Acute care Test2 Flashcards
Chronic bronchitis
COPD Type
Cough and sputum production, especially during winter
Not due to specific or localized disease
Present on most days for at least 3 months per year for 2 consecutive years
Salmeterol (Serevent)
Rescue inhaler
SABA- short acting
Brochodilator
Adrenergic agonist
Beta-2 specific agonist
LABA- long acting (maintenance)
Time to effect 10-20 min
Duration 12 hours
Side effects- tachycardia, tremors, nervousness, restlessness, weight loss
Disease - air trapping, increased RV, flat diaphragm
Emphysema
SGRQ
St. George’s Respiratory Questionnaire
50Q disease-specific (COPD) instrument designed to measure impact
0-100, lower better
MCID: 4 slightly, 8 moderate, 12 very efficacious
___ position tends to decrease ventilation, which affects ___
Supine
Affects ventilation and perfusion matching (decreased O2 saturation)
Airway- radiograph
Site
Size
Shape
Shadow
Patent, or narrowed indicating stenosis or edema?
Is it central? (It can deviate to R due to aortic arch in adults)
Epinephrine
Bronchodilator
Epi-pen
Nonspecific beta agonist
Used most in emergency (anaphylaxis and sepsis/respiratory failure)
Short time to effect (3-15 min)
Short peak effect time ~20 min
Will affect other tissues with beta and alpha receptors
Children with CHD are at increased risk of …
Developmental disorders, disability or delay
Neurodevelopmental disability affects as many as 50% of infants undergoing interventions for congenital heart lesion.
Children with Down syndrome have impaired tolerance to exercise, altered sympathetic response to exercise and are at increased risk for aneurysm.
MMRC dyspnea scale
Dyspnea with…
Strenuous exercise or walking on slight hill (0 points)
Walking on level ground, must stop d/t sob (1 point)
Must stop d/t sob after 100 yards (2 points)
Dressing/ADL (3 points)
Pathophysiological changes -
Pulmonary problems
Metabolic inefficiency w/ some fiber shift from type 1 -> 2
Reduced FFM (esp quads)
Increased REE (resting energy expenditure) 15-20% above predicted values due to increased work of breathing
Impaired mitochondrial function and decreased density
Multiple suspected causes: disuse atrophy; mitophagy
Indications for oxygen therapy
Hypoxemia
Reduced work of breathing, heart (especially RV)
Typically:
pulse oximetry <88%
OR
SpO2 < 55 mmHg
May also be RX for pt w/ PAH and RV HF
OSA
Obstructive sleep apnea
Intermittent upper airway obstruction (Pharyngeal musculature doesn’t maintain)
Fall in SaO2, increased CO2 levels (hypercapnea)
Sleep disturbance, hypersomnolence
COPD physical exam findings
Chronic cough Sputum production Exertional dyspnea Barrel chest Paradoxical chest wall movements
Crackles, decreased breath sounds, early satiety and difficulty eating, balance and strength deficits, BW changes, cyanosis (severe cases)
Crackles (Rales)
“Popping” open/close of alveoli compressed by fluid
Best heard during inspiration
Sounds like Velcro
Non-cardiogenic : typically 1 lung field; resolves with cough or deep breath
Cardiogenic: (Pulmonary edema from HF) : bilateral lung fields, doesn’t resolve with coughing or deep breath; Resolves with Sidelying
Fick’s principle: oxygen consumption is the product of …
CO and arteriovenous difference
Patent ductus arteriosum results in Cyanotic or Acyanotic deficits
Acyanotic
Muscles of inspiration work against what forces
Elastic recoil of chest wall
Airway resistance
Bi-directional Glenn shunt procedure
Usually performed 4-6 mo old
Creates direct connection between pulmonary artery and superior vena cava
Directly returns venous blood to lungs from UE
R ventricle still pumps mixed blood but procedure reduces its work
Diffusion capacity (DLCO) Dependent on
- Volume inspired
- Pulmonary blood flow
- AC surface area
- Hemoglobin
- Thickness of AC membrane
Generally reduced with emphysema and restriction, normal in asthmatics
PH s/s
Pulmonary HTN progressive dyspnea, particularly with exertion and later at rest Dull retrosternal chest pain Fatigue, lightheaded, fatigue, malaise Exertional syncope Reduced DLC, normal spirometry Non-productive cough Narrow splitting of S2 with loud accentuated pulmonary component (P2) May progress to R side heart failure
Pickwickian syndrome
Obesity- hypoventilation syndrome
Early s/s: headache, fatigue, hyper-somnolence (as with OSA)
Fat deposits on chest wall decrease wall excursion/mobility.
Combines obesity and hypercapnea (high CO2)
Can eventually lead to pulmonary HTN and R ventricular failure
Diphenhydramine
Benedrly
Antihistamine
H1 receptor subtype of histamine involved with respiratory system and hypersensitivity (nasal congestion, sinusitis, rhinitis, mucosal irritation)
Side effects - sedation, fatigue, dizziness, incoordination
COPD: muscle pathophysiological changes
Metabolic inefficiency
Fiber type shift in some skeletal muscles from Type 1 to Type 2
Reduced fat free mass (esp in quads)
Increased resting energy expenditure (REE) 15-20% above predicted values due to increased work of breathing
Impaired mitochondrial function and decreased density
COPD prognosis
Assessment of 4 year survival 4 domains: Severity on FEV1 Distance 6MWT Score on MMRC dyspnea scale BMI (<21 is 1 point- weight loss bad sign)
0-2 80%
3-4 67%
5-6 57%
7-10 18%
Meconium aspiration syndrome
Aspiration of bowel substance just prior to or just after birth
Meconium can be inhaled into lungs of baby gasp while still in the womb or during initial gasps after delivery
Can cause airway blockage decreasing blood to brain
Increased risk of lung infection
S/s: rapid/labored breathing; retractions, or pulling in of chest wall; grunting sounds breathing; cyanosis
Dehydration
Q?
SV?
HR?
Q- decreases
SV - decreases
HR- increases
Tracheal shift
Implications on side
Tracheal shift contralateral to pneumothorax or pulmonary effusion
Tracheal shift ipsilateral on atelectasis
Thoracic wall palpation
Indicated if chest pain, mass seen on inspection, breast masses, or draining sinuses
Examine for tenderness and masses
Soft tissues also assess for crepitus
Large thoracic muscles
Costal cartilages, intercostal spaces, costochondral junctions and xiphisternal
Palpate ribs for point tenderness, swelling, crepitus, and pain in compression
Blood lab to assess/track severity of heart failure
BNP
Brain natriuretic peptide
SCD in athlete
Sudden cardiac death
Leading cause of non-traumatic death in athletes
Males > Females (9:1)
Any sport- but usu football, basketball
Low overall prevalence ~100-150 year (2.3-4.4 per 100k)
Black higher risk (5.6 per 100k)
Athletes aren’t at greater risk than general population
Evaluation of diaphragmatic action
Pt supine with anterior chest exposed
Palpate anterior chest wall with thumbs over costal margins so tips meet at xiphoid
Instruct pt to take deep breath, allow thumbs to move with chest wall
Normal test is = upward movement of costal margins
Tracheal position
Pt flex neck Index finger in suprasternal notch Top of finger in suprasternal notch medial to L SC joint Push onwards toward cervical spine Repeat on R
Normal = no obstruction to advancement of finger
Most common line of deviation = midline shift due to pneumothorax (moves away from lesion)
Obstructive pulmonary disease
Problems getting air OUT
FEV1/FVC ratio < 0.70
Unresponsive to bronchodilators
Increased airway compliance
Persistent progressive airflow limitation
Associated w/ enhanced chronic inflammatory response to noxious particles or gases
COPD common impairments
Reduced functional capacity (6MWT or other ETT)
Decreased strength
Impaired balance (fall risk)
Dyspnea with minimal activity
Reduced gait speed
Altered cardiorespiratory response to exercise
Back pain and chronic pain
Common Cyanotic Defects
Transposition of the great vessels Pulmonary valve atresia Tetralogy of fallout Hypoplastic left heart syndrome Shone’s syndrome TAVPR
Coarctation of the aorta
SCD common causes
Youth-
HCM 33-50%
Coronary abnormalities 15-20%
Adults-
80% undiagnosed CAD, plaque rupture
Most common mechanism of death is ventricular tachyarrhythmia
- exception: Marfans usu aortic dissection/rupture
Shunting R -> L
Cyanotic
Transposition of great vessel
Tricuspid atresia
Tetralogy of fallot
Total anomalous pulmonary venous return
Fetal blood flow of heart
There are 2 small openings between _____, called ___ and ___.
In utero only 8% flow goes through ___, the rest flows through ___.
Fetus receives oxygenated blood from ___.
Two small openings between left and right side of heart:
DA: ductus arteriosus
FO: foramen ovale
These normally close a few days after birth
Only 8% goes through non-functioning lung,
Rest flows through DA.
Fetus receives oxygenated blood from mother vis placenta, travels back through umbilical vein.
50% oxygenated blood passes through liver
50% to inferior vena cava to R atrium through FO to -> L atrium -> L ventricle -> aorta
Breath sounds- Bronchial
E>I (Duration of insp vs exp)
High pitch expiration
Loud intensity of expiration
Location: over trachea
Atelectasis- sounds
Breath sounds: decreased to absent
Adventitious sounds: crackles
PT exam for child with asthma
Measure thorax on inspiration and expiration
Examine exercise tolerance, strength, posture
Asthma QoL questionnaire
Hemoptysis
Bloody sputum
Coughing up blood/bloody mucous
Hallmark sign of PE
May also occur with trauma, pneumonia
Pulse and heart rate
Are NOT the same thing
In heart transplant the ___ paces the allograft heart resulting in ___.
During exercise the transplant heart is regulated by___.
SA node
Higher RHR- appx 90-110 bpm
Circulating catecholamines to elevate HR, lengthening the time between onset and activity and HR increase, and prolonging recovery (why need longer warm up and cool down: 5-10 min)
Symbicort
Combo of Budesonide and Formoterol
Benefit of both steroid and LABA
Typically 1 puff twice day
Pirfenidone (Esbriet)
Nintedanib (Ofev)
Pulmonary fibrosis medications
Anti-fibrotic
Inhibit pathways that lead to fibrosis and scarring of lungs - Suppress fibroblast proliferation and fibrotic mediator production
When to hold exercise
- QRS widening > 0.12 sec
- > 6 PVC per min or Couplet
- Glucose >250 or <60
(Make sure they have a snack prior) - RHR >100 or with AFib >110 bpm
- Systolic <90 mmHg or >180 mmHg
or diastolic > 110 mmHg
CV system arises from
What embryonic tissue?
Mesodermal germ layer
PT considerations of pediatric heart (general)
Labored breathing Increased RR Diffuse generalized edema Decreased urine output Eating problems Impaired tolerance to activity Irritable (track using NIPS scale)
Compression test for rib fracture
1 hand supporting back
Compression of sternum with other hand elicits pain at untouched fracture site
ECMO
Extracorporeal membrane oxygenation
Support cardiac and respiratory systems until disease process resolved
Used for longer-term support 3-10 days
Disease process must be reversible
(reversible lung/cardiac disease, bridge to transplant, ARDS)
CV disorders and Marfans
Marfans results from overproduction of TGF-beta (transforming growth factor beta)
CV disorders in 90% Marfans Aortic tear/rupture (most often ascending/thoracic aorta) Mitral valve prolapse Aortic regurgitation Arrhythmias
Acute rejection s/s heart related symptoms
S3 gallop Arrhythmias Jugular vein distention Decreased exercise tolerance Shortness of breath
Thoracic wall movement (symmetry)
Hand on each side of chest wall
Extend thumbs so tips meet in midline
Have pt inspire deeply permitting your palms to move freely with the chest while fingers anchored to chest wall
Normally- thumbs move laterally from midline in equal distances
Asymmetric excursion suggests a lesion on lagging side in chest wall, pleura or upper lobe of lung
Myocardial bridge
Epicardial coronary artery is tunneled w/in myocardium
Characterized by systolic compression of tunneled segment
Most asymptomatic - May present atypical or angina-like chest pain w/ no consistent assoc between symptom severity and length/depth of tunneled segment or degree of systolic compression
Resting ECGs frequently normal
Stress testing may induce nonspecific signs of ischemia, conduction disturbances or arrhythmias
Common antibiotics
Acute bronchitis, pneumonia, etc
Bactericidal:
Penicillins (incl amoxicillin)
Cephalosporins (Cipro)
Bacterostatic:
Macrolides - Azithromycin (Z pack)
Paced breathing
Volitional coordination of breathing during activity
Expiration is a primarily passive activity
Having pt expire during exertion may prevent dyspnea during activity
Ex: inhale while walking 2 steps then exhale while walking 4 steps- repeat
Diffusion capacity (DLCO) Normal vs pulmonary pathology
Normal 80-100%
Pulmonary pathology < 80%
Of predicted uptake.
Diffusion capacity of CO
Wells PE
3 points:
Clinically suspected DVT
Alternative diag less likely
1.5 points:
HR > 100
Immobilization/surgery prev 4 weeks
Hy of PE or DVT
1 point :
Hemoptysis
Malignancy
Score > 4 PE likely- consider imaging
4 or less unlikely, can d-dimer to rule out.
Most common cause of heart failure in US
Ischemic heart disease
Albuterol (Proventil)
Beta-adrenergic agonist
Short acting brochiodilator
Inhalation:
5-10 min onset of action
3-6 hr duration
Oral;
15-30 min onset of action
8 or more duration
Increased breath sounds…
Normal breath sounds are vesicular
Brochiovesicular in peripheral fields indicate:
Partial pulmonary consolidation or compression
If consolidation or compression increases, breath sounds become bronchial in nature
COPD: diaphragmatic adaptations
Generate 60% of normal max trans-diaphragmatic pressure
Fiber switch to type 1 to compensate for increased diaphragmatic loading
Possibly from hyperinflation-induces diaphragm shortening
Heart innervation?
Works by?
Vagus nerve
Depressing intrinsic rate of heart set by SA node
Pulmonary pressure > 60 mmHg
Implication?
Contraindications for exercise
Visual inspection- pulmonary and chest
Disposition: distress, SOB, somnolent
Skin: edema, JVD, cyanosis, sweating
Body position/posture: normal, barrel chest, slouched, guarding, pes escavatum, pectus carinatum
Braced/Splinted breathing
Used over areas of chest wall that are painful
Sustained supportive pressure can stabilize or brace the segment of the chest wall
Allows for better ventilation
Reduces atelectasis
Hands or pillow
Pleural rub
Coarse, grating, or leathery sound
Usually heard late in inspiration;
Early in expiration
Location: Posterior lung bases or lower axilla
Causes: increased friction due to inflammation of pleural linings
Chronic respiratory disease is the ___ killer in US
3rd
Eisenmenger’s syndrome
Cyanotic
Due to VSD where pressure in R ventricle becomes too high - shunting blood R to L (VSD usually is L to R)
Conditions prone to developing secretions
CF Asthma COPD; esp chronic bronchitis Bronchiectasis Acute pulmonary disease Mechanical ventilator dependency Post-surgery
Exercise capacity post lung transplant
Peak exercise capacity following lung transplant typically improves to 40-60% of predicted level
2 years post transplant- average 6MWD improvements following transplantation range between 307-498 ft
MVV
Minute ventilation
Amt of air expired per minute
TV x RR
4 L/min, the CO of ventilation
Tetralogy of fallot
4 defects: VSD Pulmonary valve stenosis Overriding aorta (usu lies over VSD) RV hypertrophy (due to PV stenosis)
Blueness appears after birth, infancy or childhood
Infants may have sudden episodes of cyanosis, unconscious (tet spells)
Early surgery indicated
Antitussive
Suppress coughing response/reflex
2 types:
1. Centrally mediated inhibition
DM- Codeine and dextromethorphan
(Opiates, act on brainstem)
- Local mediated inhibitors
Antihistamines and local anesthetics
(Act on respiratory tissue)
Commotio cordis
Sudden blunt impact to chest causes sudden death in absence of cardiac damage
Usually triggers ventricular fibrillation
3% is SCD in young athletes
Prevention:
Shields not effective
Have defibrillators present
Educate coaches/players to turn away chest from inside pitches
Fluid location in rales/crackles
Alveoli
Intrinsic RLD prognosis
FEV1/FVC ratio normal or high
FVC < 80%
Mild 60-80%
Moderate 50-60%
Severe < 50%
6MWT < 212 meter
Associated with poor 2-3 year survival rate
ABCs of chest radiographs
A- airway B- bone C- cardiac D- diaphragm E and F- equal (lung) fields G- gastric bubble H- volume (and mediastinum)
Apex of lung has ____ perfusion and ___ ventilation.
Low perfusion
High ventilation
High V/Q ratio
How many weeks post-op MI begin resistance training
5 weeks
CF (cystic fibrosis)
Genetic
Defect in Na+ and Cl- channels resulting in excessive mucous formation - multisystem
Life expectancy 37 y/o
Theophylline, Theobromine and caffeine
Bronchodilator: Methylxanthines
Inhibit PDE (phosodiesterase enzyme)
Increases cAMP
May also act as adenosine antagonist
Most common oral- but can be injected
Side effects: tachycardia, HA, irritability, restlessness
Theophylline toxicity- can cause arrhythmias and seizures
Phase 1
Cardiac rehab
In acute hospital
Goals: prevent skin breakdown, deconditioning, DVT/VTE; early mobilization
Direct gradual return to activity
Careful monitoring of vitals, signs and symptoms of MI; Recurrent MI can be possible within 4-8 weeks post MI
Recommend guidelines:
Intensity < 5 METs for 6-8 post-MI
HR <120 bpm OR no more than +20 bpm from resting
Asbestosis and Silicosis are forms of ___.
Intrinsic RLD
Asthma- sounds
Breath sounds: decreased
Adventitious sounds: inspiratory and expiratory wheezes
Transposition of the great vessels
Positions of pulmonary artery and aorta reversed
Deoxygenated blood from RV goes into systemic circuit
O2 from blood goes back into lung
Child only survives if AS, VSD or PDA present
Surgery option- arterial switch
Absent or decreased breath sounds can mean…
Air or fluid in/around lungs
(Pneumonia, HF, pleural effusion)
Over-inflation (emphysema)
Reduced airflow to part of lungs
(rib fracture, pneumothorax)
Increased chest wall thickness
Pulse oximetry
SpO2
Indirectly measures oxygen saturation of hemoglobin in arterial blood (SpO2)
Healthy individual w/ normal lungs, at sea level: 95-100%
(+/- 2% error when SaO2 >90%; SaO2 is direct measurement taken from ABG)
Pulmonary rehab guide
12 weeks norm (unknown what ideal is- longer better)
Ideal if clinic provides oxygen
Sessions usually 75-90 min
1:3 work rest ratio
Maintain SpO2 >90%
Limitations to compliance and referral
Hypertrophic cardiomyopathy
Strong genetic link to HCOM
55% familial relative
More common in blacks
Ejection murmur changes with position
Softens during sitting/squatting
Amplified during standing/valsalva
Persistent S2 Split - no change w/ breath holds
S4 gallop possible
Syncope or dyspnea during exercise
Persistent hypertrophy despite detraining
Post transplant - inpatient goals
Increase functional capacity
Improve level of independence
Progression of exercise
Education: HEP, guidelines for termination of exercise, special considerations for exercise post-transplant
DSB (deep slow breathing)
6-8 breaths/minute
Improves pain
Relaxed state; parasympathetic tone
Emphysema
COPD type
Loss of alveolar walls
Associated with increase in size of acinar airways of the upper lobe segments in a centrilobular “centriacinar” pattern
Budenoside (Pulmicort),
Beclemethasone (Belcovent),
Fluticasone (Flovent)
Inhaled: Longterm asthma maintenance
Anti-inflammatory:Glucocorticoids
Control inflammatory mediated bronchospasm
Inhibit production of pro-inflammatory products (cytokines, prostaglandins, leukotrines..)
Immunosuppressive- inhibits migration of neutrophils and monocytes
Increases effects of beta agonists
Side effects- hyperglycemia, HTN, osteoporosis, myopathy, mood swings
Dehydration
Performance suffers, earlier fatigue Can reduce SV and CO- esp in heat Less able to tolerate hyperthermia Eventually MAP may drop When coupled with heat illness can trigger arrhythmias
Rehydration strategy (NATA)
Post exercise RV remodeling- Chronic changes
Accumulation of coronary artery calcium (CAC) with myocardial fibrosis
AND
RV fibrosis 2ndary to episodic volume/pressure overload
Increased prevalence of atrial fibrillation
Study did NOT support an adverse impact of endurance athletes on either CAC or CV events
Prednisone
Oral: Acute infections, or exacerbation, 1-3 weeks max
Anti-inflammatory:Glucocorticoids
Control inflammatory mediated bronchospasm
Inhibit production of pro-inflammatory products (cytokines, prostaglandins, leukotrines..)
Immunosuppressive- inhibits migration of neutrophils and monocytes
Increases effects of beta agonists
Side effects- hyperglycemia, HTN, osteoporosis, myopathy, mood swings
Cardiovascular embryology
Mesodermal germ layer gives rise to CV system
Week 2: heart develops from 2 simple epithelial tubes
Week 3-4: tubes fuse to form single chambered heart. Elongates and bends on itself. Endo, myo and epicardium differentiated. Heart beating
Week 4: primitive heart. Atrial segment assumes cranial position
Week 5: endocardial cushions grow towards each other and fuse
Week 8: partitioning into 4 chambered heart complete
Common Acyanotic Defects
ASD- atrial Septal defect
PDA- patent ductus arteriosum
VSD- ventricular Septal defect
Acute respiratory failure- Type 1
Hypoxia without hypercapnea
Low PaO2 (<55 mmHg) Normal PCO2 (35-45 mmHg)
Lung segment examination
Fremitus
Voice sounds
Breath sounds
Stringy mucoid sputum
Increased mucous production and mucous plugs occur in asthma
During resolution retained mucous and plugs are mobilized
Phase 2
Cardiac rehab
12 weeks
2-3x week
45-60 min
W/ or W/O ECG monitoring
Reassessment and progressions at least every 2 weeks
Formal reassessment at 6 weeks
Most common anomalies are:
___ coronary artery origins in ____.
___ coronary artery origins in ____.
L coronary artery origins in R sinus of Valsalva
R coronary artery origins in L sinus of Valsalva
RLD (restrictive lung disease)
Problems getting air IN
FEV1, FVC, TLC reduced
FEV1/FVC normal or increased
Reduced DLCO
Lungs prevented from fully expanding
Reduced minute ventilation
COPD staging
Mild: FEV1 >= 80%
Moderate: FEV1 50-80%
Severe: FEV1 30-50%
Very severe: FEV1 < 30%
FEV1/FVC < 0.70
Common sequelae of chronic lung disease
Pulmonary HTN Cor pulmonale (R heart failure) Atrial fibrillation (especially COPD) Obstructive sleep apnea (especially COPD)
Optimum work rest ratio in pulmonary rehab
3:1
Pediatric conditions that affect the lungs (prematurity, anatomical anomalies)
Cause chronic respiratory insufficiency
Brochopulmonary dysplasia (BPD)
tracheobronchomalacia
What intervention is prioritized in COPD patients
Balance training
Huff cough
Deep inspiration followed by forced expiration without glottal closure
Mouth and throat s/b open
Often done after ACB or other secretion mobilization techniques
Great for elderly pt and those who have pain with coughing
Exercise dosage
Stable angina ____% HR at onset of angina
Consider ___
70-85%
Consider RPP
Acute rejection s/s lung related symptoms
Decreased FEV1 >10%
Decreased O2 saturation
Decreased exercise tolerance
Reduced vital capacity
Cough
Change in sputum (color or amount)
Changes in respiratory status; breathlessness; prolonged need for ventilator support
Radiographic changes
Positions to relieve dyspnea
W/ arms supported accessory muscles can act on chest wall and allow for greater ventilation
Supporting spine may “unload” diaphragm from its postural control role
HNP (hypersensitive pneumonitis)
Intrinsic RLD
Extremely aggressive progression
Hypersensitivity to certain allergens
Unlike asthma, which affects larger airways (HNP) affects alveolar septae
Thoracic rib cage movement during diaphragm contraction
Inspiration
Superior, anterior and lateral
Pulmonary valve atresia
Pulmonary valve fails to develop
No exit from R ventricle
Blood regurgitates into L atrium via FO (foramen ovale)
Lungs get perfused retrograde flow via wide PDA
Considered critical congenital defect - requires intervention soon after birth, drugs to keep PDA patent
Very rare 1-3%
Pediatric heart transplant
~10% of CHD cases uncorrectable
Most common: HLHS
Survival >20 years after pediatric heart transplant (HTx) has been achieved in some cases
70% survive at least 5 years
HTx can provide excellent QoL but will not last lifetime- only effective is re-HTx
Re-HTx 5.6% pediatric HTx in No.Amer and nearly 10% of HTx in pediatrics >11 years old
Normal respiratory rates in children
Birth- 1 month
24-40
40-70 (preterm)
1-3 years
20-30 breaths per minute
4-9 years
20-24 breaths per minute
> = 10 years
14-20 breaths per minute
Inspiratory hold
Hold breath after max inspiration
Without valsalva for 2-3 sec
Increases back pressure and stretch on Type 2 alveolar cells
Rehab considerations- lung transplant
Qua muscle biopsies after lung transplant show reduced skeletal muscle oxidative capacity
RPE and dyspnea- preferred methods of monitoring intensity
MSK complaints, post-surgical chest wall pain and osteoporosis common post-transplant complications
Myopathy involving respiratory and peripheral muscles- may be related to meds
“Bronchial hyperreaponsiveness” after transplant may contribute to bronchospasms and SOB during exercise
Common impairments associated with pulmonary problems
Functional capacity Decreased strength Impaired balance Dyspnea with minimal activity Reduced gait speed Impaired cardiorespiratory response to exercise Back pain Chronic pain
PAH
Pulmonary arterial HTN
Relatively rare; can be idiopathic or due to drugs/toxins
Symptoms of dyspnea, chest pain, syncope
Leads to R heart failure
No cure. High mortality
Primary reported symptom is dyspnea on exertion
Frequently mis-diag as asthma or COPD
Spirometry guidelines
Must inhale maximally to TLC, then blast air out
No cough or hesitation during 1st sec of exhale
Exhale forcefully at least 6 sec
Min 3 trials
Largest FVC and FEV1 reported
Pt: sit upright, feet flat on floor, no ab use
Loosen tight fitting clothing
FRC
Functional residual capacity
Air remaining in lungs after expiration
FRC = ERV + RV
Men: 2.3 L
Women: 1.8 L
Bronchophony 99
Spoken syllables normally heard indistinctly
With lung consolidation syllables are distinct and sound close to the ear
Rehab considerations- heart transplant
Sternal precautions
Denervation of heart (warm-up, cool down; RPE scale to monitor exercise intensity)
Risk of myopathy, osteoporosis
Typically no angina symptoms due to denervation
Peak HR may remain elevated post exercise
VO2 peak is reduced
Systolic and diastolic BP May be elevated at rest, but peak systolic is usually lower
Reduced sensitivity of ECG to detect ischemia
May see 2 p-waves on ECG
Tactile fremitus
Increased transmission of sound, can be detected as fremitus over affected area while patient repeatedly vocalizes
“One, two, three…ninety-nine”
Examiner moves palms systematically over the 2 hemithoraces
Common cause of increased fremitus (vibration) - consolidation of lung
Impairment of sound transmission diminishes vocal fremitus - ie pleural effusion
NM dysfunction: abnormal breathing patterns
Brainstem: apnea (abnormal breathing)
Quad and paraplegics:
Abdomen rises; upper thorax sucks in
Post polio:
Upper thorax rises; abdomen sinks
Autonomic control of airway diameter
Sympathetic:
Bronchodilation by increasing cAMP
Facilitates smooth muscle relaxation
Inhibition of Mast Cells (inflammatory response and mucous production)
Parasympathetic:
Bronchoconstriction by increasing cGMP
Facilitates smooth muscle constriction
Facilitates Mast cells (inflammatory response and mucous production)
Angina- what heart rate when exercising
HR 5-10 beats below angina threshold
Fluticasone and Salmeterol (Advair)
Combo corticosteroid and long lasting beta2 agonist
Obstructive disease Anatomy affected? Breathing phase difficulty? Pathophysiology? Useful measurements?
Airways
Expiration
Increased airway resistance
Flow rates
Physiological changes post heart transplant
Transplanted heart is denervated.
Absence of direct neural regulations HR/SV
Absence of chest pain
Higher RHR
Rib fracture
Most common bony injury in chest trauma, ~ 50% of patients admitted into hospital
Ribs 1-3…high intensity (MVA)
Lower rib fractures high risk of possible intra-abdominal injury
COPD diagnostic test findings
FEV1/FVC ratio < 0.70
Reduced FEV1 < 80%
Air trapping (increased TLC)
Reduced DLCO
Flattened diaphragm Hypoxemia Hypercapnia Impaired ventilation Polycythemia
Mediate percussion
Evaluates Regional or side-to-side differences in lung density
Normal : sound resonant
Areas of increased density will sound dull (atelectasis, consolidation)
Areas of decreased density will sound hyper-resonant (emphysema; puffed our cheeks, bloated belly)
Pad of middle finger of non-dominant hand on chest in intercostal space
Use middle finger of dominant hand, tap knuckle of non-dominant hand
Keep percussino finger rigid, tap like woodpecker
Listen for pitch of sound and note vibrations
Respiration assessment
ABG (arterial blood gases)
SpO2 (Pulse oximetry)
Frothy pink sputum
Alveoli and respiratory bronchioles are flooded with fluid from capillaries
Producing thin secretions containing air bubbles, frequently colored with hemoglobin
Hallmark sign of PE
Breath sound- Vesicular
I>E (Duration of insp vs exp)
Low pitch expiration
Soft intensity of expiration
Location: most of lung
PH
Pulmonary HTN
Spectrum of diseases involving pulmonary vasculature
Elevation is pulmonary arterial pressures
Diag with R heart catheritization
>= 25 mmHg at rest OR
> 30 mmHg during exercise
Atelectasis
Small airway collapse
Common post surgery, obese at greater risk
Easy to prevent- take full breaths (at least 10 per hour), early mobilization, frequent position changes, encourage coughing and use of incentive spirometer
S/S: Fever, tachypnea, tachycardia, scattered rales, and decreased breath sounds
If a segment remains Atelectatic > 72 hours, highly likely to develop pneumonia
Pseudoephedrine
Sudafed
Nasal decongestant - upper respiratory tract
Most often Alpha-1 agonist
Causes vasoconstriction in nasal passages
“Dries up” mucosal vasculature and reduces nasal congestion
Guanefisine
Mucinex
Mycolytics
Decrease viscosity of respiratory secretions
Allows for easier mobilization of secretions
Ipratropium (Atrovent)
Anticholinergic bronchodilator that decreases bronchial spasms/short acting
BPD (brochopulmonary dysplasia) results in abnormal development of
Alveoli
Pediatric Cardiopulmonary
Physical therapy exam
(10)
- Lab values
- Vital signs
- Appearance
- Pain (if on morphine encourage deep breaths)
- Integumentary screen
- Posture
- Respiratory screen
- Strength
- Functional abilities
- Cardiorespiratory response to movement/exercise
CLDI
Chronic lung disease of infancy
Diagnosis
Clinical exam and chest radiographs continue to be abnormal and the O2 need is still present
HLHS
Hypoplastic L heart syndrome
Failure or inadequate development of L ventricle
Variable aortic and mitral involvement
Child is dependent upon a PDA for systemic perfusion
W/O intervention, is fatal within first weeks of life
Advair
Fluticasone and Salmeterol
Benefits of both steroid and LABA
Typically 1 puff twice day
Genetic disorder with defects in Cl- and Na+ channels
Cystic fibrosis
COPD- emphysema
Increased airway compliance
Air trapping/hyperinflation
Decreased surface area of alveoli for gas exchange (V/Q mismatch)
Reduced expiratory flow
Reduced elastic recoil pressure
Narrow and poorly supported airway
Increased airflow resistance
“Punk puffer”
Atrial Septal Defects results in Cyanotic or Acyanotic deficits
Acyanotic
Complications of mechanical ventilation
Tracheal lesions Infections Excessive secretions-> atelectasis Intracranial hemorrhage Cerebral vasoconstriction Septicemia Increased work of breathing (fighting the ventilator) Stress ulcer
COPD : diffusion and blood gas changes
Hypoxemia: mild to moderate COPD
Hypoxemia and hypercapnea: severe cases FEV1 < 1L or 50% (CO2 retainers; may down-regulate chemoreceptor response to CO2)
DLCO- generally reduced (except asthma, is normal) due to damage of alveolar capillary membrane
Fluid in pleural space (normal)
10-25 mL
Pre-transplant goals
Preserve muscle strength and endurance
Maximize functional independence
Education- what to expect post-transplant; precautions
Pre-transplant therapy has been shown to have beneficial effects on post-transplant mortality, functional capacity and QoL
Obstructive lung IRV TV ERV RV
IRV- decreases
TV- remains same
ERV- increases
RV- increases
FVC (IRV+TV+ERV)- same or decreases
TLC- increases
FRV (ERV+RV) - increases
FEV1% FVC = <70%
ACB (active cycle breathing)
Series of maneuvers to help mobilize secretions
Cycle of normal tidal breaths to deep breaths, followed by coughing
3 normal breaths
3 deep breaths
Repeat 3 x
Finish with cough technique (usually Huff cough)
Flail chest
Segmental fractures (in 2 or more locations on sand rib) of 3 or more adjacent ribs, resulting in unstable chest
Inspiration- chest wall falls in
Expiration- chest wall falls out
Unequal chest expansion
V:Q mismatch, Atelectasis, impaired pulmonary drainage
Pain due to dyspnea, hypoventilation, hypoxemia. Possible respiratory failure
ASD
Atrial Septal Defects
Blood flow between atria
Forms L to R shunt
Volume overload: R heart and pulmonary vasculature damage
May result in R heart failure
Shortened lifespan
Usually repaired at 4-6 years
Normal RR
Adults: 12-20 breaths/min
Infants 30-60 Toddler 24-30 Preschooler 22-34 School-age 18-30 Adolescent 12-16
Consolidation - sounds
Breath sounds: decreased sounds over consolidation, bronchial sounds in periphery
Adventitious sounds: inspiratory crackles
Blood-streaked sputum
Inflammation in nose, nasopharynx, gums, larynx, or bronchi
Sometimes occurs after severe paroxysms if coughing and Minor airway trauma
Main risk factor in development of COPD
Smoking
Quitting prevents accelerated decline in lung function and may improve FEV1
BPD diagnosis
Brochopulmonary dysplasia
28 days and still continues to require supplemental oxygen and has abnormal chest radiograph
Testing recommendations
Cardiac rehab
prognostic assessment, activity prescription, evaluation of medical therapy and cardiac rehab
Before hospital discharge: submaximal at about 4-6 days (6MWT, stair climb test…)
Early after discharge:
Symptom limited; about 14-21 days
(Esp if pre-discharge not done)
Late after discharge:
Symptom limited; about 3-6 weeks
HF exercise dosage
70-85% of maximal if tolerated
Or
To onset of moderate dyspnea
Respiratory muscle strength assessment
Max inspiratory/expiratory pressure
MIP and MEP
QoL and subjective assessment for pulmonary/chest
VAS RPE MMRC Dyspnea scale St. George respiratory scale Dyspnea index
Post exercise RV remodeling-
Acute changes
Elevations of proBNP and increased cardiac troponin T levels in 60% subjects
40% exceed threshold usu used to diag MI
Non elite runners post-marathon (ave 41 y/o)
Biomarkers correlate w/ impaired LV diastolic dysfunction, increased pulmonary artery pressures, and RV dysfunction
Similar findings in ultramarathon runners
Acute effects all reverse in days post-event
Airway resistance
Bronchoconstriction
Mucous plugs
Airway thickening
Strength training
Pulmonary rehab
May be better tolerated than aerobic
6-26 weeks, 2-3x week
5-12 exercises
Combo of arm, leg and trunk
2-4 sets of 8-12 reps for each exercise
Intensity ranging and progressing from 32% -> 90% 1 RM
Normal respiratory rate
12-20 breaths per minute
Shunting-
L -> R
Acyanotic
ASD
VSD
PDS
Exercise capacity post heart transplant
56% of patient exercise capacity is <70% of predicted normal
Only 13% achieve >90% predicted normal
Contributing factors:
Transition from type 1 -> 2 fibers
Neuro-hormonal changes from long standing HF resulting in elevated TPR
Side effects of corticosteroids and immunosuppressive
Budesonide (Pumicort)
Long acting corticosteroid
Contraindications to spirometry testing
Hemoptysis (of unknown origin)
Pneumothorax
Unstable CV status, recent MI or PE
Thoracic, abdominal or cerebral aneurysm
Recent eye surgery
Acute disorders affecting test performance, such as nausea or vomiting
Recent thoracic or abdominal surgical procedures
PLB (pursed lip breathing)
COPD
Exhale slowly (4-6 sec) through pursed lips
Inhale (2 sec) through nose with mouth closed
Improves ventilation
Reduces respiratory rate
Prevents premature airway collapse by increasing back pressure (+ pressure) in airways
Prolonged breathing cycle = greater opportunity for diffusion
Thoracic wall movement (excursion)
Measure tap around chest wall
Xiphoid process = most reliable landmark
May also use axilla and interval between xiphoid and umbilicus
Normal = 2-3” (4-6 cm)
Syncope and the athlete
Common but concerning event - most cases are benign
Post exercise syncope-
Exhaustion, exercise-induced hyponatremia, heat illness, rapid reduction in preload and functional sympatholysis with elevated contractility and HR
Syncope during exercise- more concerning; linked to HCOM, arrythmogenic RV cardiomyopathy
Screening recommendations:
until diag pathological causes excluded, exercise generally restricted
R/O post vs during - ask bystanders
Screen for defects (marfans, HCOM etc)
Exercise dosage
Beta-blocker consideration
RPE 12-15 or Karnoven equation
MMRC dyspnea scale
Measure health related QoL
May detect QoL changes faster than GOLD classification
HRQoL of pt with COPD
PNA (pneumonia)
Infection in pulmonary parenchyma
Bacterial or viral
PT considerations of pediatric heart - post-op
Prevent complications (inactivity, pulmonary complications, FAMILY EDUCATION)
Early mobilization
Ambulation- if appropriate, team effort
Positioning: Prone > side-lying > supine
For ventilation/perfusion matching
Some activity/exercise restrictions may be present
Acceptable pulse ox cutoffs May be lower depending on case- communicate with RN, MD etc
Some may need guidance away from competitive sports
Maximum of ___% used for supplemental oxygen vents to avoid O2 toxicity
60%
Sequence method count
300 150 100 75 60 50 43 37
Diffusion capacity (DLCO)
Diffusion capacity of CO
Indirect assessment of alveolar gas exchange during pulmonary function tests
Procedure: known quantity of CO introduced prior to max inhalation
Patient holds breath for 10 sec followed by max exhale
Comparison of initial and final alveolar CO concentrations are made
Cardiac- radiograph
Site: L or R Size: less than half transthoracic diameter Shape: ovoid with spec pointing L? Shadows: any density change? Borders: clear or well defined?
Unclear border suggests middle lobe consolidation (R) or lingular consolidation (L)
Recommended intensity of exercise among patients with heart disease is ?
(% HRmax or VO2 peak)
Goal?
60-80% HRmax
50-85% VO2 peak
Consider 30-50% target HR early on
Goal to build up to 45 min of continuous exercise by 3-6 weeks
(Increase to at least 20 min)
Consider increasing intensity 1 MET every 2 weeks
Diagnostic criteria for obesity hypoventilation syndrome
BMI >= 30
Daytime PaCO2 > 45 mmHg
Associated sleep related breathing disorder
Absence of other known causes of hypoventilation
Birth to 1 month
HR
BP
Arterial oxygen saturation
HR: 100-160
(120-170 preterm)
Systolic BP: 60-90
Diastolic BP: 30-60
Arterial oxygen saturation
87-89 low
94-95 high
90-95 preterm infant
Ipratropium (Atrovent)
Tiotropium (Spiriva)
Bronchodilator: cholinergic antagonists
Block muscadine receptors in bronchioles (LAMA)
Drug of choice for COPD
Not often used for asthma
Not absorbed well into blood stream; less side effects than beta agonists
Alpha-Antitrypsin 1 (AAT) deficiency
COPD type
Genetic deficiency
Develop pancinar emphysema
Lower regions of lungs typically first effected
AAT functions to protect lungs
Develop emphysema
Develops age 30-40
Accelerated by smoking
No cure
Stridor
Wheeze-like sound
Usually due to blockage/obstruction of airflow in trachea, upper airway or back of throat
Predominantly inspiratory
Best heard over the neck
Common causes: foreign body in upper airway or esophagus, an acquired lesion of airway (ex. Carcinoma)
Ventilation assessments
Spirometry (FVC ABD FEV1)
RR (respiratory rate)
Congenital defects- heart
At least 15 defects identified
Usually abnormal opening between adjacent heart chambers
Common congenital malformations
1 in 100-125 births
Death rate:
38 per 100k Caucasian
56 per 100k African-American
Causes: viral infection, hereditary, Down syndrome, teratogens
Bronchiectasis
Irreversible airway dilation
Persistent productive cough with thick, tenacious sputum, crackles and wheezing on lung auscultation, obstructive pattern on PFT
Can be focal (localized area)
Extrinsic- compression by adjacent mass
Intrinsic- airway tumor or aspiration, scarred airway, bronchial atresia
Can be diffuse- often from underlying systemic/infectious disease
PE
Pulmonary embolism : 3rd most common death in hospitalized patients
Symptoms: dyspnea, sharp chest pain, pain with breathing, tachypnea, tachycardia hemoptysis
Thrombus usually starts in lower extremities and embolizes
Can lead to cor pulmonale (R side heart failure)
Bone- radiograph
Site Size Shape Shadows Borders
Fractures?
Lyric lesions? (Discrete darker areas or change in bone density)
Deformity?
Post transplant rehab- inpatient
1-2 weeks
Early mobility in ICU
Gait, balance, ADLs, functional mobility….
Potential barriers:
Acuity of illness, medical/cognitive, ventilation/sedation, line placement, lab values and vital signs outside safe ranges, inpatient testing and procedures, patient compliance
IPF etiology
Idiopathic pulmonary fibrosis
Males > Females
Older adults
Unknown cause- but may be combo of genetics and environmental factors
2-29 cases per 100k Median survival rate: 2-3 years after diagnosis #1 reason for lung transplant in US
Combivent
Combo of
Ipratropium bromide and albuterol sulfate
Benefits of both LAMA and SABA
10 ECG findings that are normal findings in athletes
Resulting from adaptation of the cardiac autonomic nervous system to conditioning
- Sinus bradycardia (>=30 bpm)
- Sinus arrhythmia
- Ectopic atrial Rhythm
- Junctions escape rhythm
- 1* AV block (PR interval > 200 ms)
- Mobitz Type 1 (Wenckebach) 2* AV block
- Incomplete RBBB
- Isolated QRS voltage criteria for LVH
- Early repolarization
- Convex ST segment elevation combined w/ T-wave inversion in leads V1-V4 in black athletes
Breath sounds- Bronchovesicular
I=E (Duration of insp vs exp)
Medium pitch expiration
Medium intensity of expiration
Location: large bronchi
Normal TV
tidal volume
500 mL or 0.5 L
Normal range 0.4-0.7 L
12 s/s rejection (heart)
- Fatigue
- Dyspnea
- Decreased exercise tolerance
- Hypotension pericardial friction rub
- Ventricular S3 gallop
- Decreased CO
- Peripheral edema
- Pulmonary crackles
- Jugular vein distention
- Increased temperature
- Arrhythmias
- Decreased urinary output
Best training for COPD
HIIT
Infant over 1 month - children
HR
BP
HR: 70-120
1-3 years old
Systolic BP: 80-130
Diastolic BP: 45-90
> 3 years old
Systolic BP: 90-140
Diastolic BP: 50-90
Severe chronotropic incompetence
Maximum exercise HR <= 90 bpm
Whispered pectoriloquy
Consolidations transmit whispered syllables distinctly, even when too small to produce bronchial breath
Exercise capacity goal - end of phase 2 cardiac rehab
8 METS
Tricuspid atresia
Tricuspid fails to develop
Ltd blood flow from RA->RV, underdeveloped RV
Filling of L ventricle and survival depends on ASD and VSD
R to L shunt
Surgery required
Pneumonia- sounds
Breath sounds: bronchial breath sounds in periphery
Adventitious sounds: course crackles, expiratory wheezing
PDA
Patent ductus arteriosus
DA normally closes within hours of birth
L to R shunt (aorta to Pulmonary Artery)
Creates high pressure in pulmonary artery
May require surging intervention
Clinical presentation: infant fatigues quickly, susceptible to pneumonia
Orthostatic hypotension is common in early post-op phase due to …
Absence of compensatory reflex tachycardia
Position changes s/b performed slowly to allow pt to slowly adapt to new position
Pneumothorax
Air in pleural space - breach in parietal or visceral pleura
S/S: dyspnea, sudden sharp pain, fall in BP, tachycardia
Cessation if normal respiratory patterns, hypoxemia, JVD, tracheal shift
TLC
Total lung capacity : forced vital capacity (FVC) + residual volume (RV)
Males: 5.8 L
Women: 4.2 L
Normal range 5-7 L
IRV
Normal
Inspiratory reserve volume
Men: 3 L
Women: 1.9 L
Lateral costal and segmental breathing
Manual contacts to thoracic wall
“Breathe into my hands”
Facilitate breathing in lower lateral segments in pt w/ impaired chest wall expansion
“Diaphragmatic breathing”
Not too effective with COPD
Voice sounds
In normal lungs whispered words are faint and the syllables indistinct, except over main bronchi
Louder and more distinct words indicate: consolidation, atelectasis, fibrosis
Voice sounds are more useful than breath sounds in detecting consolidation and atelectasis
Whispered tends to be better than spoken
Spirometry predicted normal values affected by
Age
Height
Gender
Ethnicity
Albutrol (Ventolin)
Rescue inhaler
SABA- short acting
Brochodilator
Beta-2 specific agonist
Adrenergic agonist
Time to effect 5-15 min
Duration 3-6 hours
Side effects- tachycardia, tremors, nervousness, restlessness, weight loss
VC
Vital capacity
VC = IRV + TV + ERV
Men: 4.6 L / 5 L
Women: 3.1 L / 3.8 L
Karnoven method to determine HR taken into account…
Age
RHR
Intensity
RLD- intrinsic
reduced airway compliance
thickening/scarring of lung interstitial tissue and pleura
Causes…
Drug
Occupational (asbestos, silicosis, coal workers)
Environmental- hypersensitivity pneumonia
Autoimmune- SLE, RA, wegener granulomatosis
Idiopathic- idiopathic pulmonary fibrosis, sarcoidosis
Ventricular Septal Defects results in Cyanotic or Acyanotic deficits
Acyanotic
Intrinsic RLD
Signs and symptoms
Symptoms: Insidious onset of dyspnea on exertion Frequent dry nonproductive cough Tachypnea Air hunger Difficulty eating
Signs:
Fine bibasilar end-inspiratory crackles
Clubbing fingers
May have R side heart failure s/s
Radiograph: reticular or reticulonodular pattern with diminished lung volumes
ABG: hypoxemia
Rhonchi
Wheezes
Typically expiratory sound due to airflow through abnormally narrow or collapsed airways
May occur in both inhalation and exhalation in asthma
Common causes: obstruction to airway flow, Asthma, mucous in airway, airway inflammation, tumor, obstructing foreign body
Non-cardiogenic should decrease w/ cough
Phases of Cardiac rehab
1: in hospital (3-5 METs)
2: 1-12 weeks (8 METs)
3: supervised maintenance
4: unsupervised maintenance
Lung field location
Upper:
apex to 2nd costal cartilage
Middle:
Between 2nd and 4th costal cartilage
Lower:
Between 4th and 6th costal cartilage
Sarcoidosis
Intrinsic RLD
Multi-system disease, unknown origin (possibly autoimmune)
90% cases lead to diffuse interstitial fibrosis and PAH
Younger than 40
African-Americans 10-15x higher incidence
Obstructive pulmonary diseases
COPD: Chronic bronchitis Emphysema Alpha 1 antitrypsin deficiency Asthma
Others:
Brochiectasis
Cystic fibrosis (later stages)
Gold classification based on
Age, Sex, Height, race
Gold 1: mild
FEV1 >= 80% predicted
Gold 2: moderate
FEV1 = < 50%
< 80% predicted
Gold 3: severe
FEV1 = < 30%
< 50% predicted
Gold 4: very severe
FRV1 < 30% predicted
Bronchitis- sounds
Breath sounds: nornal
Adventitious sounds: coarse crackles, wheezes that clear with cough
HTN in a child under age 6-
90% of time is due to?
Coarctation of aorta
Fontan procedure
18 mo to 3 years old
Connect pulmonary artery to inferior vena cava
Venous blood completely bypasses R ventricle
Once complete, oxygen rich and poor blood no longer mix in heart and skin will become Cyanotic
Kid still needs heart transplant
ERV
Normal
Expiratory reserve volume
Men: 1.1 L
Women: 0.7 L
During exercise goal is to keep pulse oximetry …
Above 90%
Karnoven equation
Target HR =
((Max HR - RHR) x % intensity)
+ RHRb
Extrinsic RLD causes
SCI
Above C3: require mechanical ventilation
C3-C5: Variable impairment of diaphragm and accessory respiratory muscle strength; impaired cough
C6-C8: impaired cough
Restriction from diaphragmatic weakness; chest wall restriction
Burns
Inhalation damage
Acute- upper airway edema w/in 24 hrs, bronchospasm 12-36 hrs; gas exchange impairment, pulmonary edema, CO poisoning
Chronic- increased risk interstitial fibrosis
External burn- deep partial or full thickness, scar tissue restricts chest expansion; develops 3-9 weeks post burn
Types of bronchodilators
SNS- adrenergic agonists (sympathomimmetics)
PNS- cholinergic antagonists (anti-cholinergic)
Methylxanthines
Normal range for oxygen
75-100 mmHg
PaO2
Norwood procedure
Done within first 2 weeks of life
Surgeon creates new aorta and connect it to R ventricle
Bialock-Tussing shunt placed from either aorta or R ventricle to pulmonary arteries
Heart becomes “single ventricle” capable of pumping mixed blood to lungs and periphery
Arterial oxygen saturation post 70-75%
Mixed venous oxygen saturation usu 45-55%
Tetralogy results in Cyanotic or Acyanotic deficits
Cyanotic
FEV1
Forced expiratory volume at 1 sec
FEV1 % FVC
Normal = 0.8 or 80%
Obstructive < 0.7 or 70%
5 types of PH
- PAH (Pulmonary arterial HTN)
- PH due to L ventricular dysfunction
- PH due to lung disease
- PH due to chronic blood clots
- PH due to other miscellaneous disorders
Forces that affect work of breathing
Elastic recoil of lungs and chest wall
Airway resistance
Normal physical exam - athletes
- L ventricular hypertrophy
Reversible
LV wall thickness (LVWT) and cavity size permits enhanced filling
Increased CO maintained at high HR - Bradycardia
- Increased VO2max
- Sinus arrhythmia
- Transient split S2
Changes w/ inspiration/expiration
Less common in adults
Post transplant - outpatient phase
Weeks 2-12
First 10 weeks: VO2 improvement ~ 1 met from baseline
6 months- 1 year: 2 met from baseline
Exercise capacity improvements usually plateau within 1st year
UE and resistive training for cardiac and lung transplant s/b delayed until 6 weeks post when wound and tissue healing is complete
Delayed wound healing due to medications
Adventitious sounds
Crackles
Rhonchi
Stridor
Pleural rub
FVC
Forced vital capacity
FVC= VC (vital capacity: IRV+TV+ERV)
Largest amount of air that can be expired after a maximal inspiratory effort
Measured as index of pulmonary function
VSD
Ventral Septal Defects
Most common congenital heart defect - small defects may close spontaneously, some require surgery
L to R shunt
If R ventricle pressures become too high, blood can shunt R to L - called Eisenmenger’s syndrome (Cyanotic)
Large defects can result in increased pulmonary artery pressure- can become permanent even with repair to VSD
Methylprendisolone (Medrol)
IV: severe asthma attacks or respiratory disease
Anti-inflammatory:Glucocorticoids
Control inflammatory mediated bronchospasm
Inhibit production of pro-inflammatory products (cytokines, prostaglandins, leukotrines..)
Immunosuppressive- inhibits migration of neutrophils and monocytes
Increases effects of beta agonists
Side effects- hyperglycemia, HTN, osteoporosis, myopathy, mood swings
Digital clubbing
Lung cancer Is most common cause
Often occur in heart and lung diseases that reduce O2 in blood.
Acute rejection s/s heart/lung transplants
Sudden weight gain (>= 6lbs in less than 3 days) Peripheral edema Fever, chills, sweating, malaise Dyspnea Decreased urine output, increased BUN and serum creatine levels Electrolyte imbalances Increased BP Swelling and tenderness at graft site
Montelukast (Singulair)
Great for asthma
OK for COPD
Pill
Leukotrine inhibitors: Airway hyperresponsiveness Inflammation Smooth muscle hypertrophy Mucous secretion
Enhances glucosteroids, allowing for smaller dose- so freq RX together
Pursed lip breathing
Elongates expiration time
Alleviates dyspnea
Decreases work of breathing
Is NOT most useful for restrictive lung disease
Rehabilitation considerations- organ transplant
Motivation and adherence to exercise are the major problems
Studies have found that pt who participated in exercise interventions following transplant have scored higher on QoL questionnaires 1 and 5 years post transplant in addition to demonstrating increased exercise capacity (measured by VO2 peak)
HEP performed regularly May also help reduce side effects of immunosuppressant meds
5 common side effects of immunosuppressive drugs
HTN Hyperglycemia Renal dysfunction K+ alteration Neurotoxicity (tremors)
Pulmonary implications of obesity
Change in lung volumes
Decreased ERV, FRC, TLC, VC, FEV1
Residual volume is normal.
FEV1/FVC ratio usually normal
Respiratory muscle weakness
OSA (obstructive sleep apnea)
Asthma due to fatty deposits in neck
Acute respiratory failure- Type 2
Hypoxia with hypercapnea
Low PaO2 (<55 mmHg) High PCO2 (> 45 mmHg) Low pH (< 7.3)
Purulent sputum
Inflammatory cells, enter airways and alveoli in response to lower airway infection
Yellow, green, dirty gray
Small amounts: acute bronchitis, resolving pneumonia, smaller tuberculous cavities, or lung abscess
Copious: bacterial pneumonia, lung abscess, brochiectasis, bronchopleural fistula communicating with an empyema
Foul smelling: anaerobic infection (PNA) and/or lung abscess
Asthma
COPD type
Reversible Bronchospasm with wheezing
Short lived episodes
Manifests early in life
COPD- asthma
Reversible brochoconstriction Hyper-reactive airways Manifests earlier in life Associated with chronic inflammation If severe- may be cyanosis
Best position for respiratory problems
Sidelying and prone
Airways tend to collapse during
Expiration
FRC
RV
Residual volume
Air remaining in lungs (all times)
Men: 1.2 L
Women: 1.1 L
Restrictive disease Anatomy affected? Breathing phase difficulty? Pathophysiology? Useful measurements?
Lung parenchyma, thoracic pump
Inspiration
Decreased lung or thoracic compliance
Volumes or capacities
Apgar score
1 and 5 min after birth Appearance, pulse, grimace activity, respirations
0-3 = critically low
4-6 = fairly low
7-10 = generally normal
0: blue/pale appearance; no responses
1: blue extremities, pink torso; pulse <100, weak grimace when stimulated, some flexion of arms, weak/irregular/gasping
2: pink all over; pulse >=100; cries or pulls away when stimulated; arms flexed/legs resist extension; strong cry
Coarction of Aorta
“Pinching” of aorta
Usually distal to subclavian artery
May be due to abnormal involution of DA (ductus arteriosus)
Severity dependent on degree of pinching and location
Present in 15–20% of CHD cases
May not be detected until later in childhood
Kidneys see low BP and try to increase BP
BP May be normal or elevated in arms, lower in legs
Idiopathic pulmonary fibrosis (IPF)
Chronic, progressive, irreversible and usually lethal restrictive lung disease
Destruction of alveoli and surrounding capillary network
Progressive scar tissue formation which reduces lung compliance
Loss of alveolar capillary density, impaired gas exchange, hypoxemia
Aerobic training
Pulmonary rehab
Typically using moderate intensity (40-60% VO2 max)
Talk test
Or
80% of average 6MWT gait speed
Duration- 30 min continuously, or 10 min intervals
COPD- chronic bronchitis
Obstruction of the airway by mucus, leading to Bronchiectasis or Atelectasis.
Submucosal gland hypertrophy in bronchioles producing increased thickness resulting from exposure of smoking or other irritants.
Blue bloaters
Sternal precautions
Log rolling with bed mobility
No pushing, pulling with UE
Avoid UE MMT
No OH use of traps
Avoid Valsalva
Use pillow for splinting with cough
10lb weight limit
No driving or sitting in passenger front seat (airbag)
Usually ~6 weeks
TAPVR
Total anomalous pulmonary venous return
Pulmonary veins don’t connect to L atrium
Instead connect to R side of heart via abnormal connection
Usually child possesses ASD - only way for oxygenated blood to get to L side
Child will require surgery soon after birth- critical congenital defect
Static lung compliance is
The change in volume for any given applied pressure
Change in volume % Change in pressure
Increases with age and COPD
Decreases with RLD
Major causes of mortality and morbidity for children
Pulmonary disease and
Respiratory disorders
Pre-transplant rehab considerations
Chronic disease prior to transplant leads to: Muscle weakness Prolonged hospitalization Fatigue Prolonged bed rest or confinement to home Decreased mobility Poor breathing mechanics Inability to clear pulmonary secretions
Drive to breathe in healthy folks - regulated by which blood gas concentration
CO2
BDI/TDI
BDI: baseline dyspnea index
TDI: transition dyspnea index
24 item, 3 domains,interviewer administered
Multidimensional measurement of components that evoke dyspnea in ADLs
Diaphragm- radiograph
Outline s/b clear and smooth
R hemidiaphragm should be higher (2-3 cm) than L
Costophrenic angles well defined?
Whiteness immed above diaphragm indicates pleural effusion or consolidation
Fluid will cause meniscus or concave upper border
Air below each hemidiaphragm indicating bowel perforation?
Diaphragm below anterior end of 6th rib? Indicates hyperinflation
