RESPIRATORY ASSESSMENT for ventilated and non-ventilated patients, including blood gases and x-rays.
(for exercise testing, see Exercise)
To convert: kPa ↔ mmHg - www.unit-conversion.info/pressure.html
BREATH SOUNDS
www.cvmbs.colostate.edu/clinsci/callan/breath_sounds.htm
ACID-BASE TUTORIAL
www.acid-base.com/terminology.php#SBic2
AARC CLINICAL PRACTICE GUIDELINE: Pulse oximetry
www.rcjournal.com/online_resources/cpgs/pulsecpg.html
exercise testing for evaluation of hypoxaemia and/or desaturation
Ahlers SJGM (2008) Comparison of different pain scoring systems in critically ill patients in a general ICU. Crit. Care, 12, R15
ccforum.com/content/12/1/R15
comparison of the visual analogue scale, numerical scale and behavioural scale
Anderson S (1990) ABG's - six easy steps to interpreting blood gases. Am J Nurs, 90, 8, 42-5
Binnekade JM (2006) The reliability and validity of a new and simple method to measure sedation levels in intensive care patients. Heart Lung, 35, 2, 137-43
www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WG7-4JG8D4R-H&_user=10&_handle=V-WA-A-W-AD-MsSAYVA-UUA-U-AACEBVECWU-AACZEBUBWU-YEWEVUBZ-AD-U&_fmt=summary&_coverDate=04%2F30%2F2006&_rdoc=15&_orig=browse&_srch=%23toc%236815%232006%23999649997%23618713!&_cdi=6815&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=ed1cc9f14b7bddee646a937e751bd756
sedation scale which reduces over-sedation and simplifies assessment in the ICU.
Birring SS, Prudon B, Carr AJ et al (2003) Development of a symptom specific health status measure for patients with chronic cough. Thorax, 58, 339-43.
thorax.bmj.com/cgi/content/full/58/4/339?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=relevance&volume=58&firstpage=339&resourcetype=HWCIT
Bremner H, Carriere B (1999) Evaluation of breathing mechanisms in patients with pelvic floor dysfunction. WCPT Proceedings. p.578
Chanques G et al (2006) Impact of systematic evaluation of pain and agitation in an intensive care unit. Crit Care Med, 34, 6, 1691-9
accurate assessment of pain and agitation reduces duration of mechanical ventilation and hospital-acquired infections
Chiles C, Ravin C (1986) Radiographic recognition of pneumothorax in ICU. Crit Care Med, 14, 677-80
journals.lww.com/ccmjournal/Abstract/1986/08000/Radiographic_recognition_of_pneumothorax_in_the.2.aspx
how to identify pneumothorax and hydropneumothorax in a supine patient.
Connolly MA (2001) Black, white and shades of gray: common abnormalities in chest radiographs. AACN Clin Issues, 12, 259-69
www.aacnclinicalissues.com/pt/re/aacn/abstract.00044067-200105000-00009.htm;jsessionid=D48oT8PdT9msfbUhDRFB24d3SZbnLeBWhzqhIKW51KXDWJZeGiVZ!-477899252!-949856144!9001!-1?index=1&database=ppvovft&results=1&count=10&searchid=1&nav=search (abstract only)
systematic examination, common abnormalities, examples
Cornock MA (1996) Making sense of arterial blood gases and their interpretation. Nursing Times, 92(6), 30-31
www.nursingtimes.net/nursing-practice-clinical-research/making-sense-of-arterial-blood-gases/200822.article
Cuthbertson BH (2008) Optimising early warning scoring systems. Resuscitation, 77, 153-4
review of two papers on the effectiveness of early warning scoring systems
Garcia-Pachon E (2002) Paradoxical movement of the lateral rib margin (Hoover sign) for detecting obstructive airway disease. Chest, 122, 651-5
Hoover sign is easy to recognise and useful for detecting obstructive airway disease
Gershman NH (1996) Comparison of two methods of collecting induced sputum. Eur Resp J, 9, 2448-53.
Gilbert (1989) Detection of pneumonia by auscultation in the lateral decubitus positions. Am Rev Respir Dis, 140, 1012-16.
Greco FA (2004) Interpretation of breath sounds. Am J Respir Crit Care Med, 169, 1260 (letter)
ajrccm.atsjournals.org/cgi/content/full/169/11/1260
Guglielminotti J (2000) Bedside detection of retained tracheobronchial secretions in patients on mechanical ventilation. Chest, 118, 1095-9
Haitsma IK (2002) Advanced monitoring in the ICU: brain tissue oxygen tension. Curr Opin Crit Care, 8, 115-20
Haque RA, Usmani OS, Barnes PJ (2005) Chronic Idiopathic cough: a discrete clinical entity? Chest, 127, 1710-13
www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=15888850&dopt=Abstract
chronic cough may be initiated by an upper respiratory tract infection which sensitizes the cough reflex
Hacievliyagil SS, Gunen H (2006) Association between cytokines and induced sputum and severity of COPD. Respir Med, 100, 5, 846-54
www.sciencedirect.com/science?_ob=PublicationURL&_tockey=%23TOC%237138%232006%23998999994%23620763%23FLA%23&_cdi=7138&_pubType=J&_auth=y&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=6cd0ecd66e2af952b4fbc3d5d2465480
higher levels of cytokines in induced sputum indicate severity of COPD during exacerbation
Hjelmqvist H (2000) Colloids versus crystalloids. Curr Anaesth Crit Care, 11, 7-10
Ho JE, Bittner V (2010) Usefulness of heart rate at rest as a predictor of mortality, hospitalization for heart failure, myocardial infarction, and stroke in patients with stable coronary heart disease. Am J Cardiol, 105, 7, 905-911
www.sciencedirect.com/science?_ob=PublicationURL&_tockey=%23TOC%234876%232010%23998949992%231814686%23FLA%23&_cdi=4876&_pubType=J&_auth=y&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=6ffb82fc4d3542fc494e4c1bdd8648f0
for people with CVD, HR at rest of ≥70 beats/min is associated with 40% increase in mortality and more than twice the risk of HF hospitalisation, but not the risk of stroke or MI.
Hodgkinson DW, O'Driscoll BR, Driscoll PA (1993) Chest radiographs. Br Med J, 307, 1202-6, plus correction: BMJ, 307 (Nov 27), 1417.
Holleman (1995) Does the clinical examination predict airflow limitation? JAMA, 273, 313-19
Inoue H (2009) A new breath-holding test may noninvasively reveal early lung abnormalities caused by smoking and/or obesity. Chest, 136, 2, 545-553
chestjournal.chestpubs.org/content/136/2/545.ful
the fall in SaO2 during a 20-second breath-hold at resting end-exhalation reveals early lung abnormalities
Irwin R (2002) The diagnosis and treatment of cough. N Eng J Med, 343,1715-1721
Jones AYM, Jones RD (2000) The effect on sound generation of varying both gas flow rate and the viscosity of sputum-like gel. Lung, 178, 31-40
absence of crackles does not always indicate absence of secretions
Juniper MC (1997) The chest x-ray in intensive care. Care Crit Ill, 13, 198-200
Karampela I et al (2002) A dyspnea evaluation protocol for respiratory therapists. Respir Care, 47, 1158-61
www.ncbi.nlm.nih.gov/pubmed/12354334
helps ensure that SOB is not mistaken for anxiety, with wrong treatment given.
Karbing DS, Kjaergaard S, Smith BW, Espersen K, Allerψd C, Andreassen S, Rees SE (2007) Variation in the PaO2/FiO2 ratio with FiO2: mathematical and experimental description, and clinical relevance. Crit Care, 11:R118
ccforum.com/content/11/6/R118
PaO2/FiO2 quantifies effects of treatment
PaO2/FiO2 varies with both FiO2 and SaO2
classifies patients' gas exchange status, including definitions of ALI (27 kPa ≤ PaO2/FiO2 < 40 kPa) and ARDS (PaO2/FiO2 < 27 kPa)
(useful commentary on how this measurement can achieve a balance between accuracy and feasibility is on ccforum.com/content/11/6/182)
Karen KG, Higgins TL (2005) New-generation pulse oximetry in the care of critically ill patients. Am J Crit Care, 14, 26-37
Kassean HK, Jagoo ZB (2005) Managing change in the nursing handover from traditional to bedside handover. BMC Nurs, 4,1
www.biomedcentral.com/1472-6955/4/1/abstract
A handover at the bedside, rather than at the nurses station, provides greater satisfaction for patient and staff
Kjaergaard S, Rees S (2003) Non-invasive estimation of shunt and ventilationperfusion mismatch. Int Care Med, 29, 727-34
ccforum.com/content/11/6/R118/citation
Kvale A, Johnsen TB, Ljunggren AD (2002) Examination of respiration in patients with long-lasting musculoskeletal pain. Advances Physiother, 4, 169-81
fascinating insight into the effect of pain on breathing
Labib A (2010) Current trends in cardiac output monitoring in UK intensive care units. J Intens Care Soc, 11, 4, 257-60
journal.ics.ac.uk/pdf/1104257.pdf
invasive and non-invasive monitoring techniques
Lange NE (2009) Spirometry: don't blow it! Chest, 136, 2, 608-614
chestjournal.chestpubs.org/content/136/2/608.full
everything you need to know about the practicalities of spirometry.
Lichtenstein DL (2003) The "lung pulse": an early ultrasound sign of complete atelectasis. Int Care Med, 29, 12, 2187-92
ultrasound can identify atelectasis before x-rays can
Lou J-S (2010) Assessment and management of fatigue in neuromuscular disease. Am J Hospice Palliat Med, 27, 2, 14557
Malaguti C (2009) Reliability of chest wall mobility and its correlation with pulmonary function in patients with Chronic Obstructive Pulmonary Disease. Respir Care, 54, 12, 1703-11
www.rcjournal.com/contents/12.09/12.09.1703.pdf
Martin GS (2002) Findings on the portable chest radiograph correlate with fluid balance in critically ill patients. Chest, 122, 2087-95.
Martini Z (2005) Independent contributions of hypothermia and acidosis to coagulopathy in swine. J Trauma-Injury Inf Crit Care, 58,1002-10
www.jtrauma.com/pt/re/jtrauma/abstract.00005373-200505000-00020.htm;jsessionid=CO5EKlmYRMKPcbJGGy72sAD2B6RZWJFeF315LiHLGi1QDiEb20Jw!1707623050!-949856031!9001!-1
coagulopathy occurs frequently in the presence of acidosis and hypothermia.
McKenzie CA, McKinnon W et al (2005) Differentiating midazolam over-sedation from neurological damage in the intensive care unit. Crit Care, 9, R32-R36
method to distinguish over-sedation from neurological damage
McGarvey LPA, Ing AJ (2004) Idiopathic cough, prevalence and underlying mechanisms. Pulm Pharmacol Ther, 17, 435-9
www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WPM-4DS6TVN-2&_coverDate=12%2F01%2F2004&_alid=350471042&_rdoc=1&_fmt=&_orig=search&_qd=1&_cdi=6994&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=5a528a631f39b35263f5eb6f917e6dd2
Mootoosamy (1993) Computed tomography scanning of the thorax. Br J Hosp Med, 50, 2/3, 95-105.
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www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/Cough/Guidelines/coughguidelinesaugust06.pdf
comprehensive guideline on differential diagnosis and management
chronic cough is associated with inflammatory airways diseases such as asthma, COPD, post-viral infections, pulmonary fibrosis, and bronchiectasis
55% of women report urinary incontinence in association with chronic cough
patients with heart disease and chronic cough are at risk of myocardial infarction
Murphy R (2006) Capillary blood gases in acute exacerbations of COPD. Respir Med, 100, 4, 682-686 www.sciencedirect.com/science?_ob=PublicationURL&_tockey=%23TOC%237138%232006%23998999995%23617521%23FLA%23&_cdi=7138&_pubType=J&_auth=y&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=18ccd676b7f198e85937012ad7bac39d
ear capillary blood gases accurately assess PCO2, H+ and HCO3− , and combined with continuous pulse oximetry can be used as an alternative to ABGs in patients with exacerbation of COPD.
Murray MP, Turnbull K, MacQuarrie S (2009) Validation of the Leicester Cough Questionnaire in non-cystic fibrosis bronchiectasis. Eur Respir J, 34, 1, 125131
www.ncbi.nlm.nih.gov/pubmed/19196812
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Pasterkamp (1997) Respiratory sounds. Am J Respir Crit Care Med, 156, 974-87
Payen JF et al (2001) Assessing pain in critically ill sedated patients by using a behavioral pain scale. Crit Care Med, 29, 2258-63
www.ccmjournal.com/pt/re/ccm/abstract.00003246-200112000-00004.htm;jsessionid=CrtKZlmc2kHPgF99vw2YNNihO2LRsv1y2uw3DQ1HT3Ceq3D0Lc8T!-2128958162!-949856032!9001!-1
pain scale which is valid and reliable for sedated patients on IPPV
Penson RT, Rudd RM (1997) Commentary: octreotide and hypertrophic pulmonary osteoarthropathy. Thorax, 52, 297-8
early sign of lung cancer: pain and swelling of wrists and ankles
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www.ncbi.nlm.nih.gov/pubmed/18071022
Rabitsch W (2004) Evaluation of an end-tidal portable ETCO2 colorimetric breath indicator. Am J Emerg Med, 22, 4-9
breath indicator between the airway and ventilator tubing changes colour according to ETCO2
Ramsey DJC (2004) Assessment and management of dysphagia. Hosp Med, 65, 5, 274-9
Rossi SE (2005) Tree-in-bud pattern at thin-section CT of the lungs. RadioGraphic, 25, 789-801
radiographics.rsnajnls.org/cgi/content/full/25/3/789
description of small nodules of soft-tissue attenuation shown on CT which indicate various conditions such as infection, obliterative bronchiolitis, aspiration or inhalation of foreign substances, immunologic disorders or connective tissue disorders
Scherer S, Hammerich AS (2008) Outcomes in cardiopulmonary physical therapy:
Acute Care Index of Function. Cardiopulm Phys Ther J, 19, 3, 95-7
cpptjournal.org/pdfs/members/fulltext/2008/september/september-article4.pdf
incorporates mental status, bed mobility, transfers, and mobility
Schmidt M (2011) Dyspnea in mechanically ventilated critically ill patients. Crit Care Med, May.
SOB is frequent, intense, strongly associated with anxiety, sensitive to ventilator settings and associated with delayed extubation
Smith MD, Russell A, Hodges PW (2006) Disorders of breathing and continence have a stronger association with back pain than obesity and physical activity. Austr J Physiother, 52, 11-16
ajp.physiotherapy.asn.au/AJP/vol_52/1/AustJPhysiotherv52i1Smith.pdf
dual role of the diaphragm and transverses abdominis (for both breathing and posture) explains how patients with a fatigued diaphragm are unable to provide adequate support for their spine.
Srivastava R (2011) Complicated lives taking the social history. N Engl J Med, 365, 7, 587-9.
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identifying aspiration by interpretation of swallow sounds
Tantucci C, Pinelli V, Cossi S et al (2006) Reference values and repeatability of inspiratory capacity for men and women ages 65-85. Respir Med, 100, 5, 871-7
www.sciencedirect.com/science?_ob=PublicationURL&_tockey=%23TOC%237138%232006%23998999994%23620763%23FLA%23&_cdi=7138&_pubType=J&_auth=y&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=6cd0ecd66e2af952b4fbc3d5d2465480
inspiratory capacity may signal the occurrence of dynamic hyperinflation at rest or o exercise
Trotman-Dickenson B (2003) Radiology in the ICU. J Int Care Med, 18, 198-210
Van de Louw A et al (2001) Accuracy of pulse oximetry in the ICU. Int Care Med, 27, 1606-13
SpO2 above 94% is necessary to ensure SaO2 of 90%
Vincent JL (2008) Understanding cardiac output. Crit Care, 12, 4, 174
ccforum.com/content/12/4/174
succinct explanation of the four determinants of cardiac output and how cardiac output is affected by different circumstances
Voepel-Lewis T (2010) Reliability and validity of the face, legs, activity, cry, consolability behavioral tool in assessing acute pain in critically ill patients. Am J Crit Care, 19, 1, 55-61
behavioural pain scale
Walshe BK, Crotwell DN, Restrepo RD (2011) Capnography/capnometry during mechanical ventilation. Respir Care, 56, 4, 5039
www.rcjournal.com/cpgs/pdf/04.11.0503.pdf
AARC Guidelines
Williams AJ (1998) Assessing and interpreting arterial blood gases and acid-base balance. Br Med J, 317, 1213-6
bmj.bmjjournals.com/cgi/content/full/317/7167/1213?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&andorexactfulltext=and&searchid=1097998442127_8760&stored_search=&FIRSTINDEX=0&sortspec=relevance&volume=317&firstpage=1213&resourcetype=1
Wong CL, Holroyd-Leduc J, Straus SE (2009) Does this patient have a pleural effusion? J Am Med Ass, 301, 3, 309-317
jama.ama-assn.org/content/301/3/309.abstract
clinical assessment of pleural effusion
AARC = American Association for Respiratory Care
ACPRC = Association of Chartered Physiotherapists in Respiratory Care
CVD = cardiovascular disease
ETCO2 = end-tidal CO2 monitor
HCO3− = bicarbonate ion concentration
HF = heart failure
HR = heart rate
IPPV = intermittent positive pressure ventilation
JAMA = Journal of American Medical Association
MI = myocardial infarction
SOB = shortness of breath
SpO2 = saturation of haemoglobin taken by pulse oximeter
VO2 max = maximum oxygen consumption