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Acute Care > Acute care Test2 > Flashcards

Acute care Test2 Flashcards

1
Q

Chronic bronchitis

A

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

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2
Q

Salmeterol (Serevent)

A

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

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3
Q

Disease - air trapping, increased RV, flat diaphragm

A

Emphysema

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4
Q

SGRQ

A

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

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5
Q

___ position tends to decrease ventilation, which affects ___

A

Supine

Affects ventilation and perfusion matching (decreased O2 saturation)

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6
Q

Airway- radiograph

A

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)

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7
Q

Epinephrine

A

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

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8
Q

Children with CHD are at increased risk of …

A

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.

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9
Q

MMRC dyspnea scale

A

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)

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10
Q

Pathophysiological changes -

Pulmonary problems

A

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

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11
Q

Indications for oxygen therapy

A

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

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12
Q

OSA

A

Obstructive sleep apnea

Intermittent upper airway obstruction (Pharyngeal musculature doesn’t maintain)
Fall in SaO2, increased CO2 levels (hypercapnea)
Sleep disturbance, hypersomnolence

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13
Q

COPD physical exam findings

A 
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)

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14
Q

Crackles (Rales)

A

“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

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15
Q

Fick’s principle: oxygen consumption is the product of …

A

CO and arteriovenous difference

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16
Q

Patent ductus arteriosum results in Cyanotic or Acyanotic deficits

A

Acyanotic

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17
Q

Muscles of inspiration work against what forces

A

Elastic recoil of chest wall

Airway resistance

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18
Q

Bi-directional Glenn shunt procedure

A

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

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19
Q 
Diffusion capacity (DLCO) 
Dependent on
A
  1. Volume inspired
  2. Pulmonary blood flow
  3. AC surface area
  4. Hemoglobin
  5. Thickness of AC membrane

Generally reduced with emphysema and restriction, normal in asthmatics

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20
Q

PH s/s

A 
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
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21
Q

Pickwickian syndrome

A

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

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22
Q

Diphenhydramine

A

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

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23
Q

COPD: muscle pathophysiological changes

A

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

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24
Q

COPD prognosis

A 
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%

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25
Q

Meconium aspiration syndrome

A

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

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26
Q

Dehydration
Q?
SV?
HR?

A

Q- decreases
SV - decreases
HR- increases

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27
Q

Tracheal shift

Implications on side

A

Tracheal shift contralateral to pneumothorax or pulmonary effusion

Tracheal shift ipsilateral on atelectasis

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28
Q

Thoracic wall palpation

A

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

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29
Q

Blood lab to assess/track severity of heart failure

A

BNP

Brain natriuretic peptide

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30
Q

SCD in athlete

A

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

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31
Q

Evaluation of diaphragmatic action

A

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

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32
Q

Tracheal position

A 
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)

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33
Q

Obstructive pulmonary disease

A

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

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34
Q

COPD common impairments

A

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

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35
Q

Common Cyanotic Defects

A 
Transposition of the great vessels 
Pulmonary valve atresia 
Tetralogy of fallout 
Hypoplastic left heart syndrome 
Shone’s syndrome 
TAVPR

Coarctation of the aorta

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36
Q

SCD common causes

A

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

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37
Q

Shunting R -> L

A

Cyanotic

Transposition of great vessel
Tricuspid atresia
Tetralogy of fallot
Total anomalous pulmonary venous return

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38
Q

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 ___.

A

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

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39
Q

Breath sounds- Bronchial

A

E>I (Duration of insp vs exp)

High pitch expiration
Loud intensity of expiration

Location: over trachea

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40
Q

Atelectasis- sounds

A

Breath sounds: decreased to absent

Adventitious sounds: crackles

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41
Q

PT exam for child with asthma

A

Measure thorax on inspiration and expiration
Examine exercise tolerance, strength, posture
Asthma QoL questionnaire

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42
Q

Hemoptysis

A

Bloody sputum
Coughing up blood/bloody mucous

Hallmark sign of PE
May also occur with trauma, pneumonia

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43
Q

Pulse and heart rate

A

Are NOT the same thing

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44
Q

In heart transplant the ___ paces the allograft heart resulting in ___.

During exercise the transplant heart is regulated by___.

A

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)

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45
Q

Symbicort

A

Combo of Budesonide and Formoterol

Benefit of both steroid and LABA
Typically 1 puff twice day

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46
Q

Pirfenidone (Esbriet)

Nintedanib (Ofev)

A

Pulmonary fibrosis medications
Anti-fibrotic

Inhibit pathways that lead to fibrosis and scarring of lungs - Suppress fibroblast proliferation and fibrotic mediator production

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47
Q

When to hold exercise

A
  1. QRS widening > 0.12 sec
  2. > 6 PVC per min or Couplet
  3. Glucose >250 or <60
    (Make sure they have a snack prior)
  4. RHR >100 or with AFib >110 bpm
  5. Systolic <90 mmHg or >180 mmHg
    or diastolic > 110 mmHg
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48
Q

CV system arises from

What embryonic tissue?

A

Mesodermal germ layer

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49
Q

PT considerations of pediatric heart (general)

A 
Labored breathing
Increased RR
Diffuse generalized edema 
Decreased urine output 
Eating problems 
Impaired tolerance to activity 
Irritable (track using NIPS scale)
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50
Q

Compression test for rib fracture

A

1 hand supporting back

Compression of sternum with other hand elicits pain at untouched fracture site

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51
Q

ECMO

A

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)

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52
Q

CV disorders and Marfans

A

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
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53
Q

Acute rejection s/s heart related symptoms

A 
S3 gallop
Arrhythmias
Jugular vein distention 
Decreased exercise tolerance 
Shortness of breath
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54
Q

Thoracic wall movement (symmetry)

A

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

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55
Q

Myocardial bridge

A

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

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56
Q

Common antibiotics

Acute bronchitis, pneumonia, etc

A

Bactericidal:
Penicillins (incl amoxicillin)
Cephalosporins (Cipro)

Bacterostatic:
Macrolides - Azithromycin (Z pack)

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57
Q

Paced breathing

A

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

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58
Q 
Diffusion capacity (DLCO) 
Normal vs pulmonary pathology
A

Normal 80-100%
Pulmonary pathology < 80%

Of predicted uptake.
Diffusion capacity of CO

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59
Q

Wells PE

A

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.

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60
Q

Most common cause of heart failure in US

A

Ischemic heart disease

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61
Q

Albuterol (Proventil)

A

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

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62
Q

Increased breath sounds…

A

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

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63
Q

COPD: diaphragmatic adaptations

A

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

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64
Q

Heart innervation?

Works by?

A

Vagus nerve

Depressing intrinsic rate of heart set by SA node

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65
Q

Pulmonary pressure > 60 mmHg

Implication?

A

Contraindications for exercise

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66
Q

Visual inspection- pulmonary and chest

A

Disposition: distress, SOB, somnolent

Skin: edema, JVD, cyanosis, sweating

Body position/posture: normal, barrel chest, slouched, guarding, pes escavatum, pectus carinatum

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67
Q

Braced/Splinted breathing

A

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

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68
Q

Pleural rub

A

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

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69
Q

Chronic respiratory disease is the ___ killer in US

A

3rd

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70
Q

Eisenmenger’s syndrome

A

Cyanotic

Due to VSD where pressure in R ventricle becomes too high - shunting blood R to L (VSD usually is L to R)

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71
Q

Conditions prone to developing secretions

A 
CF
Asthma 
COPD; esp chronic bronchitis 
Bronchiectasis
Acute pulmonary disease 
Mechanical ventilator dependency 
Post-surgery
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72
Q

Exercise capacity post lung transplant

A

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

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73
Q

MVV

A

Minute ventilation
Amt of air expired per minute

TV x RR

4 L/min, the CO of ventilation

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74
Q

Tetralogy of fallot

A 
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

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75
Q

Antitussive

A

Suppress coughing response/reflex

2 types:
1. Centrally mediated inhibition
DM- Codeine and dextromethorphan
(Opiates, act on brainstem)

  1. Local mediated inhibitors
    Antihistamines and local anesthetics
    (Act on respiratory tissue)
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76
Q

Commotio cordis

A

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

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77
Q

Fluid location in rales/crackles

A

Alveoli

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78
Q

Intrinsic RLD prognosis

A

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

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79
Q

ABCs of chest radiographs

A 
A- airway 
B- bone
C- cardiac 
D- diaphragm 
E and F- equal (lung) fields 
G- gastric bubble 
H- volume (and mediastinum)
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80
Q

Apex of lung has ____ perfusion and ___ ventilation.

A

Low perfusion
High ventilation

High V/Q ratio

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81
Q

How many weeks post-op MI begin resistance training

A

5 weeks

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82
Q

CF (cystic fibrosis)

A

Genetic
Defect in Na+ and Cl- channels resulting in excessive mucous formation - multisystem

Life expectancy 37 y/o

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83
Q

Theophylline, Theobromine and caffeine

A

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

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84
Q

Phase 1

Cardiac rehab

A

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

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85
Q

Asbestosis and Silicosis are forms of ___.

A

Intrinsic RLD

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86
Q

Asthma- sounds

A

Breath sounds: decreased

Adventitious sounds: inspiratory and expiratory wheezes

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87
Q

Transposition of the great vessels

A

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

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88
Q

Absent or decreased breath sounds can mean…

A

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

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89
Q

Pulse oximetry

A

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)

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90
Q

Pulmonary rehab guide

A

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

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91
Q

Hypertrophic cardiomyopathy

A

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

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92
Q

Post transplant - inpatient goals

A

Increase functional capacity
Improve level of independence
Progression of exercise
Education: HEP, guidelines for termination of exercise, special considerations for exercise post-transplant

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93
Q

DSB (deep slow breathing)

A

6-8 breaths/minute
Improves pain

Relaxed state; parasympathetic tone

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94
Q

Emphysema

A

COPD type
Loss of alveolar walls
Associated with increase in size of acinar airways of the upper lobe segments in a centrilobular “centriacinar” pattern

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95
Q

Budenoside (Pulmicort),
Beclemethasone (Belcovent),
Fluticasone (Flovent)

A

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

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96
Q

Dehydration

A 
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)

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97
Q

Post exercise RV remodeling- Chronic changes

A

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

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98
Q

Prednisone

A

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

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99
Q

Cardiovascular embryology

A

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

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100
Q

Common Acyanotic Defects

A

ASD- atrial Septal defect
PDA- patent ductus arteriosum
VSD- ventricular Septal defect

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101
Q

Acute respiratory failure- Type 1

A

Hypoxia without hypercapnea

Low PaO2 (<55 mmHg)
Normal PCO2 (35-45 mmHg)
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102
Q

Lung segment examination

A

Fremitus
Voice sounds
Breath sounds

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103
Q

Stringy mucoid sputum

A

Increased mucous production and mucous plugs occur in asthma

During resolution retained mucous and plugs are mobilized

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104
Q

Phase 2

Cardiac rehab

A

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

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105
Q

Most common anomalies are:
___ coronary artery origins in ____.
___ coronary artery origins in ____.

A

L coronary artery origins in R sinus of Valsalva

R coronary artery origins in L sinus of Valsalva

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106
Q

RLD (restrictive lung disease)

A

Problems getting air IN

FEV1, FVC, TLC reduced
FEV1/FVC normal or increased

Reduced DLCO
Lungs prevented from fully expanding
Reduced minute ventilation

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107
Q

COPD staging

A

Mild: FEV1 >= 80%
Moderate: FEV1 50-80%
Severe: FEV1 30-50%
Very severe: FEV1 < 30%

FEV1/FVC < 0.70

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108
Q

Common sequelae of chronic lung disease

A 
Pulmonary HTN 
Cor pulmonale (R heart failure) 
Atrial fibrillation (especially COPD) 
Obstructive sleep apnea (especially COPD)
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109
Q

Optimum work rest ratio in pulmonary rehab

A

3:1

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110
Q

Pediatric conditions that affect the lungs (prematurity, anatomical anomalies)
Cause chronic respiratory insufficiency

A

Brochopulmonary dysplasia (BPD)

tracheobronchomalacia

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111
Q

What intervention is prioritized in COPD patients

A

Balance training

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112
Q

Huff cough

A

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

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113
Q

Exercise dosage
Stable angina ____% HR at onset of angina

Consider ___

A

70-85%

Consider RPP

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114
Q

Acute rejection s/s lung related symptoms

A

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

115
Q

Positions to relieve dyspnea

A

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

116
Q

HNP (hypersensitive pneumonitis)

A

Intrinsic RLD
Extremely aggressive progression

Hypersensitivity to certain allergens
Unlike asthma, which affects larger airways (HNP) affects alveolar septae

117
Q

Thoracic rib cage movement during diaphragm contraction

A

Inspiration

Superior, anterior and lateral

118
Q

Pulmonary valve atresia

A

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%

119
Q

Pediatric heart transplant

A

~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

120
Q

Normal respiratory rates in children

A

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

121
Q

Inspiratory hold

A

Hold breath after max inspiration
Without valsalva for 2-3 sec

Increases back pressure and stretch on Type 2 alveolar cells

122
Q

Rehab considerations- lung transplant

A

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

123
Q

Common impairments associated with pulmonary problems

A 
Functional capacity 
Decreased strength 
Impaired balance 
Dyspnea with minimal activity 
Reduced gait speed 
Impaired cardiorespiratory response to exercise
Back pain 
Chronic pain
124
Q

PAH

A

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

125
Q

Spirometry guidelines

A

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

126
Q

FRC

A

Functional residual capacity
Air remaining in lungs after expiration

FRC = ERV + RV

Men: 2.3 L
Women: 1.8 L

127
Q

Bronchophony 99

A

Spoken syllables normally heard indistinctly

With lung consolidation syllables are distinct and sound close to the ear

128
Q

Rehab considerations- heart transplant

A

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

129
Q

Tactile fremitus

A

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

130
Q

NM dysfunction: abnormal breathing patterns

A

Brainstem: apnea (abnormal breathing)

Quad and paraplegics:
Abdomen rises; upper thorax sucks in

Post polio:
Upper thorax rises; abdomen sinks

131
Q

Autonomic control of airway diameter

A

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)

132
Q

Angina- what heart rate when exercising

A

HR 5-10 beats below angina threshold

133
Q

Fluticasone and Salmeterol (Advair)

A

Combo corticosteroid and long lasting beta2 agonist

134
Q 
Obstructive disease
Anatomy affected?
Breathing phase difficulty? 
Pathophysiology?
Useful measurements?
A

Airways
Expiration
Increased airway resistance
Flow rates

135
Q

Physiological changes post heart transplant

A

Transplanted heart is denervated.
Absence of direct neural regulations HR/SV

Absence of chest pain

Higher RHR

136
Q

Rib fracture

A

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

137
Q

COPD diagnostic test findings

A

FEV1/FVC ratio < 0.70
Reduced FEV1 < 80%
Air trapping (increased TLC)
Reduced DLCO

Flattened diaphragm 
Hypoxemia 
Hypercapnia 
Impaired ventilation 
Polycythemia
138
Q

Mediate percussion

A

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

139
Q

Respiration assessment

A

ABG (arterial blood gases)

SpO2 (Pulse oximetry)

140
Q

Frothy pink sputum

A

Alveoli and respiratory bronchioles are flooded with fluid from capillaries

Producing thin secretions containing air bubbles, frequently colored with hemoglobin

Hallmark sign of PE

141
Q

Breath sound- Vesicular

A

I>E (Duration of insp vs exp)

Low pitch expiration
Soft intensity of expiration

Location: most of lung

142
Q

PH

A

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

143
Q

Atelectasis

A

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

144
Q

Pseudoephedrine

A

Sudafed
Nasal decongestant - upper respiratory tract

Most often Alpha-1 agonist

Causes vasoconstriction in nasal passages
“Dries up” mucosal vasculature and reduces nasal congestion

145
Q

Guanefisine

A

Mucinex
Mycolytics

Decrease viscosity of respiratory secretions
Allows for easier mobilization of secretions

146
Q

Ipratropium (Atrovent)

A

Anticholinergic bronchodilator that decreases bronchial spasms/short acting

147
Q

BPD (brochopulmonary dysplasia) results in abnormal development of

A

Alveoli

148
Q

Pediatric Cardiopulmonary
Physical therapy exam
(10)

A
  1. Lab values
  2. Vital signs
  3. Appearance
  4. Pain (if on morphine encourage deep breaths)
  5. Integumentary screen
  6. Posture
  7. Respiratory screen
  8. Strength
  9. Functional abilities
  10. Cardiorespiratory response to movement/exercise
149
Q

CLDI
Chronic lung disease of infancy
Diagnosis

A

Clinical exam and chest radiographs continue to be abnormal and the O2 need is still present

150
Q

HLHS

A

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

151
Q

Advair

A

Fluticasone and Salmeterol

Benefits of both steroid and LABA

Typically 1 puff twice day

152
Q

Genetic disorder with defects in Cl- and Na+ channels

A

Cystic fibrosis

153
Q

COPD- emphysema

A

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”

154
Q

Atrial Septal Defects results in Cyanotic or Acyanotic deficits

A

Acyanotic

155
Q

Complications of mechanical ventilation

A 
Tracheal lesions
Infections 
Excessive secretions-> atelectasis 
Intracranial hemorrhage 
Cerebral vasoconstriction 
Septicemia 
Increased work of breathing (fighting the ventilator)
Stress ulcer
156
Q

COPD : diffusion and blood gas changes

A

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

157
Q

Fluid in pleural space (normal)

A

10-25 mL

158
Q

Pre-transplant goals

A

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

159
Q 
Obstructive lung
IRV
TV
ERV
RV
A

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%

160
Q

ACB (active cycle breathing)

A

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)

161
Q

Flail chest

A

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

162
Q

ASD

A

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

163
Q

Normal RR

A

Adults: 12-20 breaths/min

Infants 30-60
Toddler 24-30
Preschooler 22-34 
School-age 18-30
Adolescent 12-16
164
Q

Consolidation - sounds

A

Breath sounds: decreased sounds over consolidation, bronchial sounds in periphery

Adventitious sounds: inspiratory crackles

165
Q

Blood-streaked sputum

A

Inflammation in nose, nasopharynx, gums, larynx, or bronchi

Sometimes occurs after severe paroxysms if coughing and Minor airway trauma

166
Q

Main risk factor in development of COPD

A

Smoking

Quitting prevents accelerated decline in lung function and may improve FEV1

167
Q

BPD diagnosis

A

Brochopulmonary dysplasia

28 days and still continues to require supplemental oxygen and has abnormal chest radiograph

168
Q

Testing recommendations

Cardiac rehab

A

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

169
Q

HF exercise dosage

A

70-85% of maximal if tolerated
Or
To onset of moderate dyspnea

170
Q

Respiratory muscle strength assessment

A

Max inspiratory/expiratory pressure

MIP and MEP

171
Q

QoL and subjective assessment for pulmonary/chest

A 
VAS
RPE
MMRC Dyspnea scale 
St. George respiratory scale 
Dyspnea index
172
Q

Post exercise RV remodeling-

Acute changes

A

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

173
Q

Airway resistance

A

Bronchoconstriction
Mucous plugs
Airway thickening

174
Q

Strength training

Pulmonary rehab

A

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

175
Q

Normal respiratory rate

A

12-20 breaths per minute

176
Q

Shunting-

L -> R

A

Acyanotic

ASD
VSD
PDS

177
Q

Exercise capacity post heart transplant

A

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

178
Q

Budesonide (Pumicort)

A

Long acting corticosteroid

179
Q

Contraindications to spirometry testing

A

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

180
Q

PLB (pursed lip breathing)

A

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

181
Q

Thoracic wall movement (excursion)

A

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)

182
Q

Syncope and the athlete

A

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)

183
Q

Exercise dosage

Beta-blocker consideration

A

RPE 12-15 or Karnoven equation

184
Q

MMRC dyspnea scale

A

Measure health related QoL

May detect QoL changes faster than GOLD classification

HRQoL of pt with COPD

185
Q

PNA (pneumonia)

A

Infection in pulmonary parenchyma

Bacterial or viral

186
Q

PT considerations of pediatric heart - post-op

A

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

187
Q

Maximum of ___% used for supplemental oxygen vents to avoid O2 toxicity

A

60%

188
Q

Sequence method count

A 
300
150
100
75
60
50
43
37
189
Q

Diffusion capacity (DLCO)

A

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

190
Q

Cardiac- radiograph

A 
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)

191
Q

Recommended intensity of exercise among patients with heart disease is ?
(% HRmax or VO2 peak)

Goal?

A

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

192
Q

Diagnostic criteria for obesity hypoventilation syndrome

A

BMI >= 30
Daytime PaCO2 > 45 mmHg
Associated sleep related breathing disorder
Absence of other known causes of hypoventilation

193
Q

Birth to 1 month
HR
BP
Arterial oxygen saturation

A

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

194
Q

Ipratropium (Atrovent)

Tiotropium (Spiriva)

A

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

195
Q

Alpha-Antitrypsin 1 (AAT) deficiency

A

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

196
Q

Stridor

A

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)

197
Q

Ventilation assessments

A

Spirometry (FVC ABD FEV1)

RR (respiratory rate)

198
Q

Congenital defects- heart

A

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

199
Q

Bronchiectasis

A

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

200
Q

PE

A

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)

201
Q

Bone- radiograph

A 
Site
Size
Shape
Shadows
Borders

Fractures?
Lyric lesions? (Discrete darker areas or change in bone density)
Deformity?

202
Q

Post transplant rehab- inpatient

A

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

203
Q

IPF etiology

A

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
204
Q

Combivent

A

Combo of
Ipratropium bromide and albuterol sulfate

Benefits of both LAMA and SABA

205
Q

10 ECG findings that are normal findings in athletes

Resulting from adaptation of the cardiac autonomic nervous system to conditioning

A
  1. Sinus bradycardia (>=30 bpm)
  2. Sinus arrhythmia
  3. Ectopic atrial Rhythm
  4. Junctions escape rhythm
  5. 1* AV block (PR interval > 200 ms)
  6. Mobitz Type 1 (Wenckebach) 2* AV block
  7. Incomplete RBBB
  8. Isolated QRS voltage criteria for LVH
  9. Early repolarization
  10. Convex ST segment elevation combined w/ T-wave inversion in leads V1-V4 in black athletes
206
Q

Breath sounds- Bronchovesicular

A

I=E (Duration of insp vs exp)

Medium pitch expiration
Medium intensity of expiration

Location: large bronchi

207
Q

Normal TV

A

tidal volume
500 mL or 0.5 L

Normal range 0.4-0.7 L

208
Q

12 s/s rejection (heart)

A
  1. Fatigue
  2. Dyspnea
  3. Decreased exercise tolerance
  4. Hypotension pericardial friction rub
  5. Ventricular S3 gallop
  6. Decreased CO
  7. Peripheral edema
  8. Pulmonary crackles
  9. Jugular vein distention
  10. Increased temperature
  11. Arrhythmias
  12. Decreased urinary output
209
Q

Best training for COPD

A

HIIT

210
Q

Infant over 1 month - children
HR
BP

A

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

211
Q

Severe chronotropic incompetence

A

Maximum exercise HR <= 90 bpm

212
Q

Whispered pectoriloquy

A

Consolidations transmit whispered syllables distinctly, even when too small to produce bronchial breath

213
Q

Exercise capacity goal - end of phase 2 cardiac rehab

A

8 METS

214
Q

Tricuspid atresia

A

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

215
Q

Pneumonia- sounds

A

Breath sounds: bronchial breath sounds in periphery

Adventitious sounds: course crackles, expiratory wheezing

216
Q

PDA

A

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

217
Q

Orthostatic hypotension is common in early post-op phase due to …

A

Absence of compensatory reflex tachycardia

Position changes s/b performed slowly to allow pt to slowly adapt to new position

218
Q

Pneumothorax

A

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

219
Q

TLC

A

Total lung capacity : forced vital capacity (FVC) + residual volume (RV)

Males: 5.8 L
Women: 4.2 L

Normal range 5-7 L

220
Q

IRV

Normal

A

Inspiratory reserve volume
Men: 3 L
Women: 1.9 L

221
Q

Lateral costal and segmental breathing

A

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

222
Q

Voice sounds

A

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

223
Q

Spirometry predicted normal values affected by

A

Age
Height
Gender
Ethnicity

224
Q

Albutrol (Ventolin)

A

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

225
Q

VC

A

Vital capacity

VC = IRV + TV + ERV

Men: 4.6 L / 5 L
Women: 3.1 L / 3.8 L

226
Q

Karnoven method to determine HR taken into account…

A

Age
RHR
Intensity

227
Q

RLD- intrinsic

A

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

228
Q

Ventricular Septal Defects results in Cyanotic or Acyanotic deficits

A

Acyanotic

229
Q

Intrinsic RLD

Signs and symptoms

A 
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

230
Q

Rhonchi

A

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

231
Q

Phases of Cardiac rehab

A

1: in hospital (3-5 METs)
2: 1-12 weeks (8 METs)
3: supervised maintenance
4: unsupervised maintenance

232
Q

Lung field location

A

Upper:
apex to 2nd costal cartilage

Middle:
Between 2nd and 4th costal cartilage

Lower:
Between 4th and 6th costal cartilage

233
Q

Sarcoidosis

A

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

234
Q

Obstructive pulmonary diseases

A 
COPD: 
Chronic bronchitis 
Emphysema 
Alpha 1 antitrypsin deficiency 
Asthma

Others:
Brochiectasis
Cystic fibrosis (later stages)

235
Q

Gold classification based on

A

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

236
Q

Bronchitis- sounds

A

Breath sounds: nornal

Adventitious sounds: coarse crackles, wheezes that clear with cough

237
Q

HTN in a child under age 6-

90% of time is due to?

A

Coarctation of aorta

238
Q

Fontan procedure

A

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

239
Q

ERV

Normal

A

Expiratory reserve volume
Men: 1.1 L
Women: 0.7 L

240
Q

During exercise goal is to keep pulse oximetry …

A

Above 90%

241
Q

Karnoven equation

A

Target HR =
((Max HR - RHR) x % intensity)
+ RHRb

242
Q

Extrinsic RLD causes

A

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

243
Q

Types of bronchodilators

A

SNS- adrenergic agonists (sympathomimmetics)

PNS- cholinergic antagonists (anti-cholinergic)

Methylxanthines

244
Q

Normal range for oxygen

A

75-100 mmHg

PaO2

245
Q

Norwood procedure

A

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%

246
Q

Tetralogy results in Cyanotic or Acyanotic deficits

A

Cyanotic

247
Q

FEV1

A

Forced expiratory volume at 1 sec

FEV1 % FVC
Normal = 0.8 or 80%
Obstructive < 0.7 or 70%

248
Q

5 types of PH

A
  1. PAH (Pulmonary arterial HTN)
  2. PH due to L ventricular dysfunction
  3. PH due to lung disease
  4. PH due to chronic blood clots
  5. PH due to other miscellaneous disorders
249
Q

Forces that affect work of breathing

A

Elastic recoil of lungs and chest wall

Airway resistance

250
Q

Normal physical exam - athletes

A
  1. L ventricular hypertrophy
    Reversible
    LV wall thickness (LVWT) and cavity size permits enhanced filling
    Increased CO maintained at high HR
  2. Bradycardia
  3. Increased VO2max
  4. Sinus arrhythmia
  5. Transient split S2
    Changes w/ inspiration/expiration
    Less common in adults
251
Q

Post transplant - outpatient phase

A

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

252
Q

Adventitious sounds

A

Crackles
Rhonchi
Stridor
Pleural rub

253
Q

FVC

A

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

254
Q

VSD

A

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

255
Q

Methylprendisolone (Medrol)

A

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

256
Q

Digital clubbing

A

Lung cancer Is most common cause

Often occur in heart and lung diseases that reduce O2 in blood.

257
Q

Acute rejection s/s heart/lung transplants

A 
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
258
Q

Montelukast (Singulair)

A

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

259
Q

Pursed lip breathing

A

Elongates expiration time
Alleviates dyspnea
Decreases work of breathing

Is NOT most useful for restrictive lung disease

260
Q

Rehabilitation considerations- organ transplant

A

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

261
Q

5 common side effects of immunosuppressive drugs

A 
HTN
Hyperglycemia 
Renal dysfunction 
K+ alteration 
Neurotoxicity (tremors)
262
Q

Pulmonary implications of obesity

A

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

263
Q

Acute respiratory failure- Type 2

A

Hypoxia with hypercapnea

Low PaO2 (<55 mmHg)
High PCO2 (> 45 mmHg) 
Low pH (< 7.3)
264
Q

Purulent sputum

A

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

265
Q

Asthma

A

COPD type
Reversible Bronchospasm with wheezing
Short lived episodes
Manifests early in life

266
Q

COPD- asthma

A 
Reversible brochoconstriction 
Hyper-reactive airways 
Manifests earlier in life
Associated with chronic inflammation 
If severe- may be cyanosis
267
Q

Best position for respiratory problems

A

Sidelying and prone

268
Q

Airways tend to collapse during

A

Expiration

FRC

269
Q

RV

A

Residual volume
Air remaining in lungs (all times)
Men: 1.2 L
Women: 1.1 L

270
Q 
Restrictive disease
Anatomy affected?
Breathing phase difficulty? 
Pathophysiology?
Useful measurements?
A

Lung parenchyma, thoracic pump
Inspiration
Decreased lung or thoracic compliance
Volumes or capacities

271
Q

Apgar score

A

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

272
Q

Coarction of Aorta

A

“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

273
Q

Idiopathic pulmonary fibrosis (IPF)

A

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

274
Q

Aerobic training

Pulmonary rehab

A

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

275
Q

COPD- chronic bronchitis

A

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

276
Q

Sternal precautions

A

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

277
Q

TAPVR

A

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

278
Q

Static lung compliance is

A

The change in volume for any given applied pressure

Change in volume % Change in pressure

Increases with age and COPD
Decreases with RLD

279
Q

Major causes of mortality and morbidity for children

A

Pulmonary disease and

Respiratory disorders

280
Q

Pre-transplant rehab considerations

A 
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
281
Q

Drive to breathe in healthy folks - regulated by which blood gas concentration

A

CO2

282
Q

BDI/TDI

A

BDI: baseline dyspnea index
TDI: transition dyspnea index

24 item, 3 domains,interviewer administered

Multidimensional measurement of components that evoke dyspnea in ADLs

283
Q

Diaphragm- radiograph

A

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

Acute Care (4 decks)

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