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PNEUMONIA: INTERRUPTION OR OPPORTUNITY? THE ROLE OF AUSCULTATION

OUTLINE Sharon Coffman MMSc PT CCS

April 16, 2016; 2-3:50 pm I. The Clinical Interruption: acute respiratory infection A. the common cold B. viral pneumonia C. bacterial pneumonia II. The Role of Auscultation A. Positive outcomes B. Lung SoundsTerminology & Pathophysiology: 1. Breath sounds 2. Vocal sounds C. Pre- and Post- findings D. Meet Chester III. The Clinical Opportunity: skilled PT A. Prevention teaching: shared surfaces and airborne transmission B. Treatment interventions IV. Documentation and Communication V. Application in Case Scenarios in Rehab

OBJECTIVES Learner will be able to:

1. identify reportable symptoms of pre- or new onset of pneumonia which would normally prompt a “hold” on therapy session that day.

2. identify typical auscultation techniques recommended to assess the severity of the condition: stethoscope placement and abnormal lungs sounds heard.

3. provide specific and valuable breathing exercises and education points in a billable session.

4. document findings most needed for reporting the condition to physicians.

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I. The Clinical Interruption: acute respiratory infection, fever, malaise, wheezing, increased HR, increased SOB. Patient will likely decline Rehab. A. the common cold B. viral pneumonia – hydrate, comfort, humidifier, rest. Secretions are clear or white (NO COLOR) C. bacterial pneumonia – 1. different bacteria put out different colors: yellow, green, rust 2. is superimposed on viral infection D. the typical candidates: the secretions producing diagnoses: 1. COPD: chronic bronchitis 2. recurrent pneumonia and childhood hx of pneumonia (<9 yo) 3. CF and bronchiectasis. II. The Role of Auscultation A. Positive outcomes: shorter “on hold” periods, billable visit, productivity, physician notification with supporting objective documentation especially time frames of onset of illness. B. Lung SoundsTerminology & Pathophysiology: 1. Breath sounds Adventicious sounds: rales (coarse crackles), wheezes (rhonchi) Volume differences: normal, diminished bronchial (louder than normal)

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2. Vocal sounds: “E” sounds A positive “E to A change”

Bronchial (whisper “blue moon” or “1-2-3”)

The “megaphone effect” 3. Palpable Signs: Fremitus or Palpable Fremitus: vibration caused by voice or secretions in the airways transmitted to the chest wall, thus palpable by the hand. Use if you have no stethoscope available. 4. Errors to avoid: *mistaking chest hair for fine rales *mistaking joint crepitus (listener’s digits) *listening in a noisy room *allowing clothing noise as lung sound *allowing tubing to rub against patient, clothing *avoiding the true areas needed for convenience C. Pre- and Post- findings: prove beneficial outcome D. Meet Chester

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III. The Clinical Opportunity: provide skilled PT A. Prevention teaching: shared surfaces and airborne transmission 1. give the 10 second speech 2. handwashing and waterless soaps 3. airborne exposure 4. restrict exposures of others who are ill, coughing or sneezing; respect seasonal allergies, however, which are not contagious but have alarming symptoms. 5. restrict school aged children B. Treatment interventions 1. deep breathing intervention Segmental breathing Pursed Lip Breathing Diaphragmatic breathing Unilateral deep breathing Maximal Inspiratory Hold (sigh) Incentive Spirometer 2. cough and cues: “active coughing” intervention Sitting position: ideal Loud noise with cough Prolonged expiration force Multiple rests for power, E-saving 3. cough stim techniques: laughing, position change, devices. Quick Position change Laughing, loud talking Tracheal Tickle Huffing Devices: Acapella, Flutter 4. secretion mobilization techniques: Chest PT, physician order is recommended for more aggressive interventions. 5. expectorate into tissue vs swallow???? _________________ 6. gloves vs no gloves???? _________________

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IV. Documentation and Communication: Physician notification: same day A. Vital signs: *HR, BP, *O2 saturation, RR, *temp if thermometer available. Skin clammy. 1. watch for HR to rise 10 bpm for every degree >99. 2. watch for O2 sat to be 2-4% lower than normal B. Lung sounds 1. **Most indicative of acute infection: the presence of bronchial breath sounds, “E to A” change, and course rales. 2. Other significant lung sounds include new or unusual wheezing NOW, HOW DO YOU KNOW THAT YOU HAVE DONE ANY GOOD? ? ? ? ? ? #1 Auscultate PRE- and POST- intervention or exercise Example: ”+E to A changes in ant. Segment of LUL. E sounds normalized after deep breathing instruction.” Example: “Bronchial breath sounds normalized after educ re: unilateral deep breathing to R lung, PLB, and max insp. hold maneuver.” Example: “+E to A changes in RML. E sounds normalized after cough instruction and cough productive x2 mod. amt. thick phlegm” Example: “O2 sat improved 87% to 91% on RA w/ deep breathing training.” Example: “Bronchial breath sounds normalized in LLL after cough instruction and prod x5 small amounts greenish sputum, very tiring. “

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V. Application in Case Scenarios in Rehab Patient UT: HR 90 (usually 80) O2 sat 93% (usually 95%) Lungs: palpable fremitus over R post chest which cleared with instruction in active coughing. After a productive cough x2 with light green sputum. Rx: patient was instructed in deep breathing and active coughing; patient received education on increasing hydration to thin secretions. Patient BR: HR 90 (usually 80) O2 sat 93% (usually 95%) T 99.8 oral Lungs: L LL with new wheezes, bronchial breath sounds and + E to A change that normalized, after instructed in active coughing, with a productive cough x2 thick yellow sputum 1/2 tsp. Patient CR: HR 84 (usually 60) Has palpable vocal fremitus over L posterior chest Has a reflexive wet cough with deep breathing Skin is warm and clammy. After instruction in active coughing, patient swallowed some sputum x3. Patient PB: HR 102 (usually 99), O2 sat 94% (usually 97%) T 100 oral Lungs: R LL with bronchial breath sounds, + E to A change and coarse crackles in R base. Cough: poor strength, wet, non productive After practice with active coughing and deep breathing, his RLL had normal lung sounds, normal E sounds and crackles resolved.