Interpreting Pulmonary Long-term acute care (LTACH) me facility - PowerPoint PPT Presentation

5/6/20 • BA at the University of Missouri Sydney Parriott Schumacher, MA, CCC-SLP University of Kansas Health System • MA at the University of Kansas Little about • Experience: Interpreting Pulmonary • Long-term acute care (LTACH) me… facility Findings in Relation to • Focus on ventilators/tracheostomies • Inpatient rehabilitation • Acute care/Hospital Dysphagia 1 2 Objectives Pro Tip • Identify common assessment techniques used by physicians to evaluate lung function • I will highlight key • Familiarize terms utilized to describe terms/concepts that radiographic findings and pulmonary function are most applicable • Discern information that is pertinent to to your future clinical possible aspiration based on pulmonary assessment results practice in BLUE. • Learn at least two differences between aspiration pneumonia versus pneumonitis 3 4 1

5/6/20 Why do SLPs care about When do SLPs care about chest imaging? chest imaging? Examples: Our goal is to prevent aspiration pneumonia…but how do we • A patient comes in with known history of dysphagia and team would know for sure? like you to re-assess. Do you change their diet? • Example Report 1: • Assessing chest imaging would tell you if their current diet in the known setting • Moderate to severe left lower lobe atelectasis and mild of dysphagia is causing medical complications dependent right lower lobe atelectasis with trace pleural • A nurse reports to you that a patient is consistently coughing with effusions. No pneumothorax. their drinks during meal times. Why might that be? • Example Report 2: • A review of the patient’s chest imaging tells you they have severe COPD or emphysema which may be contributing to their dysphagia. • Low lung volume with similar bibasilar opacities probably • You upgrade a patient from NPO to a mechanical soft solid, thin liquid atelectasis. Right lower lobe infiltrates present. Small left pleural diet. How do you know if they’re tolerating it versus aspirating? effusion persists. • Pulmonary findings would tell you if food/drink is collecting in the lungs over a period of days. • How can we make sense of the radiologist’s findings to apply to our practice? 5 6 Lung • Auscultation - using a stethoscope to listen to the Lung Sounds Continued lobes of the lungs during respiration • Who? Sounds • Physician, nursing, respiratory therapy What are they listening for? • Where? • Lung sound subtypes: • “Clear to auscultation bilaterally” • Indication of normal lung function • Evidence that a patient is tolerating their diet without collection of fluid/aspirated material in lungs • “Crackles” or “Rales” • Coarse or fine • Pneumonia, fibrosis, heart failure • “Wheezes” • Asthma, COPD, other airway obstruction • “Rhonchi” • Suggests secretions or aspirated material in large airways 7 8 2

5/6/20 Clinical Application of Lung Sounds • Abnormalities present as areas of Chest X- either increased or decreased density from surrounding tissue Ray (CXR) • Increased density or opacities are Request lung most common • If changes noted following intake, the auscultation by SLP can re-assess for acute changes or if nursing before further assessment (e.g., videoswallow) is needed. and after meals Assess for diet • “Clear to auscultation?” tolerance as • No fever? part of clinical • Stable white blood cell count? picture • No increased oxygen needs? 9 10 Radiographic Computed Observations Topography • 3-D model to help show size, (CT – Chest) shape, and position of the lungs and surrounding structures • More detailed than CXR • 4 pattern approach: • Often done as a follow-up when something else is found on an CXR • Consolidation • Completed in axial, sagittal, • Interstitial lung disease and/or coronal views • Nodules/masses • Atelectasis 11 12 3

5/6/20 Atelectasis Consolidation • Collapse of lung tissue due to air ( pneumothorax ), fluid ( hydrothorax ), or tumor • Lung tissue becomes more dense • Categorized as: due to disease replacing alveolar air • Collapse (due to air ) • Local vs diffuse • Compression (due to fluid ) • Acute vs chronic • Obstruction (due to tumor ) • Pneumonia most common cause of • Most common finding on x-ray consolidation • Can’t confirm if pneumonia from • Aspiration most likely in gravity x-ray but also cannot be ruled dependent areas ( lower lobes ) out • Right lower lung lobe is more • Impact on swallow likely than the left • Increased respiratory rate = more difficulty coordinating breathing and swallowing 13 14 Infiltrates • Any substance that has entered the lungs, alveolar space, or tissue space around cells ( interstitial compartment ) • Can indicate presence of pneumonia • More likely due to aspiration if infiltrates are present in gravity Additional pertinent dependent areas ( lower lobes ) findings… 15 16 4

5/6/20 Opacities Pleural Effusion • Tree-in-bud • Fluid build-up • Small, clustered, nodular • 2 types: • Mucous impaction with inflammation • Transudative = clear • Miller & Panosian (2013) • Exudative = filled with • Aspiration cause in 25% of cases proteins • Ground-glass • Type most likely to be • “Haziness” associated with • Wide variety of causes, one of which is aspiration and aspiration pneumonia • Need to consider at overall clinical picture • Usually caused by congestive heart failure • Can often be seen together • Possible to be caused by • May indicate aspiration if in lower aspiration, however unlikely lobes 17 18 Restrictive lung disease Empyema • Due to either: • CNS depression • Collection of pus between the lung • Inadequate lung expansion and surrounding pleural space • Results in increased respiratory rate à • Caused by infection impaired swallow/breath coordination Lung • Puts pressure on the lungs, causing shortness of breath Obstructive lung disease Disease and • Physicians will place chest tube to drain • Difficulty exhaling due to reduction of Aspiration • Impact on swallow airflow • Shortness of breath = more difficulty • Respiratory membrane surface destroyed coordinating breathing and swallowing • Due to: • Consider being more conservative with • COPD, asthma, emphysema, dysphagia recommendations for these bronchiectasis patients • Results in increased respiratory rate à impaired swallow/breath coordination 19 20 5

5/6/20 Pneumonia vs. Pneumonitis: Same or Different? • PLUG FOR ORAL Pneumonia Pneumonitis CARES Aspiration Pneumonia Chemical Pneumonitis “Anaerobic pneumonitis” - “Chemical pneumonitis” – • Thorough and FREQUENT! Colonized oropharyngeal Sterile gastric contents ASPIRATION EMESIS or VOMIT material • At LEAST 3 times per day (after meals) Colonized oropharyngeal Gastric contents, sterile due to Acute inflammation Acute injury • Education patient, family, staff! material; bacterial low pH Tachypnea ( rapid, shallow Asymptomatic, dyspnea • Will reduce the ability for oral Acute inflammation Inflammatory injury breathing ), cough ( labored breathing ), hypoxia, bacteria to colonize, thus reduce Tachypnea ( rapid, shallow cough, low-grade fever Asymptomatic, dyspnea the risk of aspiration pneumonia breathing ), cough ( labored breathing ), hypoxia, Can progress quickly, Progresses within 1-2 hours cough, low-grade fever gradually, or over weeks Can progress quickly, gradually, Progresses within 1-2 hours, or over weeks will clear after 24-36 hours May need to use your detective skills during your chart review! Did the patient have a recent emesis ( vomiting ) episode? 21 22 Case Study: Clinical Application of CXR, CT-Chest • 78-year old female • Prior Medical History (PMH): • Was your patient tolerating the diet they were on • Right hemisphere stroke (CVA) Current Level of at home vs since admission to the hospital? • Gastroesophageal reflux disease (GERD) Function • How compromised is their lung function prior to • Pneumonia completing your bedside assessment? • History of dysphagia from CVA • On regular solid/thin liquid diet at home as recommended from videoswallow completed ~3 months prior Determine pertinent • Does the person already have a pneumonia? • Small bites/sips, slow rate pulmonary • Consider impact of conditions such as COPD, • Daughter reports patient is very impulsive since the stroke and often doesn’t diagnoses emphysema, lung cancer, etc. follow swallow guidelines despite lots of encouragement • Admitted to hospital for respiratory failure requiring intubation for 3 days Assess for diet • Pulmonary status helps clinicians predict how well • Extubated and put on 3 liters of oxygen for bedside swallow a patient may tolerate aspiration tolerance as part of evaluation • Difference between being more liberal vs more clinical picture conservative with your recommendations 23 24 6