Cardiopulm Flashcards
Active cycle of breathing
- Diaphragmatic breathing 5-10 sec
- Thoracic expansion exercises (3-4 deeeep breaths in to max inspiratory capacity followed by passive exhalation)
- Forced expiratory techniques (huffing)
Indications for inspiratory hold technique
hypoventilation
atelectasis
ineffective cough
Indications for lateral costal breathing
asymmetric chest wall expansion or posture
Paced breathing indications
dyspnea with exertion
decreased endurance
fatigue/anxiety
Describe paced breathing
controlling breathing with exercise
ex. inhaling on rest followed by exhalation during movement or exercise (weight lifting, stair climbing)
Inspiratory muscle training
nose clips to help you breathe only through mouth + inspiratory device to create resistance
Cheyne Strokes breathing
gradual increase in depths of respirations with periods of apnea
caused by cardiac insult
Biots breathing
randoms depths of respirations with periods of apnea
biot = brain
S4 heart sound
Ventricular hypertrophy or MI
not ever normal
happens during late diastole
S3 heart sound
Ventricular gallop
CHF
Although, can be normal finding or with seasoned athlete, pregnancy, or children
happens during early diastole
Symptoms of Right sided heart failure
jugular vein distension
swelling in legs and abdomen, ascites, pedal edema
enlarged liver
Symptoms of Left sided heart failure
pulmonary congestion
pulmonary edema
crackles/diminished breath sounds
orthopnea
cool dry skin
Imaging and pneumothorax
mediastinal structures are pushed laterally away from the affected side
ex. pneumothorax or pleural effusion takes up space in left thorax - the trachea and mediastinal structures would be pushed laterally to the right away from the affected
Examples of obstructive diseases
cystic fibrosis
emphysema
asthma
chronic bronchitis
bronchiectasis
Examples of restrictive diseases
sarcoidosis
pulmonary fibrosis
Restrictive lung conditions present with what pulmonary function test values
Normal FEV1 (they dont have trouble with expelling air)
decreased FVC 0 as a function of decreased TLC
Normal FEV1/FVC ratio
70% or greater
What is a low FEV1/FVC ratio and what would that mean?
low would be less than 70%
indicative of obstructive condition
Decreased FEV1 volume, normal FVC volume
lower ratio between the volumes (less than 70%)
indicative of an obstructive condition.
Fremitus
Tactile fremitus is an assessment of the low-frequency vibration of a patient’s chest
used as an indirect measure of the amount of air and density of tissue present within the lungs
Obstructive disorders pulmonary function test results
Increased FRC (ERV+RV)
Increased TLC
decreased VC d/t decreased ERV
TV normal or increased
Functional residual capacity
the air inside the lungs after a normal exhalation
sum of ERV and RV
Restrictive disorders pulmonary function test results
decreased RV
decreased VC
decreased TLC
decreased FVC
FEV1/FVC ratio not affected
Appropriate measures of intensity for patient witch cardiovascular disease
HR
RPE
percieved dsypnea
not VO2max - these patients would not be able to achieve maximum oxygen consumption
Contraindications to manual percussion
platelets lower than 20,000 mm3
hemoptysis
pneumothorax
Can you percuss with a chest tube inserted?
Yes avoid any tender areas
VC =
IRV + TV + ERV
% of total lung volume: TV
10%
% of total lung volume: IRV
50%
% of total lung volume: ERV
15%
% of total lung volume: RV
25%
Total lung volume capacity
5 L or 5000mL
Lung changes with aging
chest wall stiffness
loss of elastic recoil
alveoli enlarging and thinning = decreased gas exchange
decline in TLC
-RV increases
VC decreases
PaO2 gas exhange decreases at . mmHg per decade
4
Common cardiac changes with aging
stiffening of valves
decreased blood flow and volume
decreased max HR
loss of pacemaker cells
decreased stroke volume
Normal PR interval
.12 -.20 seconds
3-5 small boxes
Normal QRS complex
.06-.10 sec
1-3 small boxes
How to estimate rhythm with EKG - regular rhythm
Triplets - 300, 150, 100, 75, 60, 50, 43, 38, 33
1500/ # of small squares
300/ # of large squares
How to estimate rhythm with EKG - irregular rhythm
take # of QRS complexes in full 30 box strip and multiply x10 = rough estimate of HR
6 second method - length of normal strip - x10
REEP
resting end expiratory pressure - point in which forces are balanced in equilibrium - occurs at end of tidal expiration
Normal PAO2 at room air
80-100 mmhg
90% FiO2 still seems high - what is the importance of this number
90% FiO2 corresponds to 60 mmHg - which is point where oxygen dissociates from hemoglobin
GOLD 1 classification COPD
mild severity
70%+ FEV1
GOLD 2 classification COPD
moderate
50-70% FEV1
GOLD 3 classification COPD
severe
30-50% FEV1
GOLD 4 classification COPD
very severe
less than 30% FEV1
Normal FEV1
80%
Chronic bronchitis signs and symptoms
Obstructive condition - Chronic inflammation of airways caused by airway irritants (smoke, dust)
increased mucus production/cough
SOB
increased pulm artery pressure
Asthma treatment
brochodilators - relax smooth muscle
knowing triggers
breathing exercises, airway clearance, muscle endurance and strength training
Asthma signs and symptoms
wheezing, chest tightness, SOB, cyanosis, cough
Chronic bronchitis treatment
antibiotics, anti-inflammatories, and lifestyle changes including decreasing smoke and pollutant irritation, using WARM air humidifier
Chronic bronchitis cough is worse when
morning and in cold damp environments
Emphysema signs and symptoms
Obstructive disease - destruction/enlargement of alveoli = decreased gas exchange and increased dead space within lungs
barrel chest
increased use of accessory muscles
wheezing constant cough
increased respiratory rate
Brochiectasis
chronic dilation of bronchial airways = weaken over time = frequent infections, aspiration
Cystic fibrosis is what kind of genetic disorder
autosomal recessive
Autosomal recessive disorders
Tay sachs
Sickle cell
Cystic fibrosis
TSC
Cystic fibrosis
genetic disease of exocrine glands affecting lungs pancreas liver intestines
sticky mucus production impacts lung infections, obstructs pancreas, inhibits normal digestion/absorption of food
median survival age 32 -pulm failure
Salty tasting skin
CF
Cystic fibrosis signs and symptoms
salty skin
frequent thick greasy stools
freq lung infections
wheezing/SOB/cough
failure to thrive
Pneumonia
can be aspiration, viral, or bacterial based
inflammation of lung alveoli
fever, SOB, sweating, shaking, muscle pains, fatigue
More than … PVCs in a minute is bad
6
Triplets PVC
3 PVCs in a row - stop exercise
this preludes Vtach
Calcium channel blockers use
used for HTN, CHF, decreasing cardiac arrythmias
Action of calcium channel blockers
blocks entry of calcium into smooth muscle - decreases HR contractility, BP by creating vasodilation
Side effects calcium channel blockers
decreased HR and BP - postural hypotension with change in position
use RPE
Types of calcium channel blockers
-pines
amlodipine
felodipine
isradipine
Procardia
exception in cardizem
Cardizem, Procardia
calcium channel blocker
How to remember calcium channel blockers
-pine cones are great source of calcium
ACE inhibitors how to remember
-prils
If you have pocket ACEs in poker, you relax, decrease BP
Lisinopril
Benazepril
Perindopril
Ace inhibitors use
HTN, CHF
Ace inhibitors side effects
orthostatic hypotension, dry cough, hyperkalemia
Ace inhibitors action
suppresses enzyme that converts AGTN 1 to 2 - which is a potent vasoconstrictor
decreases BP and afterload
Positive ionotropic agents use
slows HR but increases force of contraction, increases BP
- used for CHF, afib
Examples of positive ionotropic agents
digitalis, digoxin
How to remember positive ionotropic agents
I (ion)
DIG (digogin)
Star Wars (force) - increases force of contraction
Beta blockers use
cardiac arrythmias
Beta blockers action
blocks action of beta receptors of sympathetic NS = decreases HR and increases force of contraction = decreased oxygen demand
Beta blockers side effects
OH
use RPE
Types of diuretics
furosemide
hydroclorothaizide
lasix
Nitrates
dilate peripheral arteries to decrease preload and relieve chest pressure/angina
Pulmonary fibrosis
irreversible scarring of alveoli and interstitial tissue - thickens the alveoli and makes them less flexible
Pulmonary fibrosis symptoms
SOB
dry cough - not until advanced state
Pulmonary fibrosis treatment
not much as PTs - meds to manage inflammation and education/counseling, improving QOL
Sarcoidosis
multisystem inflammatory disease - affects lungs, skin, lymph, eyes, liver
affects more colored than white people
What outcome measure would you think about using with sarcoidosis
6MWT - baseline to track progression of disease
Plueral effusion vs pulmonary edema
Plueral effusion is buildip of fluid in space between lung and chest cavity (pleural space)
pulmonary edema is fluid in alveoli within the lungs
When does pulmonary edema most often occur
left sided heart failure casues fluid and pressure build up into lungs
Safety considerations with pulmonary edema
a 911 emergency if acute
signs of gasping or wheezing
extreme SOB or sweating
cyanosis
drop in BP
tinged sputum
Rule out time for TB
2 weeks on meds ans isolated
Potts disease
spinal TB - affects thoracic and lumbar vertebra, arthritic changes - flexibility and postural re-education
Is atelectasis an indication or contraindication for postural drainage
indication
Indications for percussion and vibration
atelectasis
pulmonary secretions
aspiration
Procedure for vibration
therapist hands parallel to ribs duration 5-10 breaths
Normal LDL
less than 100
Normal HDL
40-60
Upper apical lobe postural drainage
sitting HOB elevated 30-40 degrees
percussion above clavicle
Anterior segments upper lobe postural drainage
Supine with percussion below clavicles
Posterior segments R upper lobe
1/4 prone laying on L
percussion to medial border of R scapula
Posterior segments upper lobe
Leaning over pillow in sitting
L lingula lobe postural drainage
supine with 1/4 turn to elevate L side
feet raised 12 inches
persussion between axilla and nipple on L
R middle lobe postural drainage
supine with 1/4 turn to elevate L side
feet raised 12 inches
persussion between axilla and nipple on R
Lower anterior basal lobe
supine
feet raises 18 in
percussion to lower ribs on respective side
Lower lateral basal lobe
Prone w 1/4
feet elevated 18 in
percussion to lower ribs on respective side
Lower posterior basal lobe
prone
feet elevated 18 in
percussion to lower ribs on respective side
Superior segment of lower lobe
prone
table level
percussion to inferior border of scapula on respective side
Absolute exercise termination and 911 emergency with cardiac rehab
more than 6 PVC in one minute
3-4 PVCs in a row - this is Vtach
Vtach or Vfib on EKG
ST depression greater than 2 mm
ST elevation greater than 1 mm
Terminate exercise with ST depression
greater than 1.5-2 mm
Terminate exercise with ST elevation
greater than 1 mm
Stop and refer, but not 911 parameters
Second degree Type 2 AV block
A fib
Mulifocal PVC
angina
Continue exercise but at lower intensity
1st degree AV block
ST depression is indicative of
ischemia
ST elevation is indicative of
acute MI
Normal EF %
55% +
Normal stroke volume
70 mL
EDV-ESV
120-50
Normal CO
4.5-5 L
HR x SV
can increase to 25 L during exercises
Normal venous return
same as CO since heart is a closed system
4.5-5 L
PS stimulation causes coronary artery vasoconstriction or vasodilation
constriction
slows rate and force of myocardial contraction
vasodilation to skeletal muscles
Hyperkalemia
what does it mean
what are effects
increased potassium
decreases rate and force of contraction - this will show through EKG changes such as widened PR interval and QRS, tall T wave
widened PR interval and QRS, tall T wave
effects of hyperkalemia
Hypokalemia can progress to
vfib
prolonged PR and QT intervals
flattened T wave or inverted
hypokalemia
Components of WBC
neutrophils - bacteria
eosinophils - kill parasites
basophils - allergies
monocyte - garbage men
lymphocytes - infections and produce antibodies
Purpose of neutrophils
kill bacteria
Purpose of eosinophils
kill parasites
Purpose of basophils
allergies
Purpose of monocytes
clean up garbage
Purpose of lymphocytes
fight off infections and produce antibodies
Signs of respiratory acidosis
hypoventilation (Co2 is increased as they are holding in too much air)
disorientation - stupor
Signs of respiratory alkalosis
hyperventilation
hyperreflexia
dizziness/lightheaded
Conditions associated with respiratory alkalosis
pregnancy
anxiety
PE
liver disease
sepsis
fever
Conditions associated with respiratory acidosis
hypoventilation
COPD
respiratory depressants
Normal WBC count
4000-10000
Normal HCT count
45-52 males
37-47 females
Normal Hgb
13-18 males
12-16 females
Normal platelet count
150,000-450,000
Platelet count less than 20,000
ADLs only
Platelets 20-30,000
light exercise
Platelets 30-50,000
moderate exercise
Normal INR
1
High INR = risk of
bleeding
Low INR = risk of
clotting
Inverted t wave =
hypokalemia
Means ventricular hyoertrohy or ischemia
After what age do children follow adult BP guidelines
13
Aortic valve auscultation
R sternal border 2nd
Pulmonary valve auscultation
Left sternal border 2nd
Tricuspid valve auscultation
left sternal border 4th space
Bicuspid valve auscultation
left midclavicular line 5th space
Class 1 CHF
no limitation of activity up to 6.5 METS
Class 2 CHF
slight limitation 4.5 METS
Class 3 CHF
3.0 METS
Class 4 CHF
ADLs onlly 1.5 METS
3-6 METs
moderate intensity
brisk wallking, dancing, gardening, housework, building
Anterior MI affects
LADA
Inferior MI affects
right ventricle and right coronary artery
Lateral MI affects
circumflex artery
Posterior MI affects
Left ventricle posterior wall
Phase 1 cardiac rehab
inpatient portion - prescribed after stable EKG and CK/troponin levels, no chest pain 8 hours
When can active exercise begin for cardiac rehab
24 hours after CABG or 2 days after infarction
Karvonen formula
60-80%(HR max - resting HR) +resting HR
Parameters for phase 1 cardiac rehab
short low intensity (2-3 METs) exercise 2-3x day
max 50-70% HR
10-20 increase bpm initially
Goals for phase 1 cardiac rehab
educate on symptoms and monitor EKG changes
D/C home with assist ADLs
Tolerate 2-3 METS up to 4-5
Active and AAROM exercises - starting LE (UE increases HR and BP greater than LE)
At end of phase 1 cardiac rehab patient should be at what MET level
4 METs - walking up 1 set of stairs
Post MI cap on HR phase 1 cardiac rehab
120 bpm or 20 above resting
seems low but ok
Phase 2 cardiac rehab
outpatient portion
Phase 2 cardiac rehab begins when
1-2 weeks after infarct
Phase 2 cardiac rehab goals
progress towards ADLs
tolerating 30-60 mins 3-4x week
Lifting restrictions with cardiac rehab
6 weeks
Strength training for cardiac rehab should be held
5 weeks post MI
8 weeks post CABG
MET level for entry into level 3 cardiac rehab
5 METs
RPE rating 12-13
60% max HR
RPE 14-15
70% max HR
16 RPE
80% - 85% max HR
Failure of SBP to rise during exercise =
Do not exercise or STOP
10-15 mmHg fall in SBP with increase in exercise =
Do not exercise or STOP
Glucose greater than = do not exercise
Glucose less than … = do not exercise
280
70
SBP greater than 200-250
DBP greater than 110-115
Do not exercise or STOP
Patient fatigue or discomfort or wants to stop
Do not exercise or STOP
Type 1 or Type 2 heartblock warrants stop exercise
Type 2
PTT greater than 60 seconds =
do not or STOP exercise
Seek EMS with
vfib
asystole
SOB at rest
unstable angina not relieved by 3 nitro
3rd degree heart block
vtach - 3+ PVC in row
Indication for cardiac rehab
post MI
post CABG
post PTCA
CHF
PAD
stable angina
other cardiac surgeries
PTCA
less invasive than CABG
catheter introduced through femoral artery and sent up through aorta to blockage - stent placed
Contraindications for cardiac rehab
unstable angina
BP greater than 200-250 systolic; 110-115 diastolic
orthostatic
resting ST segment depression greater than 2 mm
resting ST segment elevation greater than 1 mm
When can cardiac rehab begin?
no chest pain 8 hours
no EKG changes 8 hours
no new signs CHF
stable CK and trops
First degree heart block
increase in PR interval with no dropped beat
increase in PR interval with no dropped beat
First degree heart block
Ectopic beats
synonymous to PVCs - 3 in a row
Make sure patient is comfortable then call 911 and start CPR
Causes of hypocalcemia
hypoparathyroidism
malabsorption of calcium
vitamin D deficiency
acute pancreatitis
Symptoms of hypocalcemia
tetany, twitching, muscle cramps,
Causes of hypercalcemia
hyperparathyroidism
Symptoms of hypercalcemia
fatigue, depression, mental confusion, NV, increased urination
Change in altitude initially results in
decreased BP
increased CO
tachycardia
no changes in SV
Beta blockers affect on stroke volume
decreases HR therefore decreases SV
Crackles are also known as
rales
Crackles/rales most commonly heard with
CHF
also atalectasis
pulmonary fibrosis
Lung sounds with atelectasis
diminished or crackles
Wheezes are typically associated with
asthma
chronic bronchitis
WHat is a wheeze
high pitch whistling produced by air passing through narrow airways
Wheezing is most commonly heard on
expiration
Rhonchi
low pitched dull sound d/t blockage
think RHino snoring
Rhonchi most commonly heard with
pnuemonia
CF
chronic brochitis
Stridor usually heard on
inspiration
Stridor
ST-ridor
TS - Tracheal Stenosis
heard on inspiration
Erb’s point
3rd intercostal space L sternum
point at which S1 and S2 are heard simultaneously
Closure of which valves creates S1 heart sound
mitral and tricuspid
Closure of which valves creates S2 heart sound
aortic and pulmonary
S1 heart sound occurs at
beginning of systole
end of diastole
S2 heart sound occurs at
end of systole
beginning of diastole
Which heart sound happen during late diastole
S4
Which heart sound happen during early diastole
S3
BP should be inflated … mmHg above anticipated value
20-30 above
decrease by 2-3 mmHg
Phase 1 Korotkoff sound
clear tapping - indicative of systolic BP
Phase 5 Korotkoff sound
sound disappears completely
Phases of Korotkoff sounds
1 - clear loud tapping
2 - softer and longer
3 - crisper and louder
4 - muffled and softer
5 - sounds disappear
Normal breath sounds
vesicular - normal in out breathing - rustling sound - throughout inspiration and beginning of expiration
tracheal - loud, tubular sound
bronchial - hollow echoing sound
Insipratory phase > Expiratory
w/o pause
vesicular breath sounds
Expiratory phase > inspiratory
w/ pause
bronchial
Normally heard over distal airways
vesicular
Normally heard superior anterior thorax
bronchial sound
hollow echoing
Pathologies with wheezing
COPD, asthma, anaphalxsis
Pleural friction rub
dry crackling sound
heard directly over area of inflammation and pain
happens during inspiration and expiration
Crackles vs pleural friction rub
Crackles - often heard and auscultated in bottom of lungs, mainly inspiration
PFR - heard over spot of pleuritic pain - equally during inspiration and expiration
Foreign object produces what lung sound
stridor
Most optimal perfusion position lungs
prone
Perfusion ratio is high in upright position
In upright position, top of lung is
bottom of lung is
ventilated
perfused
Bronchophany
normally lung sounds should be muffled, but 99 sounds clear
Whispered pectrilouqy
whisper 123abc, should sound muffled, but if clear - indicated secretions/consolidations
Kussmals breathing
deep and fast breathing associated with metabolic alkalosis
Graded exercise test termination criteria
Fall of 10 mmHg PaCO2; 65 mmHg or greater PaC02
fall of PAO2 more than 20 mmHg; less than 55
increase in DBP greater than 20 mmHg
max SOB , fatigue
Metabolic syndrome diagnosis
fasting glucose greater than 100
40 in Male; 35 in Female
low HDL less than 40 male; 50 female
135/85 + BP
Must have 3/4
Diabetes disgnosis criteria
126+ fasting glucose
200+ random glucose
6.5% A1C
Statin drugs
lower LDL
end in -or
lipitor, zocor, tricor
Location of 4 main limb leads EKG
Right Arm
Left Arm
Left Leg
Right Leg
`
5 lead EKG
Cloud over grass
Smoke over fire
I heart chocolate
White on right
White EKG lead location
2nd R IC space mid clavicular
Green EKG lead location
7/8 IC space R mid clavicular
Brown EKG lead location
4 IC space R of sternum
FEF 25-75
flow in med to small airways
Primary use of incentive spirometer
Atelectasis
or post surgery
Treatments for sputum in lungs
coughing, huffing
Head thrust /impulse test positive
compensatory saccade denoted by a slow phase in which the eyes drift off their fixation target and a fast phase where they return to the fixation point (nose)
Imaging and atelectasis
trachea deviates toward side of atelectasis
Pneumothorax vs atelectasis
Pneumothorax - physical leak where air escapes from lung and fills into pleural space - places pressure on lung and cannot inflate as it normally would
atelectasis - partial collapse of 1 or more lobes d/t blockage - primarily caused by surgery
EKG changes with beta blockers
causes increased PR interval - decreased HR
Pericaridal friction rub =
pericarditis
