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What frequency and duration may you suggest to this patient for performing airway clearance techniques? Guidance is available to support the clinician involved in providing such care and to aid ongoing assessment of competence (. Over the years, this syndrome has been given several names, including progressive pulmonary collapse, traumatic wet lung, congestive atelectasis, shock lung and many others. Recent viral illness that has resulted in a dry cough, wheeze and breathlessness for 1/52. This resulted in the development of bronchiectatic changes. Paediatrics - Case presentation: respiratory distress + developmental delay 1. Another key area of work where physiotherapists are required to undertake respiratory care is in the provision of emergency duty/on-call services. Some of the aspects of endotracheal suction represented in the research evidence appear contradictory, and nurses must make a professional judgement about their suction technique based on the individual circumstances of patients. C/O nausea following overnight feed via PEG tube, SV 28% O2 via venturi system mask SpO2 85% RR 34, Hyperinflated, chronic bronchiectatic/fibrotic changes throughout upper and mid zones bilaterally Intravenous access device in situ. What signs and symptoms would you highlight to your patient to recognize at the start of an exacerbation? All subjects used both circuit A (without a visible manometer) and B (with a visible manometer) in a predetermined random order. In respiratory distress. It study describes 10 therapy pitfalls in case report writing. Breathing pattern shallow, apical with active expiration, Coarse inspiratory crackles transmitting throughout chest on background of high-pitched expiratory wheeze, Limited chest excursion on inspiration (right = left) Secretions palpable upper, anterior chest wall, Admitted to respiratory ward with acute exacerbation of COPD, Diagnosed 5 years ago with severe emphysema. Monthly bulletin of the Ministry of Health and the Public Health Laboratory Service, Journal of the National Medical Association, Safety aspects of mobilising acutely ill patients, Acute respiratory distress syndrome: Searching for a satisfactory definition in the new millennium, Secretion clearance by manual hyperinflation: Possible mechanisms, Potential hazards of tracheo-bronchial suctioning, Hemodynamic effects of manual hyperinflation in critically mechanically ventilated patients, Endotracheal suction for adult, non-head-injured, patients. As an out-patient he had a CT scan, which showed brain and spinal metastases, and he has been suffering uncontrollable pain. Be supported by appropriate evidence with … To establish the levels of pressure used to perform tracheal suction (TS) and if they are affected by having a manometer visible in the suction circuit. Trache size 8.0 (with inner tube, non-fenestrated) Speaking valve in situ. Guidance is available to support the clinician involved in providing such care and to aid ongoing assessment of competence (Chartered Society of Physiotherapy 2002). … How would you assess as to whether the deep breaths the patient was attempting to take were effective? Patient problems identified from the assessment generally fall into three main categories: loss of lung volume, secretion retention and increased work of breathing. Stable overnight, difficulty clearing secretions, SV FiO2 0.28 via face mask cold humidification RR16 SpO2 89%, Scoliosis, rotated, hyperinflated, nil focal. Case Studies in Physiopedia. Learning outcomes Level 1 case study: You will be able to: describe the risk factors describe the disease describe the pharmacology of the drug outline the formulations available, including drug molecule, excipients, etc. Considering this patient’s CXR (Figure 5.2), what additional hardware/monitoring is visible? Measurements of aortic blood flow (by esophageal Doppler ultrasonography), systemic blood pressure, tidal volumes (by respirometry), and inspiratory pressures in the ventilator circuit were measured on the ventilator, during six intended manual hyperinflations (tidal volume > 150% that delivered by ventilator) using a 2-L rebreathing bag, and at 1, 5, 10, and 15 min after reconnection to the ventilator. This patient developed ARDS due to severe pneumonia. Bowels not opened for 2/7 previous. View on PubMed. To be accepted for publication in Physiopedia case studies must: Only use skills that are within the scope of practice of the physiotherapy profession. Significant changes in cardiac output can occur and appear to be related to the tidal volume rather than pressure generated. Patient has been coughing – effective and occasionally moist, nil expectorated. Print Book & E-Book. X-ray for Case Study 6 taken prior to extubation showing the patient has a scolosis with hyperinflated lungs and nil focal in lung fields. This case discusses the essential components of a case report, important issues of respiratory confidentiality, and how authorship should be determined. This can be a very challenging area of work for the physiotherapist on-call, who needs to think clearly while being faced with an acutely unwell patient who is in need of their attention, whatever the time of day. Objectives Case presentation. CHAPTER FIVE Case studies in respiratory physiotherapy, Lead authorJanis Harvey, with contributions fromSarah Ridley, Jo Oag, Elaine Dhouieb, Billie Hurst, Case study 10: Intensive Care – Surgical Patient 51. What could be your initial treatment plan for each of these problems? In respiratory distress. Attending routine multidisciplinary bronchiectasis clinic appointment, Diagnosed 6/12 ago with bronchiectasis following an in-patient admission with community-acquired pneumonia (CAP) in her right lower lobe. Patients were disconnected from the ventilator to enable six manual hyperinflations to be given. Describe the advantages and disadvantages of patient-controlled analgesia (PCA). Two episodes of frank haemoptysis also reported. Like all other areas of physiotherapy practice, respiratory physiotherapy involves accurate patient assessment in order to identify patient problems. Case Studies. The procedure for endotracheal suctioning was perceived as a problem by the members of a quality circle in the intensive care unit (ICU). Acute respiratory distress syndrome (ARDS) [chest Xray R] Is a life-threatening condition of seriously ill patients, characterized by poor oxygenation, pulmonary infiltrates, and acuity of onset. Pyrexial and requiring intravenous fluids. What is the significance of this information? Respiratory physiotherapy has a place in the treatment programme at all stages of a disease or illness from initial diagnosis, throughout both chronic and acute phases. Access scientific knowledge from anywhere. Volume restoration may be important in promoting secretion clearance, as airway closure is likely to result in a mechanical obstruction to the mucociliary apparatus. The physiology of acid-base balance is reviewed and the causes and presentation of the four acid-base disturbances is described. Physical therapy may be indicated for patients in the intensive care setting when they have retained secretions and radiological evidence of atelectasis or infiltrate, or as prophylaxis in conditions such as acute head injury and smoke inhalation.1 Physical therapy interventions include postural drainage, breathing exercises, percussion, vibration, manual hyperinflation, coughing, huffing, and suction. Log In or, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), on Case studies in respiratory physiotherapy, Like all other areas of physiotherapy practice, respiratory physiotherapy involves accurate patient assessment in order to identify patient problems. What would you look for in a patient assessment that might indicate to you a patient is ready for extubation? Such services are available to patients who have a condition amenable to physiotherapy, which has either deteriorated or is likely to deteriorate without intervention before daytime service resumes (Scottish Intercollegiate Guideline Network 2004). As a result he has been bed bound for the past month and has required increasing support from Macmillan oncology nurse specialists, Until 2/12 ago independent with walking stick, able to walk to local shops approximately 100 m, Patient admitted with a decreased GCS, frail, emaciated Family very concerned, emotional and distressed by patient’s breathing pattern and audible secretions, SV 4L O2 via non-venturi system mask, unhumidified SpO2 95% RR 10–22, Previous CXR (1/12 ago): white out of right lung field, secondary to bronchus obstruction, Pain at lower back region in keeping with spinal metastases, Flushed, drowsy, intelligible speech with audible secretions. Falls in cardiac output correlated to the increase in tidal volume but not to the increase in peak inspiratory pressure and took up to 15 min to recover to baseline values. What are the specific signs of hyperinflation on this patient’s X-ray (Figure 5.1)? However, it must be remembered that patients requiring such care may not be in these ward areas exclusively. H+ 36.35 nmol/L pCO2 5.91 kPa pO2 7.42 kPa HCO3− 28.2 mmol/L BE+ 4.7, Temp 36.5°C HR 85 BP 110/50 Noradrenaline 8 mL/hr, Pain score VAS 3/10 at rest 8/10 on movement/coughing, UO 50 mL/hr +3.2 L cumulative balance to date, Hyperinflated chest, looks well, chatting freely, dry mouth, Breath sounds throughout, coarse expiratory crackles throughout, Expansion equal, palpable secretions bilateral upper zones, Day 2 post laparotomy for right hemicolectomy (end to end anastomosis), Elective admission for bowel resection – investigated 6/12 ago due to altered bowel habit and weight loss. Why do post-operative patients tend to have a significant positive fluid balance? Why is metabolic acidosis a common finding when analysing the ABG of a post-operative patient? Which position would you choose for this patient and why? How might your initial treatment plan address this problem of increased WOB? Respiratory on call e-learning modules The Chartered Society of Physiotherapy (CSP) is the professional, educational and trade union body for the UK's 59,000 chartered physiotherapists, physiotherapy students and … What would your initial treatment plan include? Following discussion it is now evident that the patient’s knowledge about her condition is sparse. Consider this patient’s CXR report, chest shape and breathing pattern. Pressures set without a visible manometer (circuit A) were significantly higher (P <.05) than those using a visible manometer (circuit B) but the applied pressures were not significantly different (P =.166). Please find here a selection of cases we have assessed and treated. What goals would you hope to have achieved before this patient was discharged home? Drives a car. We hope this gives you a little more detail and understanding of what we do and how we do it. Patient confused and drowsy since return from theatre. The International Degree in Physiotherapy is taught jointly by the University School of Health and Sport (EUSES-UdG), a learning centre affiliated with the University of Girona and the School of New Interactive Technologies (ENTI-UB), affiliated with the University of Barcelona. Dehydrated. To assess the hemodynamic effects of manual lung hyperinflation in mechanically ventilated patients and to measure the different inspiratory pressures and tidal volumes generated by different operators. Download for offline reading, highlight, bookmark or take notes while you read Clinical Case Studies in Physiotherapy E-Book: A … The mortality rate was 58% and on pathology the non-survivors had heavy lungs, atelectasis, interstitial and alveolar oedema and hyaline membranes. No consistent change was noted in either blood pressure or heart rate. These real examples from the service show the difference good support can make to a person living with a lung condition. A problem-orientated treatment plan may include a combination of a number of interventions such as mobilisation, positioning, breathing techniques (e.g. It is required when the normal coughing mechanism is inadequate or disrupted; for example, where there is underlying respiratory or neurological disease, or where the cough is deliberately suppressed by sedative, muscle relaxants or anaesthetic agents while a patient is undergoing intermittent positive pressure ventilation. What is the difference between fixed and variable oxygen therapy? exacerbation of COPD, and those requiring critical care. Case studies. Case studies from CSP members who demonstrate some of those digital solutions they've had to employ to deliver a physiotherapy service Share We’ve gathered the case studies below to highlight the challenges, solutions, and benefits of using digital solutions to deliver physio services remotely. ResearchGate has not been able to resolve any citations for this publication. Why are patients who have undergone surgery/anaesthetic at risk of developing respiratory compromise? 2 L O. On occasion the most acutely unwell patients are in the general ward areas and not within critical care as expected. A respiratory assessment is mainly indicated for patients who have undergone surgery, those with medical respiratory conditions, e.g. Systematically analysing this patient’s CXR (Figure 5.3), what signs do you find that would confirm bibasal loss of lung volume? MEASUREMENTS and results: All set pressures (mean = 228.57 mmHg) and all applied pressures (mean = 359. Although the condition has been known for over a century, since the first clinical description of the acute respiratory distress syndrome (ARDS) in 1967, very few acronyms have become as popular and received as much attention in respiratory and critical care medicine. Respiratory case studies Patients who have been referred to the community respiratory service have benefitted from personalised support to help them manage their condition. Further research is required to determine if manual hyperinflation can be performed to create the correct profile for annular flow. When awake, able to talk in short sentences but appears slightly disorientated. No family living locally. Tumour identified and biopsy taken during colonoscopy, Lives alone, independent with ADL, non-smoker, Acute desaturation this morning requiring increased FiO2, not been out of bed as yet due to reduced blood pressure, otherwise stable, SV FiO2 0.6 via face mask cold humidification RR 12 SpO2 96%, Pain score VAS 2/10 at rest 3/10 on movement/coughing, Epidural analgesia (Bupivacaine and Morphine mix), UO 30 mL/hr +1.5 L cumulative balance to date, Breath sounds throughout, reduced at left base, Reduced expansion left base, no secretions palpable, Day 3 post-laparotomy for bowel resection, Presented to A&E with painful distended abdomen. List this patient’s physiotherapy problems(s). Normally manages all ADL independently. Review of literature – ethical issues surrounding the case 2. Acute desaturation this morning requiring increased FiO. Active expiration, Quiet BS generally with end expiratory polyphonic wheeze throughout, Decreased expansion bi-basally (right = left). What could be suggested as a management strategy if the patient required regular suctioning and why? Colour – flushed. Choose a case study below to test your knowledge Buy Clinical Case Studies in Physiotherapy: A Guide for Students and Graduates, 1e (Physiotherapy Pocketbooks) by Lauren Jean Guthrie Respiratory … The name of the case for physiotherapists book that this report is describing is The Testament, by be a … Given this patient’s present condition and past history, how might you need to modify the treatments delivered? Moving all four limbs, Obese man with barrel shaped chest and large abdomen. Request PDF | On Dec 31, 2009, Janis Harvey and others published Case studies in respiratory physiotherapy | Find, read and cite … What may be the contributing factors? We welcome examples and case studies from all aspects of physiotherapy practice, research, education, and service delivery. Respiratory Physiotherapy. Manual hyperinflation is also used by physiotherapists to promote secretion clearance in intubated patients, with some suggesting that the technique mimics a cough. To read the full-text of this research, you can request a copy directly from the authors. CT revealed free gas, fluid and faeces in the abdomen and a pelvic collection, Problems with cuff leak on repositioning. , 13/12 femalePC Respiratory distress + uncontrolled sputum production 3. No palpable secretions, Day 2 post-laparotomy for anterior resection (end to end anastomosis), Emergency admission yesterday with increasing abdominal pain, Lives with wife, recently retired, independent with ADL, plays golf three times a week, smoker 5 cpd, Acute desaturation this morning. Smokes 30 cpd, GP letter states that patient has not picked up repeat prescription for inhalers from 1/12 ago, Admitted overnight. After identifying an appropriate treatment plan, what information/instructions would you handover to the nursing staff caring for the patient? What suggestions might you make? Download Citation | Clinical Case Studies in Physiotherapy | Starting a placement or rotation in an unfamiliar clinical area is exciting but can be daunting. Your patient seems reluctant to undertake airway clearance management, how will you motivate your patient to undertake regular treatment? Case studies in respiratory physiotherapy Respiratory therapists have long been known as keen innovators in clinical practice, and many of us consider this to be central to our professional identity. Endotracheal suction, when performed in the unit, appeared to be carried out according to the nurses' experience and expertise, and had no formal research backing. If the initial treatment plan were to be unsuccessful in clearing secretions, how would you modify your treatment? Physiotherapists working in any clinical area may be required to undertake a respiratory assessment and provide respiratory care. This patient failed two attempts at extubation and so had a tracheostomy inserted to facilitate weaning. Figure 5.2 X-ray for Case Study 6 taken prior to extubation showing the patient has a scolosis with hyperinflated lungs and nil focal in lung fields. Evidence does exist, however, that secretion clearance may occur with slower expiratory flow rates via annular two-phase gas-liquid flow, provided inspiratory flow rate is slower than expiratory flow rate. All rights reserved. IPPB, CPAP) or more invasive measures (e.g. Case cases are, however, often respiratory in their study and, therefore, we need to be cautious of the weight assigned to their conclusions. Normally 1–2 exacerbations per year that are managed by GP. 52 mmHg) were significantly higher (P <.001) when compared to the expected pressures (mean = 135 mmHg). Why can the presence of an epidural lead to hypotension? Manual hyperinflation is used by physiotherapists to maintain or restore lung volume in the intubated patient. It is important, therefore, that all physiotherapists are familiar with respiratory assessment and intervention. Considering this patient’s condition and lifestyle what would be the advantages and disadvantages to each of the treatments mentioned in the previous question? What would be your initial treatment plan? You can request the full-text of this article directly from the authors on ResearchGate. Questionnaire results showed 31 % of subjects considered 100-170 mmHg a safe and effective suction pressure whilst none reported using an objective means of measuring pressure. What would be your short-term goals for this patient? Sample of case … List this patient’s physiotherapy problem(s). Click on the flags below to change language © 2016 Lung Foundation Australia Arterial blood gas analysis has become an essential skill for all healthcare practitioners. Sixty-four nurses and physiotherapists who regularly apply TS to patients in the intensive care units of this hospital. The patient is drowsy with a RR of 9. This study was designed to compare the effects of deep breathing and ambulation on pattern of breathing in patients after upper abdominal surgery. ISBN 9780702030031, 9780702039300 Is this patient adequately oxygenated? by Wendy Emberson (more info) ... originally published in issue 36 - January 1999. In the theoretical part is defined the term recidivous respiratory infection, physiological morbidity and immunological test indication. Multiple hospital admissions over last 3 years due to exacerbation of CF. What outcome measures will you use to evaluate the effectiveness of your intervention? Studies have shown reversal of volume loss in this patient group using manual hyperinflation; however, the impact of volume restoration on secretion clearance has not been studied extensively. Deep breathing and ambulation are used by physiotherapists for patients after surgery, however the precise effects of these on ventilation have not been investigated. Clinical Case Studies in Physiotherapy E-Book: A Guide for Students and Graduates - Ebook written by Lauren Jean Guthrie. Case studies in respiratory physiotherapy Slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising. No previous hospital admissions for COPD, Retired engineer. Cardiothoracic surgery and paediatrics are other specialist clinical areas that physiotherapists are involved in providing respiratory care. Poor oral intake for 1/52 – dehydrated and weak, Mild learning difficulties, irritable bowel syndrome, Lives with partner, home help twice a week, otherwise independent, Stable since admission; plan to keep sedated for at least 24 hours, Uncut ETT size 8.0 SIMV FiO2 0.65 PEEP 10 SpO2 96% RR 25/0 mandatory/spontaneous Tv 0.55 L nil-M1 secretions, Collapse consolidation left lower zone, patchy changes right middle zone, H+ 53.8 nmol/L pCO2 6.9 kPa pO2 10.7 kPa HCO3− 24 mmol/L BE –1.2, Temp 38°C HR 90 BP 95/55 CVP +12 Noradrenaline 26 mL/hr, Sedation – Propofol 10 mL/hr, Alfentanil 2 mL/hr, No result as yet, commenced on broad-spectrum antibiotics, Breath sounds throughout, bronchial breathing left lower zone, Admitted via A&E drowsy, sweaty and ‘unwell’. Other parameters including haemoglobin, platelet count, white cell count, and more subjective factors, such as the patient's appearance, level of pain, and fatigue, also should be considered. for the medicines summarise basic social pharmacy issues (e.g. Following two physiotherapy sessions with modified ACBT that morning, you feel that the patient is becoming more exhausted and unable to clear her secretions effectively. It has been proposed that the fast expiratory flows generated during cough clear secretions via mist flow, one type of two-phase gas-liquid flow. Another key area of work where physiotherapists are required to undertake respiratory care is in the provision of emergency duty/on-call services. If your initial treatment was unsuccessful in clearing the secretions, how might you modify your treatment? What factors may be contributing to this increased WOB? observations of the patient; consideration of trends in physiological observations (e.g. Figure 5.3 X-ray for Case Study 8 showing reduced lung volume bi-basally.

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