© S Collins 2020

Pulmonary Examination – Evaluationfor Physical Therapists

Sean Collins, PT, ScDProfessor & Director, Plymouth State University DPT Program

Director, PSU DPT Breathing ClinicEditor, Cardiopulmonary Physical Therapy Journal

Purpose• Basic review of pulmonary examination and evaluation

• Preparation for– possible surge situations in different regions of the country– possible redeployment of PTs to areas of need as part of

employment or volunteer opportunities

Ø Note – I am not suggesting that this presentation will equip you for immediate deployment in an ICU

Ø Also – at this point PTs in many locations are not being utilized to minimize use of PPE and to limit exposure and risk

I am aware of both points – my only purpose is to provide education to anyone interested in being educated just in case in the spirit of preparedness

© S Collins 2020

© S Collins 2020

Examination links to Intervention via…

Evaluation• Questions are asked & answered in this

process

© S Collins 2020

© S Collins 2020

© S Collins 2020

© S Collins 2020

Relevant evaluation questions for this presentation (assuming acute care facility after COVID-19 diagnosis or suspicion)

1. Is this patient stable?2. Is instability related to airway clearance, positioning or

breathing pattern?3. Is there an increased demand for airway clearance?4. Considering physical activity along the way (but not

specifically covered in this discussion given your backgrounds)

5. Is there an endurance limitation (for future sessions –particularly related to early mobility and ICU mobility)

© S Collins 2006

Comes down to three foci

• Stability – what does this mean for pulmonary function?

• Airway clearance – demand, capacity and how to examine

• Mobility (particularly whether it is effective in the case of needing airway clearance)

© S Collins 2020

Stability is

• a dynamic systems concept• about achieving homeostasis (attain)• being able to maintain homeostasis during

perturbations and variations (sustain)• I.e. - If someone can attain stable oxygen

levels we then need to consider whether they can sustain those levels

• Therefore – it’s dynamic systems concept© S Collins 2020

Pulmonary function as a dynamic system of inter related functions

• Ventilation – moving air (bulk flow)– Total ventilation -> Alveolar ventilation– Breathing patterns– Posture & position

• Respiration – moving gases (diffusion, gas exchange)– Alveolar ventilation– Alveolar health– Pulmonary blood flow to ventilated alveoli

• Influenced by position• Ventilation enables Respiration; Respiration controls

Ventilation© S Collins 2020

© S Collins 2020

© S Collins 2006

Ventilation & Respiration requires…..

• Bronchopulmonary Hygiene – ability to keep the airways healthy via normal ventilation

• Airway Clearance – ability to clear the airways when substances need to be cleared

• These are BOTH functional tasks

• Activity, mobility and movement supports healthy BPH and AC (causally) and are associated with health BPH and AC

© S Collins 2006

• Pulmonary Function Tests ð Ventilation & Respiration• Chest X-Ray ð Ventilation • Arterial Blood Gases ð Respiration• SpO2 ð Respiration• Lung Sounds ð Ventilation• Ventilatory Muscle Strength ð Ventilation • Breathing Mechanics ð Ventilation • Breathing Patterns ð Ventilation / Respiration(Note – mechanics: can they use diaphragm; patterns: are they using diaphragm)

Pulmonary Assessment Tools

© S Collins 2006

• Arterial Blood Gases ð Respiration• SpO2 ð Respiration• Breathing Patterns ð Ventilation / Respiration

Stability Achieved?

ABGs – SpO2

• ABGs– PaO2– PaCO2– pH– Bicarbonate

https://www.youtube.com/watch?v=AThF0r_FibU&feature=youtu.be

© S Collins 2020

ABGs – SpO2

© S Collins 2020

Breathing pattern• In light of the ABGs or SpO2 - - -• What is the breathing pattern?

– Rate– Depth– Mouth vs. nose– Accessory muscles– Diaphragm– Chest wall movement / excursion

• In other words – how hard are they working for this stability?

© S Collins 2020

© S Collins 2006

Even if not working hard right now – consider longer time frames in light of:

• Pulmonary Function Tests ð Ventilation & Respiration• Chest X-Ray ð Ventilation • Lung Sounds ð Ventilation• Ventilatory Muscle Strength ð Ventilation • Breathing Mechanics ð Ventilation

Stability can be sustained?

PFT’s0

5

1

4

2

3

Lite

r

1 65432

FVC

FVC

FEV1

FEV1

Normal

COPD

3.9005.200

2.3504.150 80 %

60 %NormalCOPD

FVCFEV1 FVCFEV1/

Seconds

PFT’sMild COPD• FEV1/FVC < 70 %• FEV1 > 80 % predicted

• With or without symptoms

Moderate COPD•FEV1/FVC < 70%•50% < FEV1< 80% predicted•With or without symptoms

Severe COPD•FEV1/FVC < 70%•30% < FEV1 < 50% predicted

•With or without symptoms

Very Severe COPD•FEV1/FVC < 70%•FEV1 < 30% predicted or presence of respiratory failure or right heart failure

© S Collins 2006

Hyperinflation

• Irreversible (chest x ray; Hoover’s sign; barrel chest; accessory muscle use; chest wall mobility; lung sounds)

• Reversible or Dynamic (chest x ray; Hoover’s sign; barrel chest; accessory muscle use; chest wall mobility; lung sounds)

© S Collins 2006

O’Donnell et al. 2001. Am J Respir Crit Care Med 164: 770-777

© S Collins 2006

O’Donnell et al. 2001. Am J Respir Crit Care Med 164: 770-777

© S Collins 2006

Hypoventilation

• Can be caused by Hyperinflation (as in obstructive conditions) or from restrictive processes– ILD– Pneumonia– Masses– Pleural effusions

Breath Soundshttps://www.med.ucla.edu/wilkes/lungintro.htm

Houle, 2020

Auscultation

• Bell: more effective at transmitting lower frequency (low pitch) sounds

• Diaphragm: more effective in transmitting higher frequency (high pitch sound)

• Ear piece facing forward

Houle, 2020

Auscultation

Houle, 2020

Houle, 2020

What Are You Listening For?

• Quality and amplitude of breath sounds

• Identify if gap between inspiratory and expiratory sounds

• Listen for any added sounds

https://www.med.ucla.edu/wilkes/lungintro.htm

Houle, 2020

© S Collins 2006

Breathing Mechanics / Chest wall ð Ventilation

• Normal Movements – how to measure? evaluate?

• Paradoxical movements• Accessory muscle use• Measurement

– Palpation– Tape measure– Hoover’s sign

© S Collins 2006

Ventilatory Muscle Strength ð Ventilation

• Maximal Inspiratory Pressure• Maximal Expiratory Pressure • Endurance• Relationship between strength and

endurance

© S Collins 2006

Breathing Patterns ð Ventilation / Respiration

• Ve = Vt x RR– How does pattern / balance of Vt and RR

influence alveolar ventilation?• How do you assess this influence?

© S Collins 2020

Is stability impacted by airway clearance, position or breathing pattern?

• Cough strength and productivity• Presence of mucus Don’t be afraid to ask MD/RN• Pulmonary Function Tests effective expiratory flow?• Chest X-Ray• Arterial Blood Gases / SpO2 Changes with position or after

mucus production• Lung Sounds changes with mucus production or cough• Ventilatory Muscle Strength strong enough?• Breathing Pattern and Mechanics is diaphragm an option?

© S Collins 2020

© S Collins 2020

Is there an increased demand for airway clearance?

• Presence of mucus Don’t be afraid to ask MD/RN• Consider cough strength and productivity• Consider whether activity can meet the demand

It is important to consider that in the majority of COVID-19 cases mucus is not a factor

If it is a factor then first consider whether activity and mobility can be utilized to keep AC effective.

We consider this based on changes in status across time

© S Collins 2020

Upcoming presentations• Wednesday, April 1st – Pulmonary Interventions• Wednesday, April 8th – Early Mobility Considerations

(including basics on mechanical ventilation)• Wednesday, April 15th – Long Term Rehabilitation

ConsiderationsAll a 12 noon eastern time; all will be recorded and postedhttps://breathingclinic.org/covid-19-resources-for-physical-therapists/

© S Collins 2020