CardioPulm Flashcards
Draw Lung Volumes
Phases of Cardiac Rehabilitation
Phases of Cardiac Rehabilitation
- Phase I: Inpatient
- Phase II: Outpatient (Exercise-Training)
- Phase III: Maintenance
QUESTION
A 52-year-old female avid exerciser recently had a myocardial infarction and underwent stent placement. The patient is now preparing to start cardiac rehabilitation. The patient is eager to begin strength training when cleared. Which of the following is the MOST consistent with ACSM’s guidelines for starting strength training during cardiac rehabilitation?
A.Phase I : 3 weeks
B.Phase II : 5 weeks
C.Phase II : 8 weeks
D.Phase III : 12 weeks
A: Too early
D: Too late. PHASE 3 = YMCA
People will enter phase 2 around 3-4 weeks
B: CORRECT answer. Can we begin streagth training during scar formation of 4-6 weeks? YES
C: Pt with CABG or Sternotomy must wait to 8 weeks because bone damage has to heal.
Explain
Phase I
–Process (3-5 days)
Patients enter intensive care unit (ICU) under medical surveillance until considered medically stable (typically post 24 hours)
Patients who were considered stable are transferred to step down unit
– Physical Therapy Goals
• Activate, Educate, and Initiate
–Activate
»Get the patient moving in order to combat effects of bed rest. (BSChair)
–Educate
»Promote lifestyle modifications and educate about recovery process
–Initiate
»Begin process of returning patient back to independent functioning (ADLS)
What are the ADLs to get the patient to get back to.
- ABCDTT
- Ambulation
- Bathing
- Continence
- Dressing
- Toileting
- Transfers
Phase I
Physical Therapy Exercise Guidelines
•ADL’s, Ambulation, some UE/LE exercises (UE avoid for CABG – 6-8wks)
–Low Intensity exercise (2-3 METS) -> 5 METS by DC
–
–Duration: 5-10 minutes progressing duration over days (maintain intensity within protocol)
–Frequency: 2-4x per day (ACSM)
Phase I Contraindications
– Exercise Discontinuation Criteria
- Diastolic blood pressure (DBP) >/= 110
- Decrease in systolic blood pressure >/=10 mmHg during exercise with increasing workload (other symptoms don’t matter)
- Significant ventricular or atrial arrhythmias with or without associated signs or symptoms
- Second or third degree heart block*
- Signs and Symptoms of exercise intolerance (angina, marked SOB, ECG changes related to ischemia, >1mm dep)
–
A patient is being treated in physical therapy for deconditioning following a long history of stable angina. During vigorous exercise on the treadmill, the patient begins to report significant left-sided chest pain radiating into his anterior neck. The patient is instructed to take one sublingual nitroglycerin tablet, however the patient’s symptoms seem to worsen slightly. Which of the following is the best course of action?
A.Terminate the treatment and contact the physician immediately
B.Hold treatment for 10 minutes monitoring vitals, and have the patient take a second dose of the nitroglycerin if chest pain is still present
C.Call EMS
D.Instruct the patient to take another nitroglycerin tablet after five minutes, monitor chest pain, and vitals
Stable Angina is situation angina, or exertional angina
Why do they have it when they start exercising
- Myocardial ischemia (Lack of blood flow)
Left sided chest pain radiating to the neck.
Nitroglycerin Vasodialates and increases blood flow to tissues that are not getting enough.
A: Seems like a medical emergency, terminating is good
B: No, there is a nitroglycerin protocol, and this is not consistent
C: YES, they shouldn’t be worsen, if they do, should immediately contact EMS
D: NO, doesn’t go with protocol
NITROGLYCERIN PROTOCOL
Step 1: Stop treadmill, have pt sit down
2: assess pain level (ex. 10), pt takes tablet, must wait 5 minutes. After 5 minutes, ask pain level again and pt is not better (same or worse), CALL EMS
If getting better (8), another nitro tablet, wait 5 minutes, ask pain level (3). Take a third tablet (MAXIMUM amount) and presents with 1.
If still pain and does not COMPLETELY go away, call EMS
If NO PAIN = restart activity at lower level.
Must have 12 hours period between doing tablets
MAX Heartrate = 220-age
What is Phase II
– Process (weeks to months)
- Patients enter a specialized cardiac rehabilitation outpatient program with qualified staff with ability to monitor vitals, EKG, and understand the patient’s medication regimen.
- Prior to entering Phase II it is recommended that the patient have a symptom-limited ETT at the 4-6 weeks mark.
- Phase II can begin immediately after phase I but will begin at a exercise prescription determined by the low level GXT
–
Phase II goals
– Physical Therapy Exercise Guidelines
–Intensity: Based on exercise test
»When The Test is Negative
•Common exercise prescription is 70-85% of Max HR
»When The Test is Positive
- You must keep RPP below ischemic threshold
- RPP = SBP x HR
- Stay >/=10 beats below ischemic threshold
•
WHAT IS RPP
RPP – rate pressure product
RPP = SPB X HR
systolic blood pressure X Heart Rate
A patient with a recent uncomplicated MI is being evaluated before participating in outpatient cardiac rehab. The patient had a positive exercise tolerance test however has had no symptoms while ambulating at home. Which of the following is the MOST recommended during exercise
A.Exercise only up to the point of chest discomfort
B.Keep Systolic BP 10 mmHg below any symptoms
C.Exercise the lower extremities only
D.Exercise the patient below 70% MaxHR
OUTPATIENT = Phase 2
No symptoms while ambulating at home.
A: NO, we don’t want to bring them UP to discomfort
B: Should be HEART RATE, not Systolic BP
C: Would be a CABG thing
D: YES, This is correct.
A patient being seen in fully monitored cardiac rehabilitation outpatient clinic has fair to good cardiovascular and musculoskeletal endurance. Which of the following would BEST allow for incremental assessment of the patient’s endurance?
A.FEV1/FVC
B.Respiratory rate at 70% MHR
C.6 Minute Walk Test
D.VO2max
A: FEV1/FVC – measures severity of obstructive or restrictive condition – pulmonary function test
B: Not going to determine a persons endurance
C: One of the most used for endurance
D: BEST – incremental assessment test.
Would pick C if they poor, or poor to fair test. A debilitated or deconditioned patient.
– Physical Therapy Exercise Guidelines
Phase III
–Intensity
»50-85% of functional capacity
–Type
»Aerobic
»Strengthening
–Duration:
»45-60 minutes (5-10 minute warm up/cool down)
–Frequency:
»3-5x week (begin following CDC’s exercise guidelines)
–
A patient with lymphedema is being treated in a therapeutic pool up to the waist level. Which of the following hemodynamic responses is the MOST likely to occur?
A.Decreased in respiratory rate
B.Increased cardiac output
C.Decreased central venous pressure
D.Increased peripheral resistance
A: No, if water was up the chest level, but it shouldn’t change. Plus this is not a hemodynamic response
B: Cardiac Output = Stroke Volume X Heart Rate
Stroke volume how much is pumped/contraction. So it should increase with increase volume pushed to heart
More blood flow = increased heart rate.
C: More fluid should be forced to heart, so increased venous pressure
D: Therapeutic pool is a WARM pool, so blood vessels should increase and therefore decrease peripheral resistance
What increases and decreases the heart
What slows down the heart – The vagus nerve – rest and digest. CN X
What increases – Catecholamines – They are made in the adrenal glands – out of the medulla.
IMPORTANT TO KNOW.
What is CARDIAC OUTPUT
Cardiac Output (CO) = amount of blood pumped throughout the body per minute (mL/min)
CO = HR x SV
SV = amount of blood pumped out per ventricular contraction
Blood pressure
What is
Systolic?
Diastolic?
3 ways to change blood pressure?
- Systolic BP: Pressure on the artery walls when ventricles contract
- Diastolic BP: Pressure on artery walls when ventricles are relaxed
- Changes in BP
–Peripheral artery diameter
–Blood volume
–Force of contraction
Blood Pressure Categories
What does Calcium channel blockers do?
Decrease contractility of the heart
ex. Digitalis Digoxin
What is VO2 Max
- VO2 Max = maximum oxygen consumption during incremental exercise
- Measuring efficiency of your muscles
–The more O2 you can consume the more ATP you can create AND the longer you can continue
–How quickly do your muscles go from using the aerobic system to the anaerobic system
•Gold standard for endurance testing
–This is an outcome measure!
–Determines improvement in endurance over time
PHYSIOLOGICAL RESPONSE RELATED TO BARORECEPTOR REFLEX & VALSALVA
1.Stimulation of baroreceptors
•Increasing intra-abdominal/intrathoracic pressure = increased pressure on arteries (including aorta)
- Signal the medulla (which has an inhibitory effect on Vagus nerve)
- Medulla stops inhibiting Vagus nerve (CN X)
- Vagus nerve signal = parasympathetic effect
- Implications for HR = decreased
- Implications for BP = decreased
Describe the path of blood through the cardiopulmonary system
As blood moves from feet and legs to abdomen
To superior and inferior vena cava
Into the R atrium
Through the tricuspid valve
To the R ventricle
Through semilunar valve
Through pulmonary arteries
To LUNGS
Back from the lungs TO the heart
Through pulmonary veins
To L atrium
Through Mitral valve
Into Left ventricle
Into aorta and to extremities
Afterload
•The weight (pressure) the heart must work against in order to eject blood
–Think bench press
•Afterload is determined by the size of the arteries.
–Vasoconstriction = increased (weight) afterload
–Vasodilation = decreased (weight) afterload
What does that mean? We want them to vasodilate
- Nitro (immediate)
- Ace inhibitors (Longer term basis)
PRE-LOAD
- Amount of blood that returns back the heart from the extremities and enters the heart chambers
- Pre-load is also known as End-diastolic volume (EDV)
Remember, CO = SV X HR
What does Heart Failure lead to?
- Tissue ischemia
- Diminished energy production
- Hypoxemia
Not able to supply enough oxygen to muscles
Ischemia – decreased oxygen in the bloodstream leads to necrosis (infarction) when prolonged
Diminished energy production because O2 is not getting around = no ATP which leads to anaerobic system and builds lactic acid (VO2 Max)
Why does the Left or Right side of the heart hypertrophy?
Increased Peripheral resistance increases afterload
For example: vasoconstriction
Leads to LEFT ventricular hypertrophy because it works harder.
Space is very small and doesn’t hold enough blood
What failure leads to R sided hypertrophy – Pulmonary hypertension.
What happens when the heart cannot pump blood out or fill up with blood?
–Angina (Chest Pain)
–Back up of blood (Edema)
–Cyanosis (decreased oxygenation)
–Decreased Exercise tolerance (Fatigue)
–Dyspnea (SOB)
A patient is being treated for hypertension and an acute myocardial infarction. The patient’s medical record shows that the patient is currently taking enalapril. Which of the following is the physiological rationale for this medication?
A.Decrease afterload
B.Increase afterload
C.Decrease preload
D.Decrease heart rate
A patient with cor pulmonale is being seen for functional decline and deconditioning. After 5 minutes, the patient requests a rest break secondary to muscle fatigue and complaints of heaviness in the lower extremities. Upon examination, which of the following is MOST likely present?
A.Hemosiderin staining
B.Pitting edema
C.Non-pitting edema
D.Positive Buerger’s test
Cor pulmonale (Right sided heart failure)
Heaviness in lower extremities (edema)
=congestive heart failure
A: Venous Insufficiency
B: seen with R sided edema (also called dependent edema)
C: Seen with lymphedema (scleroderma, psoriasis, late stage 2,3 lymphedema with HARDENED SKIN)
D: Would be seen Arterial Insufficiency. (Supine with hip flexion) Testing with arterial insufficiency.
Buergers and Rubor dependency test.
Buergers test: supine with hip flexion and look at color
Dependency: foot down and see how long blood gets back
Left sided Heart Failure signs and symptoms
If your in the left ventricle, backs up through mitral valve to atrium, to pulmonary veins, then to the lungs.
Right side backs up into the body and extremities.
Moderate to Severe Dyspnea
Significant fatigue (muscular weakness)
NOT ENOUGH O2
Reduced activity tolerance
NOT ENOUGH O2
Paroxysmal Nocturnal Dyspnea
When pt lays down to sleep at night and wake up bc they feel like they’re drowning
BC fluid is backing into the lungs
Productive Spasmodic Cough (Pink Frothy)
Starts to get crackles, and cough up the fluid
L Sided heart failure = pulmonary edema.
Right sided heart failure signs and symptoms
Cyanosis (back up of deoxygenation blood)
Ascites (Water retention into the abdominal region)
Mild Dyspnea (Not circulating the flood properly, shortness of breath – mod to severe with Left)
Dependent Edema (Pitting) – typically immediate
Decreased activity tolerance – bad O2 flow
Jugular vein distention – All your veins have more fluid
Weight gain – Water retention
Can Left sided heart failure result in dependent edema – CAN if it has progressed so much that it affects the Right as well.
Won’t be severe
When would you contact the physician?
- Monitor for decreases in the patient’s blood pressure and changes in cognitive status to physician immediately
- Decreasing BP with increasing workload should be reported immediately (Left ventricular pump dysfunction)
- New EKG findings should be reported directly to the physician
CONTACT PHYSICIAN - Significant changes in pt medical status
When should you contact the nurse:
Pain that affects moving forward with therapy
IMPLICATIONS FOR THE PT
- RPE should range between 11 – 14 (Add 0 for heart rate)
- Exercise intensity (40-60% HRmax) w/ longer warm-up & cool down
- Exercise __ bpm below ischemic threshold
- High Fowler’s position is recommended for Left sided CHF (20 inches above supine or more)
- Legs kept in a dependent position is recommended for Right sided CHF
Medications
Betablockers – decrease heartrate
ACE inhibitors - Dec hypertension, increase vasodilation
Calcium Ch blockers – dec contractility
Digitalis or Digoxin – NOT CA Ch Blocker – INCREASES contractility in the heart
•Left Sided Heart Failure
–Decrease Peripheral Resistance
•Ace inhibitors
–Lisinopril
–Enalapril
–Decrease Contractility
•Calcium Channel Blockers
–Amlodipine (Norvasc)
–Diltiazem (Cardizem)
•
A patient is undergoing pulmonary function testing to reveal likely reasons for his progressive shortness of breath. Which of the following forms of data is the LEAST likely obtained by the use of spirometry?
A. Forced vital capacity
B. Forced expiratory volume in one second
C. Total lung capacity
D. Vital capacity
LUNG VOLUMES and Vital Capacity Testing
•Total Lung Capacity (5 – 6 L)
•Residual Volume (1.1 L) - ONE LITER
•Vital (Voluntary) Capacity (3.5 – 4.5 L)
- Tidal Volume (~0.5 L)
- Expiratory Reserve Volume (~0.7)
•Functional Residual Capacity (AKA Expiratory & Residual Capacity) (1.8 L)
- Inspiratory Reserve Volume (1.9 L)
- Inspiratory Reserve Volume (1.9 L)
FRV = ERV + RV
Vital Capacity Testing -
- BREATHE ALL THE WAY OUT
- BREATHE IN RIGHT NOW!
BREATHE ALL THE WAY OUT
A patient’s lab values are reviewed by a physical therapist prior to treatment. The following values are identified, HgB 10 mg/dl, LDL 110 mg/dl, WBC’s 4.5x109/liters, PaO2 55mmHg, PaCO2 55 mmHg, Troponin 0.01 ng/ml. Which of the following conclusions is the MOST accurate regarding the patient’s condition?
A. Metabolic Acidosis
B. Respiratory Failure
C. Recent Acute Myocardial Infarction
D. Respiratory Alkalosis
Hemoglobin – Does it matter right now? NO – 13-14; 12-16 FEMALE; 14-17 MALE
LDL – Not important – A little high, normal is below 100
WBC – 4-10 or 5-11 is normal
PaO2 – LOW – under 60 = hypoxemia
PaCO2 – 25-45 HIGH
Troponin – marker for myocardo infarction
don’t want over .02 anywhere .01 is very significant
A: Don’t have pH so can’t determine
B: YES, when O2 is below 60, and CO2 is above 50
C: Not likely, it is in normal ranges.
D: Don’t have a pH
What are PFTs
•Pulmonary tests that measure lung volumes and capacities and gas flow rates
–Forced vital capacity (FVC)
•Maximum amount of air that you can actually move in and out of the lungs (3.5 – 4.5 L)
–Step one: Exhale deeply
–Step two: Take a maximum inhalation
–Step three: Maximally exhale as quickly as possible
•Forced Expiratory Volume
–Can be expressed as a fraction or percentage (FEV1/FVC or FEV1%)
–Interpretation
–FEV1/FVC < .70 = Obstructive Condition
–FEV1/FVC > .80 = Restrictive Condition
–FEV1% of greater than 80% indicates restrictive disease as long as FEV1/FVC is > .70
COPD GOLD STAGES
Have to be obstructive.
FEV1 Percentage = Severity on scale
Most tested COPD GOLD Stages
A 65-year-old patient with a progressive loss of trunk mobility is exhibiting significant dyspnea and exercise intolerance. The patient’s FEV1/FVC is .81 and the FEV1 is 85%. Which of the following conditions is the MOST likely present?
•
A. Emphysema
B. Ankylosing spondylitis
C. Chronic bronchitis
D. Parkinson’s Disease
CHRONIC OBSTRUCTIVE PULMONARY
DISORDERS
- Umbrella Term that encompasses:
- Emphysema
- Chronic Bronchitis
- Asthma
- Bronchiectasis
- Cystic Fibrosis
•
•Obstructive = difficulty getting the air out (i.e., difficulty expiring)
EMPHYSEMA
•Patients 40-60, M > F
- Pathophysiology
- Loss of elasticity due to bronchial wall distention
- Damage to the bronchial/alveolar walls due to inflammatory scarring
Age:
Adhesive cap
MS
Hyperthyroidism
These are all female dominated
Smoking – what does it do? Inflammatory, Vasoconstrictor.
Creates inflammation inside the lungs, at the same time, lung tissue loses its elasticity. Stretches out alveoli. Baloons out.
Alveoli is where gas exchange happens. O2 and CO2.
Therefore not good passing.
If CO2 doesn’t get out of the system = acidosis, respiratory acidosis
O2 decreases, below 60 = hypoxemia, will need supplemental O2
Emphysema - pink puffer
Signs and Symptoms
•
- Signs and Symptoms
- Increase in chest A-P diameter (Barrel Chest)
- Overdevelopment of scalenes & SCM
- Tripoding is common
- Cough with minimal sputum production
•
Late stage signs and symptoms can include muscle atrophy/wasting
A-P diameter – Greater due to trapped air. Possibly that mucus trapping air.
Or emphysema – walls are crinkled and air doesn’t get out well.
Overactive accessory muscle – Can lead to thoracic outlet syndrome
Tripoding – bend over in a triangular position to catch breath
Specific muscles assisting in breathing better in tripod – Latissamus Dorsi – hooks to lower ribs and assist in opening rib cage in closed chain position
What else causes – CO2 increased and trapped in the body alerts chemoreceptors – medulla in brainstem causes shortness of breath (a sensation); this explains hyperventilating.
ABG – getting rid of CO2 = hyperventilating
EMPHYSEMA RADIOGRAPHIC FINDINGS
- Increased air space on radiograph
- Increased subcostal angle
- What happens to the diaphragm position?
If more decreased angle – restrictive.
Diaphragm is bottomed out.
Can’t take a deep breath.
A patient with a long history of dyspnea is being examined for suspicion of emphysema. Which of the following tests would BEST confirm the suspicion and the severity of the condition?
A.Spirometry
B.Chest radiograph
C.CT Scan
D.SpO2 % change with pursed lip breathing
A: PFT – purpose is to tell you about condition (restrictive or obstructive) and severity
B: Can’t tell severity
C: Not really how we determine emphysema
D: Doesn’t confirm emphysema
CHRONIC BRONCHITIS
•
- Patients 60+
- Smoking or exposure #1 cause
- Pathophysiology
- Development of a chronic inflammatory process within the large and small airways
- Overproduction and hypersecretion of mucus by goblet cells
by overproduction and hypersecretion of mucus by goblet cells, increasing airflow obstruction
Chronic = generally going on for greater than 6 months.
Difference from emphysema = Age; and PRODUCTIVE COUGH production of mucus
CHRONIC BRONCHITIS – BLUE BLOATER
•
•Signs and Symptoms
•Wheezes and crackles (rales)
- Cyanosis
- Obesity
•Chronic productive cough, can be purulent
-heard on late inspiration, early expiration
What situation would you see crackles
- it is that popping you hear. Overall, when someone has consolidation, fluid.
- such as pulmonary edema, pneumonia, bronchitis, cystic fibrosis
Wheezes
- heard on expiration
- Produced by narrow airways.
-
- Cyanosis due to low O2, increased CO2
- Blue bloaters – excessive weight gain, weight gain, cyanosis
- Why cyanosis with this population.
- Difficulty getting air out – holding onto too much CO2
LACK OF OXYGENATION EARLY ON
EMPHYSEMA, holds onto CO2 and has oxygen problems later.
Cronchitis has O2 issues right away
CHRONIC BRONCHITIS RADIOGRAPHIC FINDINGS
- Increased fluid in the lung spaces
- Radiographic explanation for productive cough and abnormal breath sounds
The prognosis for chronic bronchitis and emphysema is poor because these are chronic, progressive,
and debilitating diseases.
MORE CLOUDY and white and fluid within the lungs
A patient with an acute exacerbation of their COPD is being treated in the hospital. The treating therapist would like the patient to ambulate using a rollator walker. Which of the following measures is the MOST important to assess?
A.Pain level
B.Systolic blood pressure
C.SpO2
D.White blood cell (WBC) count
When they just say COPD – generally saying emphysema and brochitis
Just like using iontophoresis, what medication is being used - dexamethasone
A: No, not for this patient
B: You would, but not important for question
C: Appropriate
D: No
COPD AND LUNG VOLUMES
•Increased Residual Volume
•
•Increased Functional Residual Capacity
•
•Increased Total Lung Capacity
FRC = RV + ERV
CYSTIC FIBROSIS
Impairments
•
- Impairments
- Lung secretions / Dyspnea
- Diminished activity tolerance/endurance
- Decreased thoracic mobility
•
Why fatigue – decreased O2 – due to mucus blocking O2 – also malnourishment.
A patient with long-standing emphysema is being treated in the cardiorespiratory unit. The patient presents with confusion, blurred vision, and a PaCO2 of 52 mmHg. The patient has been classified as a GOLD stage 4. Which of the following findings is the LEAST likely present?
A.FEV1/FVC = .45
B. Hyperresonant percussion
C.FEV1 55%
D.55 mmHg PaO2 with room air
PaCO2 – normal is 35-45 so it is very high
GOLD STAGE 4
A: TRUE
B: TRUE; Sounds like drums, the bigger the louder.
C: Do not expect this – would be GOLD stage 2
D: YES, Consistent
<60 O2 or >50 CO2 – respiratory failure
CYSTIC FIBROSIS
•
- 5-15 year olds
- Inherited disease; autosomal recessive
- Pathophysiology
- Excessive production of thick, sticky mucus which blocks the airways in the lungs
- The thick mucus also blocks the ducts in the pancreas which in turn blocks digestive pancreatic enzymes
____
Cystic Fibrosis is an inherited disease of the mucus and sweat glands (exocrine glands) affecting mostly the lungs, liver, pancreas and intestine
It is an endocrine condition – Endocrine means hormones that performs some function (ex. Estrogen, epinephrine, serotonin, etc.)
What happens is mucus builds up and produced in endocrine glands, pancreas, liver, lung tissues.
Keeps the glands from working properly. PANCREAS – islet cells are there and insulin release- also releases enzymes to break down fatty foods.
FOUL smelling stools (not breaking down foods properly) – ALSO food cannot be absorbed and used so results in osteoporosis.
Also, lung infections due to bacteria growing
CF S+S
- Signs and Symptoms
- Persistent lung infections
- Malnutrition, foul smelling stools
- Poor growth and weight loss
- Skin tastes like salt, excessive chloride secretion
- Productive cough
THE VEST
- A High Frequency Chest Wall Oscillation (HFCWO) Vest is a vest that is attached to an air pulse generator which rapidly inflates and deflates the vest.
- Moves mucus to large airways
•Shouldn’t be used with intubated patients or post op patients; can dislodge the tubes
___
- Arterial O2 saturation may drop during pulmonary exacerbations and use of this device.
- Absolute contraindications for usage of HFCWO include an unstable head, neck, rib cage, or back injury, or an active hemorrhage.
•
•Airway clearance techniques should not be performed before or immediately after meals, so treatment must be scheduled to avoid mealtimes
•
- USED TO MOBILIZE MUCUS PLUGS – THESE ARE MUCUS THAT’S STUCK IN THE AREA.
- They’re kind of hard – and stuck – how do we get that moving?
- Steam or humidifier – Nebulizer
- Vibration
FLUTTER VALVE THERAPY/ACAPELLA DEVICE
- Handheld device that utilizes a stainless steel ball that vibrates back and forth, opening and closing the devices air hole, pulsing the air back into the airways.
- Independent use some children and most adolescents/adults
___
Primarily used to vibrate to rattle the chest
Flutter valve therapy typically last for 15 minutes and has been found to be as effective as postural drainage and percussion.
_____
Not for pulmonary fibrosis unless there is mucus.
NOT FOR AGE UNDER 8 – WHY?
There’s a learning curve. Better choice is to use the vest. Can’t use it independently
A 8 year old patient with cystic fibrosis is being treated for recurrent respiratory infections. The patient has been on prolonged use of corticosteroids and the therapist would like to mobilize the secretions safely. Which of the following is the MOST appropriate intervention?
A.Diaphragmatic breathing
B. Vibration
C.Percussion
D.Flutter device
CF and on corticosteroids – probably osteoporosis
Safety is the key
Corticosteroids can lead to osteoporosis and muscle atrophy
A: Used, not most effective
B: CAN BE USED – is it safe? NO, it’s firm pressure, contraindicated for Osteoporosis
C: Not appropriate - contrainidcated
D: YES!
BETA Blocker – Slow down – high heart rate – older, overweight. Sometimes if they have an irregular rhythm, heart failure, in danger of heart attacks. Chest pain.
Calcium channel blocker – Vasodialator, can slow heart rate.
PULMONARY INTERVENTION FORMULA
Are the secretions stuck?
Vibration and/or Percussion, The Vest, Flutter Device
Does the patient need mobilization and clearance?
ACBT, Autogenic Drainage
Does the patient just need clearance? If so, how much assistance can they provide?
Huffing/Coughing, Manually assisted cough, MI/E, suctioning
BRONCHO
PULMONARY HYGIENE / POSTURAL DRAINAGE
Clearance requires something else as well.
Percussion
- Manual percussion consists of a rhythmical clapping with cupped hands over the affected lung segment in PD positions
- NPTE Reminders:
- No percussion with conditions/meds that create brittle bones, contusions, or blood thinning
- Percussion is used for mobilizing restricted mucus not clear
_____
TO MOBILIZE SECRETIONS
Contraindicated: Corticosteroids, aspirin, coumadin, warfarin
VIBRATION (SHAKING)
- Vibration consists of placing the palmar aspect of the clinician’s hands in full contact with the patient’s chest wall. At the end of a deep inspiration, the clinician exerts pressure on the patient’s chest wall and gently oscillates it through the end of expiration.
- NPTE Reminders:
- More gentle than percussion but similar contraindications because of pressure provided
____
Put pt in postural drainage position – DEEP breath in. weight through affected area and oscillating during exhalation
ACTIVE CYCLE OF BREATHING
•Sequence of maneuver used to mobilize mucus to larger airways and clear secretions
•
•Procedure:
- Breathing control: The patient performs diaphragmatic breathing (through belly (abdomen)) at normal tidal volume for 5 to 10 seconds.
- Thoracic expansion exercises: In a postural drainage position the patient performs deep inhalation with relaxed exhalation at vital capacity range. This inhalation can be coupled with or without percussion during exhalation.
- Breathing control for 5 to 10 seconds.
- Thoracic expansion exercises repeated three to four times.
- Breathing control for 5 to 10 seconds.
- Forced expiratory technique: The patient performs one to two huffs at mid to low lung volumes. The patient is to concentrate on abdominal contraction to help force the air out. The glottis should remain open during the huffing.
•
AUTOGENIC DRAINAGE
- Sequence of maneuver used to mobilize mucus to larger airways and clear secretions
- Procedure:
- 3 rounds of shallow breathing
- 3 rounds of medium volume breathing
- 3 rounds of deep volume breathing
•
- NPTE reminder:
- Difficult to teach <8yo or cognitively impaired
•
A patient with pneumonia and a persistent dry cough presents with increased tactile fremitus and diminished breath sounds over the right posterior basal segment. Which of the following should be initiated FIRST?
A.Active Cycle of Breathing (ACBT)
B. Manual costophrenic assist
C.Autogenic Drainage
D.Manual Percussion
Pneumonia and persistent dry cough – doesn’t make sense – they have mucus plugs
Tactile fremitus means that there is more vibration.
This is telling me that there is consolidation and mucus plugs.
A: NO, there is mucus plugs
B:
C: NO, there is mucus plugs
D: YES
HUFFING (CLEARANCE)
•A deep inspiration followed by a forced expiration without glottal closure. It is often used in post-op patient who find it painful to cough
•
Cough is a glottal closure.
This is not, no pressure
MANUAL COSTOPHRENIC ASSIST / MANUAL ABDOMINAL THRUSTS
- Active-assistive approach where the therapist places his or her hand on the child’s abdomen (just below the diaphragm). The patient takes a large breath in and holds it for 1 to 3 seconds.
- The patient then attempts to cough as hard as possible while the therapist provides compression with an upward thrust in the direction of the diaphragm.
- For Abdominal Weakness – someone that has a problem with forced expiration (coughing)
MECHANICAL INSUFFLATION-EXSUFFLATION (MIE)
- Assisted Coughing Machine that adds in a high level of positive pressure followed by negative pressure to stimulate a cough
- Typically added with a manually assisted cough for more effective removal of secretion
SUCTIONING
- Passive elimination of secretions through using a suctioning tube within the tracheostomy.
- NPTE reminders:
- All active options were exhausted
- Patient has a tracheostomy
- Suction tube should be with drawn using a rotational technique NOT pistoning
- 5-10 second suction time
A patient with a past medical history of emphysema presents with complaints of moderate dyspnea when performing basic ADL’s. Which of the following interventions would BEST improve the patient’s activity tolerance?
A.Stacked breathing
B. Diaphragmatic breathing
C.Pursed Lip breathing
D.Inspiratory Muscle Training (IMT)
Roles of Diaphragmatic Breathing: improved oxygen saturation, resolution of atelectasis, lower anxiety, mobilization of secretions
Obstructive
Primary impairment: Obstructed airways
Emphysema is condition, dyspnea is symptom
A: For lobe collapse to fillup lungs; atelectasis
B: For restrictive lung condition
C: Yes, keep airways open longer
D: No, doesn’t help with anything
Nitroglycerin
Names: Nitroglycerin; Nitrostat
Responsible for relaxing vascular smooth tissue; allows for vasodilation + venodilation
MOA: Relaxes the veins and arteries
PRIMARY ROLE: Vasodilation + venodilation (decreases preload)
CONDITION: Angina (chest pain); Hypertension
SIGNS AND SYMPTOMS:
- Dizziness/lightheadedness
- Flushing
- Headache - anytime you’re changing blood pressure - can cause headache
- Rebound Tachycardia - heart rate above 100 - decrease BP, heart senses that there is not enough blood around so it tries to compensate by increasing the rate
Digitalis
Names: (-xin) Lanoxin; Digoxin;
MOA: Opposite of Calcium Channel Blockers (which decreases heart contractility)
Increases intracellular calcium - holds it in - therefore increases force of contraction.
=> Parasympathetic response - decrease conduction through heart
Speed of signal to get from SA node to AV node increases - widened PR interval (AV node block)
PRIMARY ROLE:
Atrial Fibrilation,
Atrial Flutter,
Congestive Heart Failure (CHF)
Signs and Symptoms:
AV node block;
Bradycardia (slowing conduction of the heart),
Lethal Cardiac arrythmias (hyperkalemic -> tall peaked T wave, and ventricles have a hard time relaxing;
Rash - Digitalis actually come from a plant and pt may be allergic to it.
Diuretics
NAMES:
Lasix (furosemide) - potassium wasting - Kypokalemia
Spironolactone - potassium sparing - Hyperkalemia
Thiazide/hydrochlorothiazide - potassium wasting - Kypokalemia
**K+ normal range = 3.5-5.0
MOA:
Increase renal filtration
increase amount of urine produced.
PRIMARY ROLE
Decrease water Rentention
Decrease BP
USES:
Hypertension
R CHF
Water Retention (Cushings disease)
SIGNS and SYMPTOMS
Dizziness/light-headedness
Dehydration
Muscle cramps - decreased water and potassium in the bloodstream.
Gout - Uric acid buildup - generally in the great toe - MTP (male) - solute gets left in the bloodstream.
An avid golfer presents to physical therapy with complaints of difficulty rotating his trunk to the left during his golf swing. The patient reports that he feels “stuck.” Upon examination, the therapist observes a right upglide restriction at T5-6. Which of the following hand/finger placements would be the MOST effective in addressing the patient’s restriction?
A. Stabilizing finger on the left transverse process of T6 and mobilizing finger on the right transverse process of T5
B. Stabilizing finger on the left transverse process of T4 and mobilizing finger on the right transverse process of T5
C. Stabilizing finger on the left transverse process of T5 and mobilizing finger on the right transverse process of T6
D. Posteroanterior (PA) pressure through the transverse processes of T5
A. Stabilizing finger on the left transverse process of T6 and mobilizing finger on the right transverse process of T5
A therapist is assessing a patient’s cervical mobility and finds decreased left cervical rotation and hypomobility and C5-C6 on the left. Which of the following mobilizations is the BEST to improve the patient’s cervical mobility?
A.Stabilizing finger on the left transverse process of C5 and mobilizing finger on the right transverse process of C6
B.Mobilizing finger on the right transverse process of C5 and stabilizing finger on the left transverse process of C6
C.Stabilizing finger on the left transverse process of C4 and mobilizing finger on the right transverse process of C5
D.Posteroanterior (PA) pressure through the transverse processes of C5
B.Mobilizing finger on the right transverse process of C5 and stabilizing finger on the left transverse process of C6
CROSSED SYNDROMES
What muscles and which are inhibited or faciliated
Lower Cross Syndrome:
What muscles and which are inhibited or faciliated
A patient with persistent cervicogenic headaches presents with forward head posturing and limited cervical mobility. Which of the following muscles should the therapist stretch?
A. Rectus capitus posterior major and minor
B. Longus Colli
C. Right levator scapulae
D. Right sternocleidomastoid
A. Rectus capitus posterior major and minor
A patient presents with reports of pins and needles into his right forearm/hand when maintaining his right extremity overhead. During the examination, the patient has no sensory loss, however, the patient does have tenderness to palpation to the right side of his neck along the soft tissue. Which of the following interventions would BEST address the patient’s chief complaint?
A. Grade 5, mid thoracic, HVLAT
B. Grade 1-2 oscillations at the C6-7
C. Grade 5, first rib, HVLAT
D. Median nerve glides
C. Grade 5, first rib, HVLAT
During midstance to terminal stance, a patient is found to have an abrupt and uncontrolled movement into an anterior pelvic tilt. Which of the following interventions would BEST address this gait deviation?
A.Eccentric strengthening of the rectus abdominus
B.Stretching of the gluteals
C.Concentric strengthening of the rectus abdominus
D.Concentric strengthening of the erector spinae
A.Eccentric strengthening of the rectus abdominus
Spondylosis
What is it?
Why is it happening
Definition: egenerative changes of the spine (i.e., wear & tear)
Why is this most likely occurring? Postural Instability
•Pathophysiology
⚬Lower crossed Syndrome
⚬Poor posture
⚬Repetitive stress (i.e., lifting)
How do you treat Spondylosis
⚬Stretching
￭Rectus Femoris
￭Tight trunk extensors
⚬Strengthening
￭Gluteals
￭Abdominals
What are ABGs
- Gases such as CO2 (acid) and O2 that are found in the body to sustain life
- Measured by
- Arterial Line ([Art]erial Blood Gas = [Art]erial line
- CO2 is the primary regulator of ventilation
- CO2 levels should be between 35 – 45 mmHg
- O2 levels should be between 80 – 100 mmHg
•
pH
- Specifies the acidity or alkalinity of the blood and should be between 7.35 – 7.45 (fatal levels 6.8 & 7.8)
- Below 7.35 = ACIDOSIS
- Above 7.45 = ALKALOSIS
•
- Also known as bicarbonate (base) and is conserved and produced by the kidneys.
- HCO3- is a base and how the body increases the pH
- Normal HCO3- levels should be between 22 – 26 meq/L
•
WHAT IS RESPIRATORY ACIDOSIS?
•A condition when the lungs can’t remove enough of the carbon dioxide (CO2) causing excess CO2(acid) in the body.
•
- The pH is less than 7.35
- The PaCO2 is > 45 mmHg
•
- Signs & Symptoms (C.A.R.B.S)
- Confusion
- Agitation/Anxiety
- Restlessnesss
- Blurred Vision
- Seizures
WHAT IS RESPIRATORY ALKALOSIS?
•A condition when the lungs remove too much of the carbon dioxide (CO2) causing deficient CO2(acid) in the body.
•
- The pH is more than 7.45
- The PaCO2 is < 35 mmHg
•
- Signs & Symptoms (N.O. C.A.R.D.S)
- Numbness and Tingling**
- Orthostatic Hypotensive**
- Confusion
- Anxious**
- Rapid Breathing**
- Dizziness
- Seizures
Pain
Hyperventilation
WHAT IS METABOLIC ACIDOSIS?
•A condition when the kidneys are not producing enough HCO3- (base) causing an excess amount of acid in the body.
•
- The pH is less than 7.35
- The HCO3- (base) is < 22 meq/L
•
- Signs & Symptoms (S.H.A.M.E.D)
- Stupor
- Hyperkalemia
- Arrhythmias
- Muscle Twitching
- Emesis
- Decreased Cardiac Output/Contractility
DKA
Renal Failure
WHAT IS METABOLIC ALKALOSIS?
•A condition of deficit H+ in body leading to excess production of HCO3- by the kidneys.
•
- The pH is more than 7.45
- The HCO3- is > 26 meq/L
•
- Signs & Symptoms (T.T.T.T)
- Tetany
- Tachycardia
- Tremors
- Tingling
Excessive Vomiting
Excessive Antacids
Diuretics
UNCOMPENSATED, COMPENSATED, AND PARTIALLY COMPENSATED
- Uncompensated
- When the pH remains out of normal range
- pH = < 7.35 or > 7.45
- Compensated (Fully compensated)
- When the pH is within normal range but both PaCO2 and HCO3- are out of range
- Partially Compensated
- When pH is near normal but still out of range and both PaCO2 and HCO3- are out of range
ROME - Respiratory = Opposite, Metabolic=Equal
5 STEPS TO PERFORMING CPR
- Step 1: Assess the scene for safety
- Step 2: Check for responsiveness (tap shoulder’s and shout “are you okay?”
- Step 3: Look for normal breathing and carotid pulse (look for normal chest rise and fall)
- Step 4: Call for help (call 9-1-1 or send someone else/AED)
- Ensure the patient is lying on a firm, flat surface facing upwards
- Step 5: If not breathing and unresponsive start CPR
•
A therapist is entering an empty parking garage after leaving work to find a woman lying on the ground. The woman is unresponsive. Which of the following is the NEXT course of action?
A.Find a phone and call 9-1-1
B.Initiate chest compressions
C.Check for breathing and a pulse
D.Check for head injuries and/or bleeding
C.Check for breathing and a pulse
CPR STEPS
ADULT
•Step 1: Give 30 compressions @ 2 inch depth & 100 per minute
CHILD 1yo-8yo
•Step 1: Give 30 compressions @ 2 inch depth & 100 per minute
INFANT
- Step 1: Give 30 compressions (2 fingers) @ 1.5 inch depth & 100 per minute
- Step 2: Give two rescue breaths (Head tilt chin lift) (cover nose and mouth)
Knowing When to Terminate Exercise
Absolute indications for termination
- Drop in SBP of >/= 10 mmHg with an increase in work rate
- Patient must have additional signs of ischemia
- >/= 3/4 on Angina Scale
- Signs of poor perfusion
- (i.e., cyanosis, pallor)
- Neurological Symptoms
- (i.e., syncope, dizziness ataxia)
- Patient requests to stop ETT
- Sustained V-TACH
- Rapid progression to V-Fibrillation
- >/= 1mm ST segment elevation without diagnostic Q waves
- Current MI vs. Prior MI
UPPER LOBE Drainage - Posterior and Apical
Posterior Segments: Right & Left
- Bed level, patient leaning forward over pillow 30 degrees
- Drains upper lobe
Procedure (lower ribs close to the spine)
•Therapist stands behind and claps over upper back on both sides.
Apical Segments: Right & Left
- Bed level, patient sitting upright leaning back 30 degrees
- Drains upper lobe
Procedure
•Therapist claps between clavicle and scapula on either side
Postural drainage UPPER LOBES
Anterior Segment: Right and Left
•Bed is level and patient in supine
Procedure
•Therapist claps between clavicle and nipple on either side
Postural Drainage - LEFT UPPER LOBE
Upper Lobe Singular Segments: Left Only
- Foot of bed elevated (16”) - Trendelenburg
- Drains lower lobe
- Right side-lying ¼ turn backwards
Procedure
- Therapist claps over **left** nipple area
- Therapist uses heel of cupped hand under armpit with finger extended underneath the breast (females)
Postural Drainage - Right Middle lobe
Middle Lobe: Right Only
- Foot of bed elevated (16”) - Trendelenburg
- Drains lower lobe
- Left side-lying ¼ turn backwards
Procedure
- Therapist claps over right nipple area
- Therapist uses heel of cupped hand under armpit with finger extended underneath the breast (females)
Postural Drainage - Lower Lbes Anterior Basal Segments.
Anterior Basal Segments: Right & Left
- Foot of bed elevated (20”) - Trendelenburg
- Drains lower lobe
Procedure (lower ribs)
•Patient lies directly on side in a side-lying position
Postural Drainage
Lateral Basal Segments: Right & Left
Posterior Basal Segments: Right & Left
Lateral Basal Segments: Right & Left
- Foot of bed elevated (20”) - Trendelenburg
- Drains lower lobe
Procedure (uppermost portion of lower ribs)
•Patient lies on abdomen then rotates 1/4 turn upward (backward)
Posterior Basal Segments: Right & Left
- Foot of bed elevated (20”) - Trendelenburg
- Drains lower lobe
Procedure (lower ribs close to the spine)
•Patient lies on abdomen, head down, with pillow under hips.
LOWER LOBES - postural drainage
Superior Segment: Right & Left
- Prone over two pillows - Head Down
- Drains lower lobe
- Allows for easier access to appropriate parts of posterior lung field
Procedure
- Patient lies prone on abdomen with two pillows underneath hips
- Striking occurs a tip of the scapula on either side of the spine
What percentage of a patient’s age adjusted maximum heart rate would most likely be used as the maximum heart rate for submaximal exercise testing?
60%
70%
85%
95%
85%
A patient’s maximum heart rate is determined by subtracting the patient’s age from 220. 85% of the obtained value is often used as the maximum heart rate for submaximal exercise testing.
