVCO) 211 airways 139 pain management 77, 80 syringe driver 212 case study 274–5 palpation 30 terminal phase of care common issues in treatment pancreatitis, medical unit calls 139–40 149–50 212–13 inappropriate calls 138 pandemic pneumonia 155 thrombocytopenia 207 inhaled nitric oxide (NO) parents tumour occluding airway 208 139 communicating with 38 orthopaedic surgery patient oxygen 139–40 reactions of 38 range of conditions seen on patient 165–6 PICU 137, 142–3 communication with 13 orthopaedic trauma 132 things to consider when osteoporosis 165 called 13–16 overpressure technique 257 oxygen delivery devices for children 47 oxygen demand in infants 38 oxygen therapy 257–8 P paediatric care airway differences 40, 41

Index 313 unable to cooperate 77, 81 peripheral neuropathies 178, positions of ease 258–60 patient assessment 17–36 185–8 positive expiratory pressure ABC assessment 17–18 peripheral vascular disease 165 (PEP) mask 240–1 auscultation 32–4 personal development plan positive pressure ventilation cardiovascular observations (PDP) 2 contraindication in 22–3 personal risk assessment 8 pneumothorax 67 changes during assessment pharyngeal suction 269–70 PICC line 212 risks with COPD 69 34 plastic surgery patient 166 postoperative patients, ICU chest pain 20 pleural effusion chest X-ray interpretation calls 133 adult intensive care patient postoperative respiratory 28–30 134 considered approach to dysfunction, increased chest X-ray interpretation WOB 106, 108 assessment 21 63–4, 65, 66 postural drainage 258, cough 20 260–2 decision-making process lung volume loss 93, 99 power of attorney 15–16 Pneumocystis carinii pneumonia preparation for an on call event 17–18, 19 2–3 drug history 20–1 (PCP) 154, 209 arrange for an induction 3 early warning scores 34–5 Pneumocystis jerovici infection learning contracts 2–3 ECG monitoring 23–4 learning needs assessment 2 four key respiratory problems 154–5 on call competency check list pneumonectomy, chest X-ray 2 to look for 18, 19 reflection 2 general observations 21–2 interpretation 54, 58 spend time on the ICU and history of present condition pneumonia HDU 3 SWOT analysis 2 18, 20 bronchopneumonia 152, 154 preparation for on call working immediate danger to the chest X-ray interpretation 59, 7–9 clinical experience 8–9 patient 17–18, 19 63 contractual issues 8 increased work of breathing children 48 health and safety issues 7 fungal 152, 154–5 identification of learning 18, 19, 36 ICU conditions 131–2 needs 8 loss of lung volume 18, 19, interstitial 152, 154 infection control 7, 8 lobar/multilobar 152, 154 on call period 7 36 lung volume loss 96 on call policy/procedures musculoskeletal assessment medical unit calls 152, 154–5 7–8 pandemic 155 on call rota 9–12 26 PCP (Pneumocystis carinii personal risk assessment 8 neurological observations referral criteria 7 pneumonia) 154, 209 response time 7 24–5 Pneumocystis jerovici infection shadow duties 9 objective history 21 things to consider when palpation 30 154–5 called to a patient 13–16 past medical history 20 SARS 155 training/induction 8–9 percussion note 32 pneumothorax professional bodies, standards potential problem list 36 adult intensive care patient for on call working 1 renal observations 24, 25 prone positioning 264–5 respiratory failure 18, 19, 36 134 protective equipment 8 respiratory observations chest X-ray interpretation Pseudomonas aeruginosa 156 pulmonary embolus 26–34 66–8, 69 adult intensive care patient shortness of breath 20 contraindication for positive 134 social history 21 hypoxaemia 115 sputum 20 pressure ventilation 67 pulmonary fibrosis sputum retention 18, 19, 36 lung volume loss 93, 99 hypoxaemia 115 subjective history 18 portfolio, evidence of learning medical unit calls 149, 153 surface anatomy/surface from on call events 4–5 marking 30–1 positioning wheeze 20 peer review, learning from on gravity-assisted drainage 258, 260–2 call events 5 PEP (positive expiratory positions of ease 258–60 postural drainage 258, 260–2 pressure) mask 240–1 prone 264–5 percussion note 32 to increase volume 263 percussion technique 258 to match ventilation/ perfusion ratio 263–4

314 Index pulmonary oedema respiratory failure, Type I deep breathing exercises 237, adult intensive care patient (hypoxaemia) 111–13, 238, 239 134 114–15 chest X-ray interpretation 59, diaphragmatic breathing 61, 64–6, 67 and increased work of 237–8, 239 hypoxaemia 115 breathing 106, 107 increased work of breathing endotracheal suction 267–9 108 use of NIV 91 Flutter device 240–1 lung volume loss 94, 99 respiratory failure, Type II forced expiration technique Pulmozyme 74 (ventilatory failure) 91, (FET) 237, 238, 239–40 111, 113, 116–20 gravity-assisted positioning/ R acute-on-chronic respiratory/ ventilatory failure 120 drainage 258, 260–2 recovery room/theatre calls causes of acute ventilatory huffing 237, 238, 239–40 168–9 failure 116–17 humidification 250–1 causes of chronic ventilatory importance of training 237 referral criteria, on call policy/ failure 119–20 incentive spirometer 251–2 procedures 7 hypercapnia 111, 113, induced sputum 267 116–20 intermittent positive pressure reflection, preparation for an increased work of breathing on call event 2 105, 106 breathing (IPPB) 252–4 medications for chronic lateral costal breathing reflection on action 4 ventilatory failure 120 reflective diary 3 signs and symptoms of CO2 (thoracic expansion) 237, relatives, communication with retention 113, 116 238, 239 treatment of hypercapnia manual hyperinflation 13 117–19 242–3 relaxation techniques 266 respiratory medical patients, manual insufflation relaxed tidal breathing 237–8, ICU calls 133 exsufflation 247 respiratory muscle efficiency, mobilization 254, 255 239 and work of breathing 101 neurophysiological renal failure respiratory facilitation of respiration muscle weakness/fatigue 254 hypoxaemia 115 increased work of breathing non-invasive ventilation ICU calls 133 105 (NIV) 255–7 medical unit calls 149, lung volume loss 94, 99 overpressure 257 respiratory muscles, effects of oxygen therapy 257–8 151–2 decreased FRC 87–8 PEP (positive expiratory renal observations, patient respiratory physiotherapy pressure) mask 240–1 treatments 237–70 percussion 258 assessment 24, 25 abdominal breathing 237, pharyngeal suction 269–70 replacement joint dislocation 238, 239 positioning 258–65 Acapella device 240–1 positioning for gravity- risk 166 active cycle of breathing assisted drainage 258, respiratory acidosis, techniques (ACBT) 237–40 260–2 adjuncts 240–1 positioning for postural consequence of decreased assisted cough 245–7 drainage 258, 260–2 VT 89 autogenic drainage 241 positioning to increase respiratory assessment see bagging technique 242–3 volume 262–3 patient assessment breathing control 237–8, 239 positioning to match respiratory distress, signs in continuous positive airway ventilation/perfusion ratio children 41–2, 44, 49 pressure (CPAP) 248–9 263 respiratory failure Cornet (R.C. Cornet®) device positions of ease 258–60 acute 111 240–1 positive expiratory pressure arterial blood gas tensions cough 244 (PEP) mask 240–1 111 cough, assisted 245–7 postural drainage 258, 260–2 consequences of 111 cough assist device 247 prone positioning 264–5 definitions 111 cough stimulation/tracheal relaxation techniques 266 hypoxaemia (Type I rub 248 relaxed tidal breathing respiratory failure) 91, 237–8, 239 106, 107, 111–13, 114–15 rib springing 266–7 management 111–21 saline nebulizer 250–1 patient assessment 18, 19, 36 types of 111, 112 ventilatory failure (Type II respiratory failure) 91, 105, 106, 111, 113, 116–20

Index 315 shaking technique 267 patient unable to cooperate SWOT analysis, preparation for sputum induction 267 77, 81 an on call event 2 suction, endotracheal 267–9 suction, pharyngeal 269–70 stab injuries 200, 201, 202 syringe driver 212 thoracic expansion exercises standards for on call working 1 stridor, in children 41 T 237, 238, 239 suction tracheal rub (cough telephone calls endotracheal 267–9 appropriate and stimulation) 248 pharyngeal 269–70 inappropriate calls 10, 12 vibrations 270 sudden infant death syndrome documentation 12 response time, on call policy/ management of 10–12 risk 41 questions to ask 10, 11 see procedures 7 surface anatomy/surface also specific conditions rib fractures 198, 201, 202 rib springing technique 266–7 marking, patient tension pneumothorax, chest risk assessment, personal assessment 30–1 X-ray interpretation 66–8 surgical unit, case study protection 8 279–82 theatre/recovery room calls round pneumonia, chest X-ray surgical ward calls 159–75 168–9 advising staff on basic interpretation 63 management 164 thoracic cage, effects of aortic aneurysm 165 disrupted integrity 105 S arterial bypass graft 165 assessment of the surgical thoracic differences in children saline nebulizer 250–1 patient 159–62 38–9, 41 SARS (severe acute respiratory axillo-femoral bypass 165 ENT surgery patient 167 thoracic expansion exercises syndrome) 155 external fixators 166 237, 238, 239 secretions, excessive, sputum facial/intra-oral reconstruction 168 thoracic surgery patient 191, retention management femoro-popliteal bypass 165 196–98, 199, 200–1 73–7 general surgery patient sepsis 131 162–4 thoracic unit, case study 285–6 complication of pancreatitis general surgery treatment thoracotomy, chest X-ray 150 precautions 164 shadow duties, preparation for hip fracture 165 interpretation 54 on call working 9 laryngectomy patient 167–8 tidal volume (VT) 85, 86, 87, shaking technique 267 major abdominal surgery SIRS (systemic inflammatory patient 162–4 89, 90, 95 response to infection) 131, maxillofacial surgery patient causes of decreased VT 89 150 168 consequences of decreased VT spinal injuries 132, 178, 183–5 orthopaedic surgery patient splash incident to eyes or 165–6 89 mouth 8 osteoporosis 165 toxic hypoxaemia 112 sputum induction 267 peripheral vascular disease tracheal rub (cough sputum retention 165 adult intensive care patient plastic surgery patient 166 stimulation) 248 134 recovery room calls 168–9 tracheostomy patient (ward- clinical signs 71–2 replacement joint dislocation increased work of breathing risk 166 based) 169–75 109 rib/sternal injuries 198, 201, blocked tracheostomy tube patient assessment 18, 19, 36 202 potential causes 71, 73 spinal injuries 132, 178, (emergency) 174 sputum retention management 183–5 common tracheostomy 71–84 theatre/recovery room calls bronchospasm 83 168–9 problems 173–4 dehydration 77, 82 vascular surgery patient 165 displaced tracheostomy tube excessive secretions/impaired ward-based tracheostomy mucociliary clearance 73–7 patient 169–75 see also (emergency) 174–5 fatigued patient with laryngectomy emergency situations 174–5 increased work of essential equipment 170–1 breathing 76–7 haemorrhage (emergency) ineffective cough 77, 78–9 pain management 77, 80 173, 174, 175 indications for tracheostomy 170 local protocols for tracheostomy care 169 methods of tracheostomy tube insertion 169 mini-tracheostomy 169, 170, 171, 172 percutaneous tracheostomy 169

316 Index surgical tracheostomy 169 vaccination record (personal work of breathing (WOB), types of tracheostomy tube protection) 8 increased 101–9 170, 171, 172 vascular surgery patient 165 bronchospasm treatments see also laryngectomy ventilation/perfusion ratio, 101, 103–4 training in respiratory positioning to match 263 clinical signs 101, 102–3 physiotherapy treatments ventilatory failure see disrupted integrity of the 237 training/induction, preparation respiratory failure, Type II thoracic cage 105 for on call working 8–9 vibrations (respiratory hypercapnia and Type II traumatic lung contusion, chest X-ray interpretation 59, 60, physiotherapy treatment) respiratory failure 105, 106 61–2 270 hypoxia and Type I treatment options see volume, positioning to increase respiratory physiotherapy 262–3 respiratory failure 106, 107 treatments volume loss see lung volume oral mucolytics 109 Type I respiratory failure see loss patient assessment 18, 19, 36 respiratory failure, Type I volumes see lung volumes reduced respiratory muscle (hypoxaemia) Type II respiratory failure see W efficiency 101 respiratory failure, Type II respiratory muscle weakness (ventilatory failure) whooping cough (pertussis), children 48 105 V sputum retention work of breathing (WOB) VT (tidal volume) 85, 86, 87, definition 101 management 76–7 89, 90, 95 during quiet respiration volume loss (static and 101 effects of reduced respiratory dynamic) 106, 107 muscle efficiency 101 X X-rays see chest X-ray interpretation