Cardiopulm Final (Both Cardio & Pulm) Flashcards
With the heart, what does the term “Preload” refer to?
Preload refers to the amount of blood the heart receives during diastole (End systolic volume + venous return).
What does Preload do when the heart receives blood during diastole?
The amount of blood stretches the myocardium, preparing for contraction. The more blood the heart receives, the more it stretches, and the greater the preload.
Analogy: Like filling a ballon with water - the more water you put in, the more the ballon will stretch
With the heart, what does the term “Afterload” refer to?
Afterload refers to the resistance the heart has to overcome to pump blood out
What is Ejection Fraction (EF)?
This is Stroke Volume / End-Diastolic Volume
What is normal EF?
(Ejection Fraction)
60-70%
What is Cardiac Output?
The amount of blood (in liters) ejected by the heart per minute, depends on HR (beats/min) and SV (mililiters of blood ejected during ventricular systole).
An increase in either SV or HR results in an increase Cardiac Output
What is Blood pressure influenced by?
Cardiac Output x Peripheral Vascular Resistance
…and further influenced by vein and venule capacitance and blood volume
T/F. Ventricles eject all the blood they contain in one beat.
False
In a typical ex. a ventricle is filled with 100ml of blood at the end of its load, but only 60 ml is ejected during contraction. This will equal an ejection fraction of 60%.
- The 100ml is the End-Diastolic volume (EDV) and the 40ml that remains in the ventricle after contraction is the end-systolic volume (ESV)
What is Stroke Volume?
- The amount of blood that leaves within a cardiac cycle
(End-Diastolic Volume - End-Systolic Volume)
Stroke Volume is dependant on 3 factors, what are they?
- Contractility
- Preload
- Afterload
Stroke Volume Factors
What affects Preload?
Review
The End-Diastolic Volume
- End-Systolic Volume + Venous Return
Stroke Volume Factors
What 2 factors affect Afterload?
- Aortic Pressure
- Aortic Valvular Function
What is the Normal Value (in L/min) of Cardiac Output?
4-8 L/min
Which ventrical is typically more focused on and why?
The left ventricle, because its the biggest part of the heart, its the hearts “pump”. It pumps blood into the body, It has the most myocardium in the heart
What are the Pathologies that relate to the 4 valves of the heart?
- Stenosis
- Valvular Insufficiency
Valve Pathologies
What is Stenosis?
A pathological narrowing or constriction that may cause reduced blood flow and potential clinical complications
Valve Pathologies
What is Valvular Insufficiency?
Valves that do not close properly, often described as “regurgitant”, “insufficient”, or “leaky”
- Result in retrograde (backward) blood flow and chronically high-pressure levels, which may lead to arrhythmias
The L Coronary Artery spits up into what two arteries? What do they supply?
- The Circumflex A.: supplies the L atrium and lateral/posterior walls of the Left ventricle
- Left Anterior Descending A. (LAD): this supplies the anterior wall and septum (area between the left and right ventricle) of the Left ventricle
What does the R Coronary Artery Supply?
The R Atrium and Ventricle, inferior an posterior wall fo the L ventricle. Supplies SA and AV nodes in most people
What does the Posterior Descending A. (a branch off of the Right Coronary A.) supply?
Supplies inferior Left ventricle and posterior septum. In some people, it also supplies some of the R ventricle
What does the SA Node do?
The Sinoatrial Node (SA) is where the cardio cycle begins in normal circumstances. It depolarizes and will send electrical signals through different fibers where it would reach the AV node and the SA node will dictate the firing of the AV node
Signals start at the SA node and it will sends waves to the AV node. The AV node will then itself depolarize and then send signals down the Bundle of His which will then split into the L and R Bundle Branch then they branch again in to Purkinje fibers. These Purkinje fibers innervate the myocardium of the L and R Ventricle
What is the firing rate of the SA node?
60-100 bpm
The PNS has a constant influence in the SA node, Vagal Tone
What is the firing rate of the AV node?
40-60 bpm
However it doesnt really pace itself. The SA node paces the AV node because it fires faster
What would happen if the SA node failed?
Since the AV node has its own firing rate, it can sustain cardiac functioning. Its just slower (40-60 bpm)
What is the normal range of Mean Arterial Pressure?
70-110mmHG
- 60-65 is critical
When grading Pulse Strength, what does 0 mean?
No palpable pulse
When grading Pulse Strength, what does 1 mean?
Faint, but detectable pulse
When grading Pulse Strength, what does 2+ mean?
Slightly more diminished pulse than normal
When grading Pulse Strength, what does 3+ mean?
Normal pulse
When grading Pulse Strength, what does 4+ mean
Bounding pulse
What is the primary aim of the Capillary Refill Test?
The primary aim is to gauge how well blood is circulating through the smaller blood vessels in the body
- Apply pressure to the pad (NOT NAIL) of a finger or toe for 5-10 seconds
Should you always take the Manual Pulse Rate over a minute’s length? Why or Why not?
Measuring the pulse for 30 seconds and multiplying it by (2) is sufficient for most populations. That being said:
- Always seek to take full minute to obtain a resting value in someone with an irregularly irregular rhythem
- Consider shorter-time measurements if seeking a time-sensitive pulse rate (e.g., 10-15 seconds if trying to establish rate during or immediately after exertion/exercise)
When should you consider assessing heart rate apically vs. radially?
- When there is severe tachycardia
–The lag in time as the blood rushes from the heart into the larg arteries may make radial palpation challenging - Arrythmias (e.g., artrial fibrillation, premature ventricular contractions)
–With some arrythmias, ventricular contractions may be too weak to empty into the aorta and cause a palpable peripheral pulse. In this scenario, radial assessment may underestimate actual heart rate (a show a pulse deficit)
On the stethoscope, what is the difference between the Bell vs. Diaphragm?
- Bell: low-frequency sounds; use light pressure or else it turns into a diaphragm. Use bell with soft placement for assessment of S3 and S4
- Diaphragm: High-freqency sounds; use with firm pressure
What are some factors that may affect the accuracy of a BP measurement?
- Cuff size and placement
–Too small cuffs overestimate BP
–Too large cuffs underestimate BP - LE positioning
- Speaking moving or having arm unsupported during assessment
- Time spent in resting after most recent exertion
What is considered Normal Blood Pressure?
Less than 120mmHG (systolic) and Less than 80mmHG (diastolic)
What is considered “Elevated” Blood Pressure?
120-129mmHG (Systolic) and Less than 80mmHG (Diastolic)
What is considered “High Blood Pressure (Hypertension) Stage 1”?
130-139mmHG (Systolic) OR 80-89mmHG (Diastolic)
What is considered High Blood Pressure (Hypertension) Stage 2?
140 or higher mmGH (Systolic) OR 90 or higher (Diastolic)
What is considered “Hypertensive Crisis”?
Higher than 180mmHG (Systolic) and/or Higher than 120mmHG (Diastolic)
Outpatient HTN Management Algorithm
If you just took BP on a patient and they do not have Hypertension Diagnosis, and they have ≤ 139mmHG systolic and/or ≤ 89mmHG diastolic. What should be done after recieving the results?
- Inform the patient of the reading
- Education the patient on lifestyle modification
- Document blood pressure
Outpatient HTN Management Algorithm
If you just took BP on a patient and they DO have Hypertension Diagnosis, and they have ≤ 139mmHG systolic and/or
≤ 89mmHG diastolic. What should be done after recieving the results?
- Inform the patient of the reading
- Education the patient on lifestyle modification
- Continue current medication regimen
- Document blood pressure
Outpatient HTN Management Algorithm
If you just took BP on a patient and they do not have symptoms of HTN, and they have 140-179mmHG systolic and/or 90-109mmHG diastolic. What should be done after recieving the results?
wait 5 minutes and recheck
- Inform patient of reading
- Determine medication compliance, if appropriate
- Monitor during therapy intervention
- Document blood pressure
- Recheck at next therapy visit
–If still in abnormal range, notify physician
–If in safe range, continue to monitor
Outpatient HTN Management Algorithm
If you just took BP on a patient and they DO have symptoms of HTN, and they have 140-179mmHG systolic and/or 90-109mmHG diastolic. What should be done after recieving the results?
- Inform patient of reading
- Determine medication compliance, if appropriate
- Contact physician
- Obtain medical clearance prior to initiating exercise
- Document blood pressure
Outpatient HTN Management Algorithm
If you just took BP on a patient and they do not have symptoms of HTN, and they have ≥180mmHG systolic and/or ≥110mmHG diastolic. What should be done after recieving the results?
Wait 5 minutes and re-check
- Inform patient of reading
- Determine medication compliance, if appropriate
- Contact physician
- Physician determines next steps
- Hold Exercise
- Document blood pressure
Outpatient HTN Management Algorithm
If you just took BP on a patient and they do not have symptoms of HTN, and they have ≥180mmHG systolic and/or ≥110mmHG diastolic. What should be done after recieving the results?
- Inform patient of reading
- Determine medication compliance, if appropriate
- Contact physician
- Physician determines next steps
- Send to emergency, if unable to contact physician
- Hold Exercise
- Document blood pressure
What is Mean Arterial Pressure (MAP)?
The average pressure tending to push blood through the circulatory system, and it reflects tissue perfusion pressure
[(2 x DBP) + SBP] / 3 (This is the equation)
What would happen if a patients MAP is less than 60mmHG?
This may indicate inadequate tissue perfusion and should, in a majority of circumstances, lead the clinician to modify the pts position and/or activity to increase MAP right away
This is also a value the medical team will often use to manage pharmacology (e.g., prescribing vasopressors to increase BP)
In the Pitting Edema Scale, what does a 1+ mean?
Barely perceptible depression (pit)
In the Pitting Edema Scale, what does a 2+ mean?
Easily indentified depression (EID, skin rebounds to it original counter within 15 sec)
In the Pitting Edema Scale, what does a 3+ mean?
EID (Skin rebounds to its original within 15 to 30 sec)
In the Pitting Edema Scale, what does a 4+ mean?
EID (rebound >30 sec)
What is Sinus Bradycardia?
This is characterized by a sinoatrial (SA) node discharge rate less than 60bpm with normal P waves and QRS complexes
When is Sinus Bradycardia normal in/at?
- Rest
- Sleep
- Well-trained athletes due to increased vagal tone and stroke volume
- With some medications (e.g., beta- or calcium channel-blockers)
What is Sinus Tachycardia Characterized by? What does this often result from?
Its characterized by a sinoatrial (SA) node discharge rate greater than 100bpm with normal P waves and QRS complexes
- This most often results from increased sympathetic and/or decreased parasympathetic (vagal) tone
What does the P wave represent?
Depolarization of both atria. The P wave is the first ECG Deflection
What does the QRS Complex represent?
The QRS complex indicates ventricular depolarization
- The R wave is the initial positive deflection
- The Negative deflection before the R wave is the Q wave
- The negative deflection after the R wave is the S wave
This typically takes 0.06-0.10sec
What does the S-T segment and T wave represent?
Both represent Ventricular Repolarization
- The S-T segment extends from the S wave to the beginning of the T wave
- The T-wave represents the repolarization of both ventricles
In an ECG, what is a segment?
The region between two waves
In an ECG, what is an Interval?
A duration of time that includes one segment and one or more waves
What are the S-T segments and T wave sensitive indicators of?
They are sensitive indicators of the oxygen supply status of the ventricular myocardium
What is the P-R Interval?
This is the electrical transmission from the atria to the ventricles
This typically takes 0.12-0.20sec
What does R-R Wave represent?
Ventricular Depolarization (Ventricular systole)
- The measurment between each R-R wave give you sense on how regular or irregular the rhythm is
What is Supraventricular Tachycardia (SVT)?
Rapid heart rhythm originating above the hearts ventricles, typcially involving the atria or atrioventricular node
What are Ectopic beats/focus?
Areas where the heart contracts itself; outside the normal conduction pathway.
- They typically have weaker contractions
Supraventricular Tachycardia
What is Atrial Tachycardia?
Abnormal heart rhythm that is characterized by a series of three or more consecutive ectopic beats originating in the atria
Supraventricular Tachycardia
What is Atrial Flutter?
This is characterized by a rapid, organized, and regular atrial rhythm. It has a unique re-entrant circuit, usually in the right atrium, which leads to the classic “Sawtooth” patten seen on the ECG
- Usually has a rate of 250-350bpm
- Usually has more than 1 P wave before every QRS complex
Re-entrant Circuit: Self-sustaining electrical pathway in the heart in which the impulse continues to circle through the tissue, causing repeated stimulation and a rapid heartbeat
Supraventricular Tachycardia
What is Atrial Fibrillation?
The most common type of Serious Arrhythmia. This is characterized by a very fast and disorganized atrail rhythm, resulting from multiple ectopic foci and/or multiple reentry circuits generating electrical impulses in a chaotic manner. This leads to irregular rhythm known as “irregularly irregular” pulse.
- Erratic quivering or twitching of the atrial muscle
How can you tell the difference between Atrial Flutter and Atrial Fibrillation?
- Atrial Flutter is a more organized and REGULAR atrial rhythm
- Atrial Fibrillation, has no true P waves are found. The AV node acts to control the most of the impulses that initiate QRS complex; therefore a totally irregularly irregular rhythm exist
Is this picture an example of Atrial Flutter or Atrial Fibrillation?
Atrial Fibrillation
- There are no true P waves
Is this picture an example of Atrial Flutter or Atrial Fibrillation?
Atrial Flutter
- The P waves are organized and in rhythm, it also makes a “Sawtooth” like pattern
What can Atrial Flutter and Atrial Fibrillation result in?
Although they are not, in and of themselves, considered lifethreatening, they can lead to serious and potentially life-threatening complications if not properly managed:
- Stroke risk due to blood stasis
- Induce heart failure via tachycardia-induced cardiomyopathy
What are the Medical Options for treating Atrial Flutter and Fibrillation?
Cardioversion: A medical procedure that aims to restore a normal heart rhythm
Medications:
- Rate control medications: Beta-blockers and calcium channel blockers
- Rhythm control medications: Antiarrhythmic drugs work by altering the electrical signals in the heart to maintian a normal rhythm
- Anticoagulant: Prevent the formation of blood clots in the heart
What is Premature Ventricular Contactions (PVC)?
This occurs when an ectopic focus (or foci, in the case of mulifocal PCVs) creates an impulse from somewhere in one of the ventricles. It occurs early in the cardiac cycle before the SA node actually fires
The QRS complex is wide and bizarre and occurs earlier than normal sinus beat would have occurred. There are no P waves.
- It is wide because of slow cell to cell connections rather than through the normal rapidly conducting His-Purkinje system
When are PVCs considered serious?
- When they are paired together
- When they are mulifocal in orgin
- When they are more frequent than 10 per minute at rest
- When they are more present in triplets or more
What is common with those patients with Atrial Flutters and Fibrillations when they exercise? What Sx can be exacerbated by exercise?
They may experience reduced exercise tolerance, becoming fatigued more quickly or find that their usual level of physical activity is more strenuous than before.
- Sx like palpitations, SOB, or even chest pain can be exacerbated by exercise
Those patients with Atrial Fibrillations, how should you capture their heart rate instead of using a Pulse Oximeter?
Pulse oximeters may not be accurate due to the irregular rhythm. Instead consider assessment of the physical pulse for a full minute.
- If unsure about the ability to take radial pulse, with the stethoscope assess it apically.
In this pic, what is the name of the ECG?
Trigeminy
- Theres a PVC every 3rd
In this pic, what is the name of the ECG?
Bigeminy
- There is a PVC everyother
In this pic, what is the name of the ECG?
Couplet
- Theres 2 PVCs in a row
In this pic, what is the name of the ECG?
Triplet
- There are 3 PVCs in a row
What is Ventricular Tachycardia (VT)?
This is defined as a series of three or more PVCs in a row.
What can Ventricular Tachycardia progress to?
VT can be tolerated at lower HR, it is a highly dangerous arrhythmia because it can progress to Ventricular Fibrillation (VF), particularly in the setting of decreased myocardial contractility (e.g., after an MI)
How is Ventricular Fibrillation characterized by?
What can VF progress to?
- Erratic quivering of the ventricular muscle and a cessation of cardiac output
- VF can further deteriorate to asystole if not treated
What are AV Heart Blocks?
Disorders of the heart’s rhythm due to an obstruction - a block - in the electrical conduction system of the heart. There are 3 types of AV Blocks:
- First Degree
- Second Degree
- Third Degree
What is a First Degree AV Block?
A stable prolongation of the PR Interval to more than 200ms and represents delay in conduction at the level of the AV node
What is a Second Degree AV block, Type 1?
Mobitz Type 1 (Wenckebach): Progressive prolongation of the PR interval before an atrial impulse fails to stimulate the ventricle (e.g., a P wave is nonconducted and a QRS is dropped). Usually occurs at the level of AV node
What is a Second Degree AV block, Type 2?
Mobitz Type 2: Fixed PR interval with some P waves not conducted. Usually occurs below the bundle of His and may be a bilateral bundle branch block
What can changes in the ST-segment indicate?
This can be crucial indicator of myocardial ischemia or injury
- Ischemia can also manifest as T-wave inversions or flattening
What does this picture represent when talking about the T-wave?
This is Ischmia, without subendocardial injury (i.e. necrosis of myocardium - cell death) can present as T-Wave Inversion
What does this picture represent when talking about the T-wave?
This is Ischmia, with subendocardial injury (i.e. necrosis of myocardium - cell death) can present as ST segment depression
With the ST Segment, what can Upsloping represent??
Upsloping ST Segment depression ≥ 2.00 mm may represent Myocardial Ischemia, especially in the presence of angina. However this reponse has a low positive predictive value; it is often categorized as equivocal
With the ST Segment, what can Downsloping represent?
Downsloping ST Segment Depression ≥ 1.00mm is a strong indicator of myocardial ischemia
With ST-Segment Depression, what should be present in order for it to be “Clinically meaningful”?
ST-Segment Depression should be present in at least 3 consecutive cardiac cycles within the same lead. The level of the ST-segment should be compared relative to the end of the PR segment
- Clinically significant ST-segment depression that occurs during Post-exercise recovery is an indicator of myocardial ischemia
What is the difference between ST-Segment Elevation and ST-Segment Depression?
ST-Segment elevation is generally considered a medical emergency requiring immediate intervention, whereas ST-Segment depression may or may not be immediately life-threatening depending on the clincial contex
- ST-Segmetn Elevation MORE STRONGLY correlates with myocardial injury that has extended through the full thickness of the myocardium (i.e., transmural - “across the wall”)
What is the function of a Pacemaker?
These create an artificial electrical voltage difference between 2 electrodes
- Marked by a pacer spike on ECG
Individuals with untreated atrial fibrillation are at risk for which of the following disorders?
Thromboembolic Events
When montioring ECG, what are signs of Pacemaker Failure?
- Lack of Spike
- Spike in wrong location
What are some Post-Op Recautions with Pacemakers?
Immediately after permanent pacemake placement:
- Ipsilateral AROM should be < 90° for 4 weeks
- Arm sling may be used
What are Automatic Implantable Cardioverter Defibrillator (AICD/ICD) used for?
Used to manage uncontrollable, life-threatening ventricular arrythmias by sensing the heart rhythm and defibrillating the myocardium
- Knowing the discharge rate allows for safe prescription of exercise
–Stay ~20-30 bpm under this rate
With the AICD/ICD, what is the LifeVest used for?
- This is increasingly used as bridge to AICD placement or heart transplant
- Gives a warning alarm
Can you “shock” or defibrillate someone in Asystole?
No, only if they are in V-Fib or V-Tach
In general, Arrythmias that increase in frequency or complexity with progressive activity/exercise are associate with what?
Associated with Ischemia or with Hemodynamic instability, these are more likely to cause a poor outcome than isolated arrhythmias
In general, Frequent and Complex Ventricular Ectopy during exercise, especially in recovery is associated with what?
Associated with increased risk for Cardiac Arrest
After a diagnosis of ventricular tachycardia, a patient has an ICD implanted. The purpose of the ICD is to:
Prevent sudden death due to Ventricular Tachycardia
What can having a “Normal” VO2 mean, and how is this important?
Having a “Normal” VO2 (around >85% predicted for your age, gender etc.) essentially rules out significant cardiovascular and pulmonary disease
The greater the amount of oxygen consumed at peak exercise, the more fit the individual
What is the normal HR response to incremental exercise?
There is an increase with progressive workloads at a rate of ~10bpm per 1 MET
MET: A unit that describes how much oxygen someone is consuming at rest
For ex: If a person is doing an exercise at 2 METS of intensity, this means that the exercise is having the person consume twice the amounnt of oxygen as they perform at rest
What is the normal BP response to exercise?
- Systolic BP (SBP): Gradual rate of rise (~10mmHG/MET) until reaching steady state
- Diastolic BP (DBP): Increases or decreases withing 10mmHG
What is a Hypertensive Response to exercise?
- A SBP ≥ 210 mmHG in men and ≥ 190 mmHG in women during exercise is often considered a hypertensive response
- A DBP ≥ of 110 mmHG is often considered a hypersensive response
What is a Hypotensive Response to exercise? What is this often associated with?
- A decrease of SBP by > 10 mmHG with or without a preliminary increase is considered abnormal and often associated with myocardial ischemia, left ventricular dysfunction, and an increase risk of subsequent cardiac events
This is a serious concern
Pre-Exercise Screen
What is recommended for a person that does not participate in regular exercise and does not have CV, metabolic, or renal disease AND no S/S suggestive of CV, metabolic or renal disease?
- Medical Clearance is not necessary
- Light to moderate-intensity exercise recommended
- May gradually progress to vigorous-intensity exercise follwing ACSM guidelines
Medical clearance is approval from a healthcare progessional
What does the term “Regular Exercise” mean?
Performing planned structured physcial activity for at leat 30 minutes at a moderate intensity at least 3 days per week for the last 3 months
Anyone who does not meet that criteria is said to not be a regular exercise participant
Pre-exercise Screen
What is recommended for a person that does not participate in regular exercise and has Known CV, Metabolic, or Renal disease and Asymptomatic?
- Medical Clearance Recommended
- Following medical clearance, light to moderate-intensity exercise recommended
- May gradually progress as tolerated following ACSM guidelines
Pre-exercise Screening
What is recommended for a person that does not participate in regular exercsie and has any S/S suggestive of CV, metabolic or Renal disease (regardless of disease status)?
- Medical Clearance Recommended
- Following medical clearance, light-moderate intensity exercise recommended
- May gradually progress as tolerated following ACSM guidelines
Pre-exercise Screen
What is recommended for a person that does participate in regular exercise and does not have CV, metabolic, or Renal disease and S/S suggestive of CV, metabolic or renal disease?
- Medical clearance is not necessary
- Continue moderate or vigorous-intensity exercise
- May gradually progress following ACSM guidelines
Pre-exercise Screen
What is recommended for a person that does participate in regular exercise and has Known CV, Metabolic, or Renal disease and Asymptomatic?
- Medical clearance for moderate-intensity exercise NOT necessary
- Medical clearance (within the past 12 months if no change in S/S) recommended before engaging in vigorous-intensity exercise
- Continue with moderate-intensity exercise
- Following medical clearance, may gradually progress as tolerated following ACSM guidelines
Pre-exercise Screen
What is recommended for a person that does participate in regular exercsie and has any S/S suggestive of CV, metabolic or Renal disease (regardless of disease status)?
- Discontinue exercise and seek medical clearance
- May return to exercise following medical clearance
- Gradually progress as tolerated following ACSM guidelines
What are the Absolute Indications that the patient is unstable and Treatment should (Totally) be withheld?
- S/S of decompensated Cogestive Heart Failure
- > 10 PVCs/minute at rest
- Mutlifocal PVCs, unstable angina, and ECG changes associatd with ischemia/injury
- Dissecting aortic aneurism
- New Onset (< 24 hrs) A-fib with rapid ventricular response (RVR) > 100bpm (at rest)
- 2nd degree-heart block coupled with ventricular tachycardia
- 3rd degree heart block
- Chest pain with new ST segment changes on ECG
What are the Relative (it depends) indications that a patient is unstable and treatment should be Modified or withheld?
- Resting tachycardia (especially if new)
- Resting SBP > 160 or DBP > 90 (Escpecially if new)
- Resting SBP < 80
- Ventricular ectopy at rest
- MI or extension of infarction within previous 2 days
- Uncontrolled Metabolic Disease (e.g., DM)
- Psychosis or other unstable psychologic condition
What are different methods to predict max HR and work capacity?
- 220-age= predicted max HR (PMHR)
(This may overestimate true HRmax in young adults and underestimate true HRmax in persons older than 40) - 208-(0.7 x age)
(This more accurately identifies true HRmax among healthy adults across the life span, Still has a wide variation of 10-12bpm)
-With this, you also multiply by 85% (.85) to get the endpoint bpm
What is the method to predict max HR and work capacity specifically for individuals on Beta-Blockers?
164-(0.7 x age)
What are some reasons for Termination of Submaximal Testing?
- Pt request to stop
- A predetermined physiologic or other end-point has been reached
- Technical failure of any monitoring equipment
- Excessive dyspnea (using 0-10 Borg scale; will depend on case by case level)
- Sustained ventricular tachycardia
- Changes to cardiac rhythm as assessed by ECG, palpation or auscultion
- SpO2 drops below prescribed levels
- ST-Stegmetn depression ≥ 1 mm or reports of sx that could be angina
- Max tolerable (Grade 3) claudication pain
- Decreased in SBP > 10 mmHG or if SBP decreases from resting value obtained in same postural position prior to testing
- Consider cut off at a exaggerated BP response (SBP > 210 mmHG or Diastolic >115 mmHG; this will vary case-by-case)
With findings from an ET, what can we say about the patients likely maximal work capacity?
We can likely estimate peak workload to be 1-2 stages above near-maximal performance to provide information for exercise prescription
What happens after the first hours after Acute MI?
- Ischemia leads to necrosis of cardiac tissue in the affected area within minutes of coronary artery occlusion
- Initiation of an inflammation response that involves the release of various inflammation mediators and signals the recruitment of WBCs to the site of injury
- The overall pumping efficiency of the heart decreases as the affected part of the heart may become hypokinetic or akinetic
What happens after the First days after Acute MI?
- The inflammatory response continues with the removal of dead cells and debris, preparing the groundwork for healing and scar formation.
- The area surrounding the necrotic tissue may become edematous and hemorrhagic due to the disruption of microvasculature.
- Fibroblasts begin to proliferate at the site of injury, laying down the extracellular matrix that will form the basis of the scar tissue.
What happens after the First week after Acute MI?
- The development of a fibrous scar begins as granulation tissue and collagen deposition begins to form by about the end of the first week.
- This area remains vulnerable to mechanical stress due to the ongoing remodeling and relatively weak tensile strength of the new tissue.
- The shape and size of the ventricle begins changes through a remodeling process
What happens after several weeks after an Acute MI?
- Over the next several weeks, the scar tissue continues to mature and strengthen, replacing the necrotic tissue.
- The collagen fibers reorganize, and the scar contracts. The process of ventricular remodeling can continue for months after an MI.
- This can involve hypertrophy (thickening) of the unaffected myocardium in an attempt to compensate for the lost muscle function
What can Adverse Ventricular Remodeling lead to?
Can lead to impaired systolic and diastolic dysfunction and arrythmias
What are the Prognostic Factors for Mortality and Functional Status after an AMI?
(AMI = Acute Myocardial Infarction)
- Remaining Left Ventricular function (MOST IMPORTANT)
- Complications
- Infarction size
- Presence of disease in other coronary arteries which leave other parts of myocardium still at risk
With AMI Complications, the severity and the type of complications depend on what factors?
- Factors like the extent of myocardial damage, the location of the infarct, the speed of medical intervention, and the overall health of the patient.
Increased levels of habitual physical activity before hospitalization for heart-related conditions are associated with better short-term cardiovascular outcomes
With AMI, what is essential to minimize the risk of complications and reducing future risk?
Immediate and appropriate medical treatment(e.g., reperfusion therapy) is crucial to minimize the risk of these complications. Long-term management, including lifestyle changes and medication, is also essential for reducing future risks.
Patients with an “uncomplicated” profile will more often experience notably reduced rates of morbidity and mortality after their initial cardiac events
What is the Criteria for Complicated Myocardial Infarction?
(9 items in chart)
Complications after AMI
What happens if you have an occlusion of the L Main (L coronary) or LAD?
Most Common
- We will see pump dysfunction of failure
Complications of the (L coronary or LAD)
If there is an occlusion of the L coronary or LAD. What happens when the Left Ventical is ~15% is compromised?
Decreased contractility -> hypotension -> decreased driving pressure/coronary perfusion -> increased ischemia -> decreased contractility
If there is an occlusion of the L coronary or LAD. What happens when the Left Ventical is ~25% is compromised?
May see signs of heart failure (e.g., pulmonary edema)
If there is an occlusion of the L coronary or LAD. What happens when the Left Ventical is ~40% is compromised?
Increased mortality due to ventricular tachycardia and fibrillation. Cardiogenic shock (SBP < 90 mm HG / MAP < 60-65) occurs around this range as well
What happens if you have an occlusion of the RCA?
- Right Ventricular Dysfunction, SA/AV nodal dysfunction, and arrythmias
- The pt may experience bradycardia, AV block, Atrial Fibrillation and Atrial Flutter
Complications after AMI
What is Persistent Sinus Tachycardia?
Elevated HR originating from the SA node
Complications after MI
After an MI, how can this affect the patient HR?
- After an MI, the heart may become less efficient at pumping blood due to damage to the myocardial tissue. The body compensates by increasing the HR to maintain adequate cardiac output and perfusion to vital organs. This compensatory mechanism can result in persistent sinus tachycardia
After an MI, what would happen if the patients HR is too high? What S/S should we look for?
- Cardiac output may fall due to the markedly reduced ventricular filling time (affecting pre-load)
In these cases, look for signs of:
- Hypotension
- Acute Altered Mental Status (AMS)
- Ischemic chest discomfort due to increasing myocardial oxygen demand but reduced coronary blood flow
- Acute Heart Failure (e.g., fluid back up with pulmonary edema, dyspnea)
Complications after MI
What is a useful method to assess arterial blood flow and ensuring there is sufficient organ perfusion?
Monitoring Mean Arterial Pressure (MAP)
- MAP = [(2 x DBP) + SBP] / 3
- Normal Values 70-110 mm Hg
- A MAP less than 60 mmHg may indicate inadequate tissue perfusion and should, in a majority of circumstances, lead the clinician to modify the pt’s position and/or activity to increase MAP right away
What is Pulmonary Edema?
Abnormal accumulation of fluid in the alveoli and interstitial spaces of the lungs
How does Pulmonary Edema result from an MI?
- Cases where the left ventricle is affected, the heart’s ability to effectively pump blood can be significantly compromised.
- This leads to an increase in pressure in the left atrium and subsequently in the pulmonary veins and capillaries.
- The elevated pulmonary capillary pressure forces fluid out of the capillaries and into the alveolar spaces, resulting in pulmonary edema.
- This fluid accumulation interferes with gas exchange, leading to decreased oxygenation of the blood and respiratory distress.
Complications after MI
With patients with Pulmonary Edema, during the screening process, what should PT look out for?
- Shortness of breath, especially when lying flat
- Rapid, shallow breathing
- Coughing, noting any presence of frothy sputum that may be tinged with blood
- Audible “crackles” or wheezing upon auscultation of the lungs
Continuous monitoring of respiratory rate, oxygen saturation, and subjective reports of dyspnea during therapy sessions is critical for any patient who has pulmonary edema. Immediate action should be taken if signs of worsening pulmonary edema are observed.
What is Atherosclerosis? What is the Primary Pathology for this?
A disease that causes progressive hardening and narrowing of medium and large arteries including the coronary, cerebral, and peripheral arteries
- Due to the build up of plaques made up of lipids, cholesterol, calcium and cellular debris
What are the Risk Factors of Heart and Cardiovascular Disease?
Guidelines for Risk Assessment
With a person with Hypertension, what is the goal we should have to decrease risk assessment?
- < 140/90mmHG
- < 130/85mmHG if renal insufficiency or heart failure present
- < 130/80mmHG if diabetic
- Initiate drug therapy if lifestyle modification is ineffective physical activity
- The Goal: At least 30 min of moderate intensity (40-60% of max) activity, most days of the week
Guidelines for Risk Assessment
With a person with Hypertension, what is the goal for Lipid management to decrease risk assessment?
Goal:
- LDL < 160mg/dL if ≤1 risk factor for CHD present
- LDL < 100mg/dL if ≥ 2 risk factors present and CHD risk is
≥ 20% or if person is diabetic
- Drug therapy may also be indicated if triglycerides are >150mg/dL or HDL is < 40mg/dL for men or < 50mg/dL for women
CHD = Coronary Heart Disease
Guidelines for Risk Assessment
With a patient under weight management, what is the goal for Diabetes management to decrease risk assessment?
Goal:
- Normal fasting plasma glucose (110mg/dL) and near normal HbA1c (7%)
What is the General Clincial Course of Coronary Heart Disease (CHD)?
often used interchangeably with Coronary Artery Disease (CAD)
- Stable Angina (This may be skipped with sedentary pt)
- Acute Coronary Syndrome (Heart Attack)
- Cardiac Muscle Dysfunction (After HA, tissues not regen. it scars)
- Sudden Cardiac Death
When a person has Coronary Heart Disease and they are at the last stage, Sudden Cardiac Death, what happens that usually causes the death of the patient?
Venticular Tachycardia and Ventricular Fibrillation, leading to the cessation of CO, are the usual cause of death
When a person has Coronary Heart Disease and they are at the last stage, Sudden Cardiac Death, what must be done for the patients only chance of survival?
Prompt delivery of quality cardiopulmonary resuscitation with AED within 10 min and entry into medical system is their only chance of survival
What happens if Metabolic Demand and Oxygen supply do not match each other?
There will be Ischemia
What is Angina?
- Sensation of Cardiac ischemia produced by an imbalance between myocardial oxygen supply and demand
-Its often the reason the patients seek initial medical attention
What may cause an onset of Stable Angina? What is it relieved by?
The onset of this imbalance is generally predictable at a certain workload
- Relieved by resting, reducing the intensity of the activity and/or taking sublingual nitroglycerin
Beyond physical exertion and emotional stress, cold weather and heavy meals are also known precipitants of angina
Where is Angina felt?
- Anywhere above the waist but most likely in the chest, neck or jaw
What is Angina typically described as?
Diffuse ache, squeezing, tightness, fullness, heaviness, burning or pressure
- It is not usually described as focal, sharp or stabbing
What Sx of angia will men present with?
Substernal (e.g., Levine’s Sign) or chest tightness or indigestion that radiates, sometimes into the arm or into the jaw or neck
What Sx of angia will women present with?
Tightness or discomfort posteriorly between the scapula or with Sx of indigestion, nausea, SOB or simply excessive fatigue
What may cause Silent Ischemia?
Neuropathy with impaired sensory afferentn conduction (e.g., as in diabetes)
What must a clinician do upon presentation of suspected angia?
Have the patient stop and assume a resting position, then consider the following:
- Do the Sx relieve with rest? True stable angina pain should only increase with increases in myocardial oxygen demand and decrease with cessation of exercise/activity and/or nitroglycerin
- Does the patient have risk factors for atherosclerosis?
- Could the patient have a MSK chest injury?
-Does palpating the painful area, deep breathing or AROM of the thorax/UEs increase sx? Any changes in sx with palpation, deep breathing, AROM of UEs argues against MI source of pain
Chest pain that does not relieve with rest should be considered an emergency
What should be done with those individuals with suspected demand ischemia, that is used for risk stratification, exercise prescription and clinical diagnosis?
They should ideally be referred to cardiology and be assessed with Cardiopulmonary Exercise Testing (CPX or CPET) or at least an Exercise Tolerance Test (ETT) or a chemical stress test
In the absenceof the results from a CPET, ETT or Chemical stress test, what should us, the PTs be monitoring?
- Vitals
- S/S that suggest cardiac ischemia
- S/S of a developing arrhythmias (e.g., irregular pulses and/or reports of “palpitations/fluttering”)
What may PTs use to SCREEN Vitals, S/S that suggest cardiac ischemia, and S/S of a developing arrhythmias?
A submaximal exercise test that utilizes target HRs (e.g., 85% of the age-predicted Maximal HR) via walking or cycle protocols
If an individual has increased arrhythmia(s) with activity, particularly if accompanies by S/S of hemodynamic instability (hypotension, lightheadedness), what must be done?
This warrents Termination of testing and follow up with the medical team for ECG-guided, graded exercise testing and/or Holter Monitoring
What is an Anginal Threshold?
The Anginal Threshold is the point during physical exertion at which cardiac ischemia occurs due to insufficient oxygen supply to the heart muscles
What happens if a patient has an identified ischemic threshold (i.e. angina and/or ≥ 1 mm ischemic ST-segment depression on exercise test)?
The exercise intensity should be prescribed at a HR andn work rate below this point , with an upper limit of a minimum of 10 beats/min below the HR at which the ischemia was initailly identified
What is Acute Coronary Syndrome (ACS)?
This is a range of conditions associated with sudden, reduced blood flow to the heart
What is Acute Coronary Syndrome typically associated with? What 3 heart conditions is it primarily related to?
Typically associated with an atherosclerotic plaque rupture in an already blocked artery
Primarily related to 3 heart conditions:
- Unstable Angina
- Non-ST-Segment elevation MI (NSTEMI)
- ST-Segment elevation MI (STEMI)
The NSTEMI and STEMI are types of heart attacks
What is Unstable Angina?
aka “Preinfarction Angina”
The presence of S/S of an inadequate blood supply to the myocardium that doesn’t follow a predictable pattern like stable angina, which typically occus with exertion and alleviates with rest
What is the Symptom Severity and Pattern of Unstable Angina?
The pain and discomfort associated with UA can be more severe, frequent, or prolonged than the individuals typical anginal episodes
What are the Precipitating Factors of Unstable Angina?
Unlike Stable Angina, which is often triggered by physical exertion or stress, unstable angina can occur spontaneously without a clear trigger or with a lower level activity
What is the Response to Medications for Unstable Angina?
While stable angina usually response well to rest and sublingual nitroglycerin, Unstable Angina might not respond as effectivley to these interventions (e.g., relief may be less complete or of shorter duration)
How is Unstable Angina Diagnosed?
This involves a combination of clinical assessments, ECGs and Blood Test.
- ECG may show changes indictative of schemia (ST-segment depression and/or T-wave inversion)
- Blood test for cardiac biomarkers- proteins and enzymes that suggest myocardial damage- are usually negative
What can Unstable Angina progress to?
It may progress to Acute Myocardial Infarction (AMI) if the underlying pathophysiology is not promptly corrected
What is a Myocardial Infarction?
A clincial event resulting in myocardial necrosis due to ischemia
MI is characterized by what Sx?
typically more intense compared to those of unstable angina
- Sweating
- Weakness
- Lightheadedness
- Palpitations
- This can also lead to a dramatic sympathetic nervous system response due to a sudden drop in cardiac output
What is Acute Myocardial Infarction?
A clinical event resulting in myocardial necrosis due to ischemia
What are the 2 different types of AMI?
- Non-ST Segment Elevation Myocardial Infarction (NSTEMI)
- ST-Segment Elevation Myocardial Infarction (STEMI)
What is a Non-ST Segment Elevation Myocardial Infarction (NSTEMI)?
(Type of AMI)
- The blood supply to the heart is reduced, usually due to a partial blockage of a coronary artery, causing some amount of heart muscle damage.
- The ECG does not show ST-segment elevation but may display other signs of ischemia, such as ST-segment depression or T-Wave inversion (similar to stable or unstable angina)
NSTEMIs are sometimes referred to as subendocardial infarctions as they only affect the inner layers of the heart muscle
What is a ST Segment Elevation Myocardial Infarction (STEMI)?
(A type of AMI)
- A more substanital blockage of a coronary artery leads to a significant portion of the heart muscle being deprived of oxygen
- The ECG shows elevation in the ST segment, indicative of extensive heart muscle damage
STEMIs are sometimes referred to as Transmural infarction because they typcially involve the full thickness of the heart muscle wall, from the endocardium to the epicardium
Beyond ECG changes, both NSTEMI and STEMI show evidence through blood analysis, what may we see?
We may see characteristic changes to Cardiac Biomarkers such as Troponin, Creatine Kinase-MB, and/or Myoglobin can indicate heart muscle injury and are used to confirm diagnosis of AMI
With AMI management, what happens with Immediate reperfusion?
If reperfusion occurs within about 20 minutes, most of the at-risk area can be salvaged, meaning the heart muscle can recover without significant damage. This is the ideal scenario and underscores the importance of prompt medical intervention
With AMI managment, what happens with Reperfusion within a few hours?
If reperfusion occurs within about 2 to 4 hours, there can be partial salvage of the heart muscle. Some areas will become necrotic with hemorrhage and contraction bands, which are signs of irreversible damage, but some muscle tissue remains viable albeit with post- ischemic dysfunction
With AMI management, what happens with Permanent Occlusion?
Without reperfusion, the entire area at risk progresses to a completed infarct, meaning all the tissue in the area becomes necrotic. This results in the loss of muscle function in the affected area and can lead to serious complications, including heart failure and arrhythmias
What is Cardiac Catheterization?
An invasive procedure that provides valuable information for the diagnosis and management of patients with cardiac disease
What is the Goal of Cardiac Catheterization?
- Establish of confirm a diagnosis of cardiac dysfunction of heart disease
- Demonstrate the severity of coronary artery disease (CAD) or valvular dysfunction
- Determine guidelines for optimal management of the patient, including medical and surgical management as well as program of exercise
What are the Guidelines for Post-Cardiac Catheterization care?
- Involves 4 to 6 hours of bed rest for femoral access to prevent complications
or - Wrist weight bearing restrictions for 24 to 72 hours if the radial artery is used
What are the PT Considerations for Cardiac Catheterization?
- Patients are usually on bed rest for approximately 4-6 hours when venous access is performed or for 6-8 hours when arterial access is performed
- The extremity that provided access should remaining immobile with a sandbag over the access site to provide constant pressure to reduce the risk of vascular complications. Some hospital use a knee immobilizer as assist with immobilizing
PT interventions should be modified or deferred within the parameters of these precautions. Normal mobility can progress after precautionary period
What is Percutaneous Coronary Intervention (PCI)?
PCI is an umbrella term that encompasses any of the following coronary procedures that are used to treat narrowed or blocked coronary arteries:
- Percutaneous transluminal coronary angioplasty (PTCA) a.k.a. angioplasty
- Stenting
- Atherectomy
Many patients undergo outpatient testing for stenosis or ischemic changes to plan an elective PCI, but those with Acute Coronary Syndrome (ACS), characterized by sudden-onset ischemia leading to unstable angina, may necessitate emergency PCI
What is an Angioplasty and Stenting?
- A catheter with a small balloon at the tip is threaded through the blood vessels to the narrowed or blocked coronary artery. Once in place, the balloon is inflated to compress the plaque against the arterial wall, thereby widening the artery and restoring blood flow.
- Frequently, a stent—a small wire mesh tube—is also inserted to keep the artery open after the procedure
- This treatment is commonly used in cases of CAD and ACS to alleviate symptoms and improve blood flow to the myocardium
What is Atherectomy?
- A catheter typically equipped with a cutting or grinding device is used to remove plaque from a blood vessel.
- There are different types of atherectomy procedures, including rotational, directional, and laser atherectomy, each with its own specific technique for plaque removal.
- The objective is the same as with other PCI procedures: to improve blood flow through the coronary arteries by removing or reducing obstructions caused by plaque buildup
What is a Coronary Artery Bypass Graft (CABG)?
- A blood vessel from another part of the body (i.e., a “graft”) is used to create a “bypass” around the blocked or narrowed section of a coronary artery.
- This allows blood to flow more freely to the heart muscle, alleviating symptoms like angina and reducing the risk of heart attack
- If uncomplicated, the typical length of stay (LOS) after a CABG is about 4-7 days
What is Median Sternotomy?
A technique which involves making a vertical incision down the middle of the chest and then dividing the sternum to provide direct and wide accessto the heart and surrounding structures
What are the Complications of Median Sternotomies?
Bleeding and hematoma formation, chronic pain, arrythmias, post-operative pulmonary complications
(e.g., pneumonia), and sternal dehiscence and infection
What are the Impacts and Restrictions Post-Surgery with a Median Sternotomy?
Impacts:
- Surgery results in systemic effects altering body structure, function, activity levels, and participation in Activities of Daily Living (ADLs)
Restrictions:
- Though variations in restrictions and timelines by surgeons exist, many restrict arm use for 6 to 12 weeks to prevent wound infection or dehiscence. However, the concept of a fixed “amount of load” or “healing time” may be inappropriate, and patients are encouraged to resume load-bearing ADLs at their own pace, following the principle of “Keep Your Move in the Tube”
Why is “Moving In the Tube” important Post-sternotomy?
- Encourages active patient participation in functional tasks and ADLs, based on current evidence of its safety and benefits.
- Based on biomechanical principles the relate to the load on the lever arm of the humerus across different positions
-As weighted and resistive motions move away from the midline, the greater the stress on the sternum. This is movement outside “the tube”. - The implementation of “Keep Your Move in the Tube” should start immediately post-operation, emphasizing consistent messaging from the treatment team
What are the Expected S/S following CABG?
- Pain, discomfort, and some degree of swelling, redness, and drainage at the incision site (chest and possibly leg if a graft was taken from there) is common.
- Feeling tired and weak is common as the body is using a lot of energy to heal.
- Patients may have limited mobility and may need assistance with movement.
- Some degree of fluid retention and swelling, especially in the legs, can occur due to decreased physical activity.
- Shortness of breath, especially if fluid accumulates in the lungs (i.e., due to pleural effusion), is not uncommon.
- Cognitive changes, including memory loss, concentration issues, or other cognitive impairments, is not uncommon within a condition known as “postperfusion syndrome”.
- Mood swings, anxiety, or depression can occur as a response to the stress of surgery and the recovery process
What is Peripheral Arterial Disease (PAD)?
This is caused by an atherosclerotic narrowing of large-
and medium-sized arteries of the lower extremities.
It is a result of the same atherosclerotic processes
that leads to coronary heart/artery disease
With Peripheral Arterial Disease (PAD), when do Sx arise?
Symptoms arise when the atheroma:
- Becomes so enlarged that it interferes with blood flow to the distal tissues
- Ruptures and extrudes its contents into the bloodstream or obstructs the arterial lumen
- Encroaches on the media, causing weakness of that layer and aneurismal dilation of the arterial wall
With Peripheral Arterial Disease, what is Intermittent Claudication?
When the blood flow is not adequate to meet the demand of the peripheral tissues (e.g., during activity) the patient may experience symptoms of ischemia
What are the Signs and Symptoms of Peripheral Arterial Disease?
- Intermittent Claudication
-Resting claudication pain may be seen in
advanced PAD - Skin changes
-Loss of hair
-Loss of temperature
-Dry, Shiny skin
-Thick toenails
-Pale or bluish(cyanotic) appearance - Nonhealing wounds or ulcers
- Plantarflexor atrophy
- Decreased or absent pulses
-Gangrene may be seen in advanced PAD
Subject Gradation of Claudation Discomfort Chart
With PAD, what is a Grade 1 for Claudication Discomfort/Pain?
Initial discomfort (established, but minimal)
Subject Gradation of Claudation Discomfort Chart
With PAD, what is a Grade 2 for Claudication Discomfort/Pain?
Moderate discomfort but attention can be diverted
Subject Gradation of Claudation Discomfort Chart
With PAD, what is a Grade 3 for Claudication Discomfort/Pain?
Intense Pain (attention cannont be diverted)
Subject Gradation of Claudation Discomfort Chart
With PAD, what is a Grade 4 for Claudication Discomfort/Pain?
Excruciating and unbearable pain
How is PAD assessed?
With ABI
- A non-invasive test that compares the BP obtained with a doppler probe of the dorsalis pedis (or post. tib A.) to the BP in the higher of the 2 brachial pressures
With ABI, what does the value 1.00 - 1.4 mean?
Normal
- Adequate Blood supply
With ABI, what does the value > 1.4 mean?
Abnormal, suggest incompressible tibial arteries due to calcification/atherosclerosis, obse lower limbs
With ABI, what does the value 0.90- 0.99 mean?
Borderline Occlusion
Abnormal
With ABI, what does the value 0.80 - 0.90 mean?
Mild disease
- < .90 is diagnostic for PAD
Abnormal
With ABI, what does the value 0.50 - 0.79 mean?
Moderate Disease
- Seek routine specialist referral
Abnormal
With ABI, what does the value ≤ 0.50 mean?
Severe Limb Disease
- Likely will have pain at rest. Seek urgent specialist referral
With ABI, what does the value ≤ 0.20 mean?
- ABIs in this range are associated gangrenous/necrotic extremities.
- Seek urgent specialist referral
How is PAD assessed, as a Functional Assessment?
Individuals with PAD are unable to produce the normal increases in peripheral blood flow essential for enhanced oxygen supply to exercising muscles
- Walking tests such as incremental-ramping treadmill protocols or the 6-minute walk test are the preferred examination modes as they closely approximate actual activity limitations
For Aerobic Exercise, what is the FITT recommendation for PAD?
- F: Minimally 3x / week ; preferably up to 5x / week
- I: Moderate Intensity (40-59 VO2 R) to the point of moderate pain (i.e., 3 out of 4 on the claudication pain scale) or from 50-80% of maximum walking speed
- T: 30-45 min (excluding rest) for a minimum of 12 weeks; may progress to 60 min
- T: Weight bearing (i.e., free or treadmill walking) intermittent exercise with seated rest when moderate pain is reached and resumption when pain is completely alleviated
For Resistance Exercise, what are the FITT recommendations for PAD?
- F: At least 2x / week performed on nonconsecutive days
- I: 60-80% 1RM
- T: 2-3 sets of 8-12 reps ; 6-8 exercises targeting major muscle groups
- T: Whole body focusing on large muscle groups; emphasis on lower limbs if time limited
When the patient with PAD is walking, how far should we push the patient?
Walking should be performed at a safe pace with the intensity of exercise (e.g., incline of a treadmill) that causes the onset of claudication within 3-5 minutes.
- The patient should continue walking until the claudication pain is unbearable and then rest until the claudication resolves. This cycle should continue for the full duration of therapy
With Patients with PAD, what are Exercise Considerations?
Exercising in a non-weightbearing posture is likely not as effective. However, if unable to perform treadmill exercise or if walking duration is so short that benefit is unlikely, consider alternative mode:
-Seated aerobic arm exercise
-Recumbent total body stepping (NuStep)
-Lower extremity cycling
- Exercise at a under a moderate level of claudication symptoms (e.g., at 0 or 1 on scale) may not be as effective but could be considered to increase exercise compliance.
- Longer warm-up times are useful, particularly in colder environments.
- Sensory considerations and foot care should be emphasized due to increased risk of peripheral neuropathy
What is an Aortic Aneurysm?
- A localized, permanent enlargement of the abdominal aorta such that the diameter is greater than 3 cm or more than 50% larger than normal diameter.
- This structural change can compromise the integrity of the aorta to cause serious systemic implications
What is the Pathophysiology behind the Aortic Aneurysm?
It relates to a weakening of the aortic wall due to:
- Build up of plaques
- Structural degradation due to breakdown of elastin and collagen
- Chronic inflammation
What are the S/S that require medical management for Aortic Aneurysms?
- Pulsating Abdominal Mass: Can be a Hallmark, warranting further investigation
- Abdominal and Back Pain: that is severe, sudden in onset and located in the abdomen and back can indicate the rapid expansion of an aneurysm or imminent rupture
- LE Sx
- Signs of Rupture: Sudden, severe pain in the abdomen or back, often described as “tearing” or “ripping,” accompanied by signs of shock (hypotension, rapid heart rate, clammy skin) is a medical emergency indicative of a ruptured aneurysm. This scenario requires urgent diagnostic imaging and surgical intervention to prevent fatal outcomes
With Cardiorespiratory Exercise, What is the %HRR, %HR Max and RPE for Moderate Intensity exercise?
- %HRR: 40-59%
- %HR Max: 64-76%
- RPE: Fairly light to somewhat hard (RPE 12-13)
With Cardiorespiratory Exercise, What is the %HRR, %HR Max and RPE for Vigorous Intensity exercise?
- %HRR: 60-89%
- %HR Max: 77-95%
- RPE: Somewhat hard to very hard (RPE 14-17)
When Creating HR Zone, what is the HRmax Method?
Find the bottom and top ends off the Predicted HR Max (PHRM)
- Basically, PMHR (HRMax%)
For example if we want to do moderate intensity for a patient that is 60 y.o, the range for HR Max is 64-76%
- Assess PHRM: 208 - (0.7 x 60) = 166 PHRM
- Find Zone:
64% of 166 = 106 bpm
76% of 166 = 126 bpm - The person should exercise between 106-126bpm if they want to work at a “moderate” load
When creating HR Zones, what is the Karvonen (HRR) Method?
This considers resting HR
- The equation: [RHR + X% (PMHR - RHR)] and [RHR + Y% (PMHR - RHR)]
- This method is useful when considering the patient with higher resting HRs (e.g., someone with a very poor fitness)
For ex. if the patient is 70 y.o and has a RHR of 90bpm, and we want to do Moderate Intensity (64-76%)
- First get PHRM = 208 - (.7 x 70) = 159
- Then HRR (PMHR-RHR) = 159 - 90 = 69
- Find Zone: (HRmax)
159 (.64) = 101
159 (.76) = 121 - Find Zone: (HRR)
90 + 69 (.40) = 117
90 + 69 (.59) = 130
What is the FITT recommendation for Aerobic (Cardiovascular Endurance) Exercise?
-
F: At least 3x / week,
-For most adults, spreading the exercise session across 3-5 days per week may be the most conductive strategy - I: Moderate Intensity (40-59 HRR) and/or Vigorous (60-89% HRR) intensity is recommended for most adults
-
T: 30-60 min per day (≥ 150 min a week) of moderate intensity; 20-60 min per day (≥ 75 min a week) of vigorous intensity exercise; or a combination of mod and vig daily to atain the targeted volumes of exercise;
-(Also 500-1000 MET-min/week) - T: Aerobic exercise performed in a continuous or intermittent manner that involves major muscle groups is recommended
How can we prevent non-adherence with patient with our exercise programs?
Consider making exercise programs that:
- are more immediately rewarding
- allow for social interaction
- make the connection between the short-term cost and the long-term goal clear
What are the 4 Phases of Cardiac Rehabilitation?
Cardiac rehab begins as soon as the patient is stable and a PT consultation is ordered
- Phase 1: Acute of Hospital Phase
- Phase 2: Early Outpatient or Intensive Monitoring Phase
- Phase 3: Training or Maintenance phase
- Phase 4: Disease Prevention program
With Phase 1 of Cardiac Rehab, what is the Initiation and Main Goals of this phase?
This is Inpatient
- Initiation: Often begins in telemetry unit or bedside in intensive post-surgical/coronary care units.
-
Main Goals:
-Safety assessment: Evaluate safe performance of home activities post-discharge
-Patient education: Increase disease knowledge and management
-Teamwork: Ensure cohesive patient preparation for discharge
Day 1 of rehab for uncomplicated MI, what MET level is the patient doing and what activities? What should you educate the patinet on?
METs: 1-2 METs
Activity: Up in chair assessment, short distance ambulation as tolerated; Bedside commode
Education:
- Explaination of event
- Explaination of PT role
- Assess readiness to learn
- Treatment plan
Day 2-4 of rehab for uncomplicated MI, what MET level is the patient doing and what activities? What should you educate the patinet on?
METs: 2-3 METs
Activity: Walk in hall 5-10 min, 3-4 times/day, assess stairs ; Self care activities
Education:
When walking/stairs
- Safety factors
- Do’s and dont’s for home activity
- Introduce phase 2-secondary prevention
self-care
- Teach S/S
- Nitrogycerin use
- Emergency response to Sx
Phase 1 Cardiac Rehab
What is the FITT Recommendation for Inpatient Cardiac Rehabilitation Programs?
F: 2-4 session/day for the first 3 days of the hospital stay
I: Seated or standing resting HR + 20 bpm for individuals with MI and + 30 bpm for individuals recovering from heart surgery ; Upper limit ≤120 bpm that corresponds to an RPE ≤ 13 on a scale of 6-20
T: Begin with intermittent walking bouts lasting 3-5 min as tolerated ; progressively increase duration. The rest period may be a slower walk (or complete rest) that is shorter than the duration of the exercise bout ; Attempt to achieve a 2:1 exercise/rest ratio ; Progress to 10-15 min of continuous walking
T: Walking. Other aerobic modes are useful in inpatient facilities that have accommodationss
Patients who demonstrate appropriate hemodynamic, ECG, and symptomatic responses to the self-care and ambulation evaluation can have their activity levels increased
What is the FITT Recommendation for Aerobic exercise for those in Outpatient Cardiac Rehabilitation?
F: Minimally 3 days/week; preferably up to 5 days/wk
I: With an exercise test, use 40-80% of exercise capacity using HRR, VO2R or VO2 Peak ; Without an exercise test, use seated or standing resting HR +20 bpm to +30 bpm (OR do your own Exercise test)
T: 20-60 min
T: Arm ergometer, combination of upper and lower (Dual action) extremity cycle ergometer, upright and recumbent cycle ergometer, recumbent stepper, rower, elliptical, stair climber, treadmin
What is the FITT Recommendation for Resistance exercise for those in Outpatient Cardiac Rehabilitation?
F: 2-3 non-consecutive days/wk
I: Perform 10-15 reps of each exercise without significant fatigue; 40-60% of 1RM
T: 1-3 sets ; 8-10 different exercise focused on major muscle groups
T: Select equipment that is safe and comfortable for the individual to use
What is Cardiac Muscle Dysfunction (aka “Heart Failure”)?
Forward output of blood by the heart is insufficient to meet the metabolic needs to the body
- A syndrome with a variety of interrelated pathophysiologic phenomena of which impaired ventricular function is the most important
- Results in a reduction of exercise capacity and other characteristic clinical manifestations
What is Primary Cardiomyopathies?
Generally idiopathic or genetic in nature, involve pathologic processes in the heart muscle itself (often in the mitochondria) which impair the heart’s ability to contract
What is Secondary Cardiomyopathies?
The result of another underlying condition or external factor affecting heart muscle function. Can be classified according to the systemic disease that subsequently affects myocardial contraction (e.g., excessive alcohol consumption can lead to alcoholic cardiomyopathy)
What is Heart Failure Systolic Dysfunction? What are some causes?
(Systolic is when heart contracts)
This is impaired cardiac contractile function
Causes:
- Ischemic Heart disease (MI, Transient/persistent myocardial ischemia)
- Dilated Cardiomyopathy (Idiopathic, viral, genetic, alcohol, etc){over enlarged ventricles, not enough myocardium}
- Valvular Heart Disease (Aortic/Mitral valve stenosis or regurgitation)
What is Heart Failure Diastolic Dysfunction? What are some causes?
(Diastolic is when heart fills)
Impaired filling of the left or right ventricle due to hypertrophy and/or changes in the composition of the myocardium
Causes:
- Left Ventricular Hypertorphy (e.g., as a result of chronically increased afterloads in HTN)
- Restrictive Cardiomyopathy
- Myocardial Fibrosis
- Pericardial Effusion or Tamponade
With Hear Failure, what is the difference between HFrEF and HFpEF?
Due to significant overlap between systolic and diastolic dysfunction (i.e. many patients with HF suffer from both), it is common to categorize patients into having either:
- Heart Failure with reduced ejection fraction (HFrEF)
-< 40% EF
- Heart Failure with preserved ejection fraction (HFpEF)
-> 50% EF
This type of categorization is:
- useful, in part, because of the widespread availability of methods to measure LVEF (e.g., echocardiography)
- used as a variable in many clinical HF trials
- useful within medical management of individuals with HF
EF = Systolic / End-Diastolic volume (review)
What is Dilated Cardiomyopathy?
This is when the ventricals of the heart are enlarged, without hypertrophy. However there is not enough muscular capacity to pump out the blood, decreases cardiac output
Inotropic meds are used with this to increase contractility
What is Hypertrophic Cardiomyopathy?
When the walls of the Ventricles thicken and become stiff. CO will decease, because there is impaired filling and contractility and there is less blood supply. Arrythmias may present with this as well
What is Restrictive Cardiomyopathy?
When the walls of the ventricles become stiff, but not nessessarily thickened; this will affect systoli and diastoli
When there is a decrease in CO, why is there activation of the sympathetic nervous system and renin-angiotensin system?
In order to:
- Increase myocardial contractility and HR
- Produce arterial vasoconstriction (to help maintain arterial pressure)
- Produce venous constriction (to increase venous pressure)
- Increase blood volume (to increase preload/ventricular filling)
With Decreased CO, what is the affect of Increased activity in the Sympathetic Nervous System? What may happen over time?
This will stimulate myocardial contractility, HR, and arterial/venous tone which results in an increase in central blood volume which serves to further elevate pre-load (to attempt to elevate CO).
- Over time though, the heart becomes insensitive to B-adrenergic stimulation, which results in a decreased force of myocardial contraction and an inability to attain higher heart rates during physical exertion
What commonly causes Left-Sided Heart Failure?
- CAD with ischemic LV damage (i.e., acute MI)
- Chronic HTN
- Dilated Cardiomyopathy
- Valvular hear disease with its pressure and/or volume overloading the heart
What commonly causes Right-Sided Heart Failure?
- Left-sided heart failure where there is an uncompensated left ventricular pressure that leads
to elevated pulmonary vascular pressures and then stress onto the right-ventricle
-This is considered “Biventricular Failure” - Diseases of the lung parenchyma or pulmonary vasculature (e.g. COPD, interstitial lung diseases, lung infection, pulmonary embolism)
-When right-sided heart failure is resultant of pulmonary processes, it is known as cor pulmonale
What is Orthopnea?
Sensation of dyspnea or observation of labored breathing while lying flat which is relieved by sitting up
What is Paroxysmal Nocturnal Dyspnea?
Severe breathlessness that awakens the patient from sleep 1-3 hours after lying down
Extra Heart Sounds
What does a S3 Heart Sound (aka Ventricular Gallop) indicate?
- Indicates a very compliant left ventricle. Thought to occur as blood passively fills a quickly distending left ventricle that makes contact with the chest wall during early diastole.
- May be normal (“physiologic S3”), particularly in young people, but in the presence of other indicators of heart disease, it is one of the most sensitive indicators of significant ventricular dysfunction
Extra Heart Sounds
What does a S4 Heart Sound (aka Atrial Gallop) indicate?
- Represents “vibrations of the ventricular wall during the rapid influx of blood during atrial contraction” from an exaggerated atrial contraction. It is found in diseases with ventricles so thick to require a strong atrial contraction. As it is related to atrial systole, this sound is appreciated in late diastole.
- Unlike S3, this extra heart sound is almost always abnormal.
What is Jugular Venous Pressure/Distension an indication of?
An indication of increased volume in the venous system and may be an early sign of right-sided heart failure
What are Sx of Left heart Failure?
Breathing Signs
- Dyspnea and increased WOB
- Orthopnea
- Paroxysmal Noctornal Dyspnea (PND)
What are the Physical Findins of Left Heart Failure?
- Diaphoresis
- Tachycardia/Tachypnea
- Pulmonary Rales
- S3/S3 (extra) heart sounds
What are Physical Findings of Right heart Failure?
- Jugular Venous Distension
- Peripheral Edema
What are Sx of Right heart Failure?
systemic signs
- Anorexia
- Right Upper Quadrant Discomfort (because of hepatic enlargement)
What is Heart Failure Exacerbation/Decompensation?
The presence of new or worsening signs/symptoms of dyspnea, fatigue, or edema that lead to hospitalization or unscheduled medical care (doctor visits or emergency department visits)
- This Typically requires hospitalization
What happens if the A-line is dislodged? What are major comlications associated with arterial lines?
- If A-Line is dislodged, apply firm pressure and immediately notify RN
- Major complications are:
-Bleeding
-Infection
-Lack of blood flow to the tissue supplied by the artery
Valvular Approach
With Median Sternotomy, what valves are accessed through this?
This is for the Aortic, Mitral or Tricuspid valve
Also used for Coronary Bypasss
Valvular Approach
With Upper Hemi-Sternotomy, what valves are accessed through this?
Aortic valve
Also used for Coronary Bypasss
Valvular Approach
With Right Anterior Thoracotomy, what valves are accessed through this?
Mitral or Tricuspid
Also used for Coronary Bypasss
Valvular Approach
With Lower Hemi-Sternotomy, what valves are accessed through this?
Mitral or Tricuspid
Also used for Coronary Bypasss
(FITT recommendations)
What is the ACSM guideline for Aerobic Exercise for Individuals with Heart Failure?
F: Minimally 3 days per week; preferably up to 5 days per week
I: Start at 40 to 50% and progress to 70-80% VO2 reserve (HRR)
T: Progressively increase to 20-60min a day
T: Aerobic exercise: focusing on treadmill or free-walking and stationary cycling as capable
(FITT recommendations)
What is the ACSM guideline for Resistance Exercise for Individuals with Heart Failure?
F: 1-2 nonconsecutive days
I: Begin at 40% 1RM for Upper Body and 50% 1RM for Lower Body. Gradually increase to 70% 1RM over several weeks to months
T: 1-2 sets of 10-15 reps focusing on major muscles
T: Weight machines, dumbells, elastic bands and/or body weight can be used
What is Decompensition?
New or worsening of Sx of Dyspnea, fatigue or edema that leads to hospitalization or unscheduled medical care (doctor visits or emergency department visits)
What is Absolute Stability?
Involves the appreciation of the absolute indicators of decompensation that need to be assessed and documented in their own right.
What is Relative Stability?
This considers whether the patient is on a stable temporal trajectoryand the relative changes in hemodynamic parameters over time. In other words, relative stability considers alterations that occur on a day-to-day or visit-to-visit basis relative to the patient’s baseline.
The patient presents to the clinic with 78/40 mmHg, a heart rate of 110 bpm at rest, respiratory rate of 34 breaths per minute, oxygen saturation of 86% on room air, and bilateral
rales heard on auscultation. They report difficulty breathing even while sitting still. Is this an example of Absolute or Relative Stability at Rest?
Absolute Relative Stability
- This patient is not absolutely stable at rest, as their vital signs and symptoms at this visit show acute decompensation that is not evaluated based on previous sessions. These signs and symptoms are serious on their own, regardless of his historical readings or conditions. This patient’s condition is critical, warranting immediate MD consultation and an emergency visit
to address acute decompensation and potential respiratory distress
The patient has a typical resting blood pressure in the 140s/80s mmHg and often reports fatigue. Today, the patients blood pressure is 102/68 mmHg and reports significantly more
fatigue than usual. Is this an example of Absolute or Relative Stability at rest?
Relative Stability at rest
- This patient appears relatively unstable at rest, as there is a negative change over time from one visit to the next, relative to their individual baseline, even though their BP is considered WNL. The patient may not require an emergency visit but likely benefits from an MD consult
The patient begins a supervised exercise program. During the initial session, they exhibits signs of exercise intolerance including severe shortness of breath, chest pain, and a drop in
blood pressure with minimal exertion. Is this an example of Absolute or Relative stability with exercise?
Absolute Stability with Exercise
- The patient’s response to exercise is concerning irrespective of his previous capacity or sessions. Due to the acute and severe nature of the symptoms, the exercise should be stopped immediately, the intensity of future sessions should be reconsidered, and the patient may require an urgent medical consultation if their clinical status doesn’t improve
with rest
The patient has been participating in a cardiac rehabilitation program. Initially, they could tolerate 10 minutes on the treadmill at a moderate pace. Over the past few sessions,
they’ve only been able to manage 5 minutes before becoming excessively fatigued. Is this an example of Absolute or Relative stability with exercise?
Relative Stability with Exercise
Despite being stable in the short term, they show a decline in exercise tolerance across sessions, indicating they are not relatively stable with exercise. The exercise prescription
should be reassessed, potentially reduced, and the patient should consult with their physician to address the decline in her exercise capacity.
WIth the assessment of Stability, what will the patient Self-Assess with “Red”? What do we do?
Patient Self-Assesses:
- Difficulty breathing even at rest
- Unrelieved SOB
- Wheezing, chest pain or chest discomfort
- Feeling faint
- Confusion
What to do:
- Call physician immediately or immediate visit to the emergency department
WIth the assessment of Stability, what will the patient Self-Assess with “Yellow”? What do we do?
Patient Self-Assesses:
- Weight Gain > 2lbs in 1 day or 5lbs in one week
- Increase swelling
- Increase cough
- Increase in SOB with activity
- Increase in the number of pillows needed
What to do:
- Communicate with physician as the patient may need adjustment to medication
WIth the assessment of Stability, what will the patient Self-Assess with “Green”? What do we do?
Patient Self-Assesses:
- No SOB
- No weight gain
- No swelling
- No chest pain
- No decreased in ability to maintain activity level
What to do:
- Proceed with interventions, exercises, and activity as planned
With the Assessment of Stability, if the patient self-assesses as “Yellow” what should happen next?
A physical exam takes place,
-We assess Pulmonary Crackles, S3 auscultations, and JVD
- If the patient does not have any of these,
-This may indicate need for an adjustment in meds and therefore warrents communication with the physician - If they do have these,
-Overt decompensation: an immediate visit to the ED or call physician office immediately
With the Assessment of Stability, if the patient self-assesses as “Red” what should happen next?
Overt decompensation: an immediate visit to the ED or call physician office immediately
MUST KNOW
In the CPG, what is Action Statement 2?
Educate on and Facilitate Components of Chronic disease management
- PTs MUST make appropriate nutrition referrals, perform medication reconciliation and provide appropriate education on preventative self-care behaviors to reduce risk of hospital readmissions
- These include:
-Daily weight measurement to identify increases greater than 2 to 3 lbs in 24 hrs or 5 lbs over 3 days
-Recognition of S/S of an exacerbation
-Action plan with Red/Yellow/Green CHF tool
-Following nutrition plan
-Medication management/medication reconciliation
If you are doing an Assessment of Stability at Rest with a patient (vitals, Sx of decompensation {red, yellow, green zones}, signs of decompensation, what would happen if they DO have Absolute and Relative stability at Rest?
Continue and assess Stability with Exercise
-Vitals with exercise
-Recovery time
-S/S of Exercise tolerance
If you are doing an Assessment of Stability at Rest with a patient (vitals, Sx of decompensation {red, yellow, green zones}, signs of decompensation, what would happen if they DO NOT have Absolute and Relative stability at rest?
MD consult Emergency Visit
After you do the Assessment of Stability with Exercise, what would happen if they DO have Absolute and Relative Stability with Exercise?
Increase the intensity/Dose of Exercise
After you do the Assessment of Stability with Exercise, what would happen if they Do Not have Absolute and Relative Stability with Exercise?
Reduce intensity/Dose of exercise and/or MD consult Emergency Visit
What is Absolute Stability with Exercise?
The absolute degree of change in hemodynamic parameters including but not limitied to a drop in BP or rapid increase in HR that might occur with exercise
What is Relative Stability with Exercise?
The relative changes in exerices response that occur at the same intensity of exercise from one visit to the next
MUST KNOW
In the CPG, what is Action Statement 3?
Prescribe Aerobic Exercise Training
PTs MUST prescribe aerobic exercise training for patients with Stable, NYHA class 2 to 3 HF using the following parameters:
- Time: 20-60 min
- Intensity: 50-90% of Peak VO2 or Peak work
- Frequency: 3 to 5 x a week
- Mode: Treadmill or cycle ergometer or dancing
Total energy expenditure during the program was the most important determinant of improvement in peak VO2
What should a PT do if Maximal Exercise Testing is not feasible due to lack of expertise, monitoring or safety equipment?
Utilize submax exercise testing to determine a baseline for cardiopulmonary fitness
MUST KNOW
In the CPG, what is Action Statement 4?
Prescribe High-Intensity Interval Exercise Training in Selected Patients
PTs SHOULD prescibe high intensity interval-based exercise (HIIT) for patients with stable, NYHA Class 2 to 3 HFrEF using the following parameters:
- Time: >35 total minutes of 1 to 5 minutes of high-intensity (>90%) alternating with 1 to 5 minutes at 40% to 70% active rest intervals, with rest intervals shorter than the work intervals
- Intensity: >90 of peak VO2 or peak work.
- Frequency: 2 to 3 times per week.
- Duration: at least 8 to 12 weeks.
- Mode: treadmill or cycle ergometer
Shorter HITT sessions may allow for the greatest long-term adherence
MUST KNOW
In the CPG, what is Action Statement 5?
Prescribe Resistance Training
Physical therapists SHOULD prescribe resistance training for the upper and lower body major muscle groups for
patients with stable, NYHA Class I to III HFrEF using the
following parameters:
- Time: 45 to 60 minutes per session.
- Intensity: 60% to 80% 1RM, 2 to 3 sets per muscle group.
- Frequency: 3 times per week.
- Duration: at least 8 to 12 weeks
Resistance training can be especially effective in patients that do not tolerate continuous or interval aerobic training or other therapeutic modalities. Accommodating patient preference for mode of exercise may increase patient adherence, and thus resistance training should be offered as an option
What is Ventilation?
This refers to the delivery system that presents oxygen‐rich air to the alveoli and removes CO2 from the blood/alveoli
What are the Clinical Signs that can be use to evaluate the adequacy of ventilation at bedside?
Chest Rise and Respiratory Rate
With ventilation, what is CO2 levels affected by?
CO2 levels are mainly affected by Minute Ventilation which can be described as the amount of air that ventilated per breath (tidal volume) and the rate of breathing (TIDAL VOLUME x RESPIRATORY RATE)
What is Oxygenation?
The patient’s ability to take in oxygen from the alveoli and distribute it to the tissues and organs of the body to maintain cellular activity.
What is Pleural Effusion?
This refers to an excess of pleural fluid in the pleural cavity caused by damage to pleura (e.g., by trauma, infection,
malignancy) or when there is either excessive production
of pleural fluid or the resorption capacity is reduced (e.g., lymphatic obstruction)
What can the pleural space be filled with?
- Hemothorax (blood)
- Empyema (pus)
- Air (Pneumothorax)
Is the pleural space continuous with the airways?
The pleural space is NOT continuous with the airways
What can the Functioning of the Diaphragm be affected by?
- Weakness and/or fatigue (e.g., after invasive ventilatory support)
- Hyperinflation
- Paralysis or Hemi-paralysis
- Medical procedure (e.g., surgical pain
What is the role of the Bronchial Smooth Muscle?
This is under Autonomic nervous system:
- It increases in parasympathetic outflow that causes bronchoconstriction
- It increases in sympathetic stimulation that causes bronchodilation
With Gas Exchange, What are Type 1 Pneumocytes?
These are thin, flat cells which allow gas exchange between the alveolus and capillaries
With Gas Exchange, What are Type 2 Pneumocytes?
These secrete surfactant to prevent the collapse of the alveolus and to prevent the inner walls from sticking together
What is Total Lung Capacity (TLC)?
The volume in the lungs at
maximal inflation, the sum of VC and RV
What is Tidal Volume (TV)?
That volume of air
moved into or out of the lungs during quiet breathing
What is Residual Volume (RV)?
The volume of air remaining in
the lungs after a maximal exhalation
What is Vital Capacity (VC)?
The volume of air breathed out after the deepest inhalation. Also called “Forced” Vital Capacity during Pulmonary Function Testing.
What is Forced Expiratory Volume in 1 Seconds (FEV1)?
Volume of air that is exhaled during the 1st second of
the FVC and reflects airflow of the large airways
What is Compliance?
This refers to the ease with which the lungs can expand during inhalation
Some diseases change the lung’s compliance which negatively affects respiratory mechanics and gas exchange
What is Ventilation-Perfusion (V/Q) Matching?
This describes the relationship between the amount of air reaching the alveoli (ventilation) and the amount of blood passing by the alveoli in the pulmonary capillaries (perfusion)
What is the Difference between Shunt and Dead Space?
- Shunt is when blood bypasses the alveoli without gas exchange
- Dead Space is when the areas of the lungs are ventilated but not perfused with blood
Why is patient positioning important to those with respiratory problems?
A patients position can help a optimize gas exchange in the lungs
Why would Upright positions be beneficial to patients with respiratory problems?
These positions can be beneficial, especially in patients with conditions like COPD by improving diaphragmatic movement and reducing the work of breathing. Upright positioning can enhance ventilation to the lung bases, improving the V/Q match in these areas, which are more heavily perfused due to gravity
Why would Mobility be beneficial to patients with respiratory problems?
Mobilizing the patient as much as possible can also assist
in improving V/Q matching. It promotes lung expansion, secretion clearance, and enhances overall lung function
Why would Postural Drainage Positions be beneficial to patients with respiratory problems?
These positions can help mobilize secretions from specific lobes or segments of the lungs, enhancing ventilation to these areas and consequently improving V/Q matching. For example, in patients with bronchiectasis or cystic fibrosis where mucus accumulation is a significant issue, postural drainage positions can facilitate mucus clearance, improve ventilation, and thus enhance V/Q matching.
What are the Cardinal Signs of Bronchospasm?
The cardinal signs of bronchospasm include wheezing, a high-pitched whistling sound during exhalation, and dyspnea. Individuals often experience chest tightness and persistent coughing as reflex responses to airway irritation. Visible use of accessory muscles and prolonged expiration reflect the increased effort to breathe due to narrowed airways
What is Pulmonary Consolidation?
A region of normally compressible lung tissue that has filled with liquid instead of air. Consolidation occurs through accumulation of infiltrates in the alveoli and adjoining ducts which can be made up of:
- white blood cells (e.g., pus)
- inhaled fluid (e.g., water)
- blood (from bronchial tree or hemorrhage from a pulmonary artery)
What is Pleural Effusion?
Fluid in the pleural space, caused by various conditions including heart failure and infections, presenting with fluid collections at the lung bases and symptoms like dyspnea
and pleuritic chest pain
What is Pulmonary Edema? What causes this?
Fluid within the alveoli and interstitium (spaces between the alveoli and the capillaries), often due to heart failure (cardiogenic), where increased pressure in the pulmonary capillaries causes fluid to leak out. Non-cardiogenic causes include acute respiratory distress syndrome (ARDS), where increased permeability of the alveolar-capillary barrier allows fluid to enter the alveoli
What is Atelectasis?
A pathological collapse or incomplete expansion of lung tissue, resulting in partial or complete loss of lung volume due to alveolar airspace closure
Atelectasis can also happen when a person takes small, shallow breaths, which can happen due to pain, sedatives, or prolonged bed rest. Over time, this inadequate lung expansion can cause parts of the lung to collapse.
What is Obstructive Atelectasis?
A consequence of blockage of an airway. Air retained distal to the occlusion is resorbed from nonventilated alveoli, causing the affected regions to become totally gasless and then collapse
With Non-obstructive Atelectasis, what is Relaxation (i.e., Passive) Atelectasis?
This ensues when contact between the parietal and visceral pleurae is eliminated (e.g., as within pleural effusion or pneumothorax)
With Non-obstructive Atelectasis, what is Compressive Atelectasis?
This occurs when a space occupying lesion of the thorax (e.g., pleural effusion or solid mass of the chest wall, pleura, or parenchyma) presses on the lung and causes the lung volume to diminish to less than the usual resting volume (i.e., the functional residual capacity)
With Non-obstructive Atelectasis, what is Adhesive Atelectasis?
When there is a surfactant deficiency and there is a greater tendency of the alveoli to collapse. Conditions include Acute Respiratory Distress Syndrome (ARDS), Pulmonary Embolus and Pneumonia
With those patients that have Atelectasis and are Post-op or Bed Ridden, what does treatment/management include?
Post-op or bed ridden patients can respond to interventions like deep breathing, incentive spirometry, and coughing. Prevention should be goal for all hospitalization patients.
How does the body attempt to correct hypoexemia (low levels of O2) and Hypercapnia (High levels of CO2)?
By increasing tidal volume (TV) and respiratory rate (RR). Together, TV (mL/cycle) x RR (cycles/min) = Minute Ventilation (mL / min)
With a respiratory exam, what is the normal repsonse to activity?
Hyperpnea (increased depth of breathing) followed by increases to RR
What is Tachypnea?
> 20 cycles/min
- Poor specificity but usually suggests moderate-to-severe cardiorespiratory disease that is triggering a compensatory increase in ventilation effort/work of breathing
- Has better sensitivity such that its absence challenges the differential diagnosis of significant
cardiorespiratory dysfunction
What is Apnea? What are the causes?
This is the cessation of breathing
Caused:
- Drug-induced
- CNS dysfunction
- obstructive sleep apnea
What is the Difference between Hyperventilation vs Hypoventilation?
-
Hyperventilation: Increased rate and/or depth of ventilation where the body eliminates more carbon dioxide than is being produced.
Common causes:
-Metabolic Acidosis w/ Kussmaul’s breathing:
-Anxiety, Fear -
Hypoventilation: Decreased rate and/or depth of breathing which leads to increased concentration of CO2 and eventual hypoxia
-Sedation, somnolence, neurologic depression of respiratory centers, metabolic alkalosis
What is Paradoxical Breathing? What are the causes of this?
Inward abdominal or chest wall movement within inspiration and outward movement with expiration.
This Generally follows orthopneic pattern
-Laying supine exacerbates diaphragmatic weakness due to abdominal contents applying a greater pressure onto it
in the supine position
Causes:
- Diaphragmatic fatigue (e.g., as seen in severe COPD), trauma, or respiratory muscle weakness due to neurologic dysfunction:
-Trauma to chest wall (i.e., flail chest)
-Neurogenic vs Non-neurogenic
What is Chyne-Stokes?
Periodic breathing pattern where each cycle has near-constant repsiratory rate but variable depth
- In CHF, it is due to poor cardiac output and carries a poor prognosis
- Can be seen in various CNS disorders that can increase sensitivity of the repsiratory centers to CO2
What does a Pulse Oximetry do?
Calculates the degree of oxyhemoglobin saturation based on the intensity of transmitted light. SpO2 has a normal range of 98-100%
Accuracy of SpO2 readings should be challenged when SpO2 decreases at rest or with activity if the heartrate (HR) and the respiratory rate (RR) aren’t rising. When SpO2 decreases, the HR and RR should both rise.
During the Respiratory Exam, what are the areas that we measure with the Tape-Measure? Why choose to examine with a tape measure?
- At Axilla - upper chest/lobes
- At Xiphoid - Middle chest/Lobe/Lingula
- Halfway between Xiphoid and Umbilicus - Lower chest/Lobes
Why a tape measurer?
- Increases objectivity
- Repeatable with better precision
- Good for goal setting
Adventitious Sounds
What are Wheezes?
Continuous, most frequently heard on exhalation and are associated with airway narrowing or obstruction
- Example: bronchospasm
Adventitious Sounds
What are Rhonchi?
Mostly defined as continuous, snoring sound
- Example: Large airway obstruction (e.g., secretions). Can often be cleared with cough.
Adventitious Sounds
What are Crackles (aka Rales)?
Discontinuous, mostly during inspiration
Adventitious Sounds
What are Pleural Rub?
Raspy breathing sound - “like to pieces of leather being rubbed together” - heard through inspiration and expiration
- Example: Pleuritis, pleural effusion
This pic represents the Oxyhemoglobin Dissociation Curve, what is the relationship between SaO2 and pO2?
SaO2 = Hemoglobin saturation
PaO2 = Partial Pressure of Oxygen
This is a Sigmoidal Curve
- Normally there is a drop of 5
- This means that small changes in PaO2 can lead to large changes in SaO2 at certain points on the curve
- Typically after 60 PaO2, there is a steep drop off of SaO2
When PaO2 is < 60 mmHG what does this mean?
< 60 is the standard threshold for defining the Hypoxemia seen in Respiratory Failure
Can Oxygen Saturation Measurement be a replacement for RR Measurement?
No, pulse oxymetry monitors the amount of oxygen saturation which can be normal as the body compensates by changing the RR to maintain oxygenation within early stages of a patient’s health deterioration
With Breathing sounds, what is the Quality, I:E Ration and Location of Tracheal Sounds?
(I:E = Inspiration:Experation)
- Quality: Harsh; High-Pitched
- I:E Ratio: I=E
- Location: Above supraclavicular notch, over the trachea
With Breathing sounds, what is the Quality, I:E Ration and Location of Vesicular Sounds?
(I:E = Inspiration:Experation)
- Quality: Soft, low pitched
- I:E Ratio: I > E
- Location: Remainder of lungs
These are “normal” breath sounds throughout the lung fields
With Breathing sounds, what is the Quality, I:E Ration and Location of Brachial Sounds?
(I:E = Inspiration:Experation)
- Quality: Loud; High-Pitched
- I:E Ratio: I < E
- Location: Just above clavicles on each side of the sternum, over the manubrium
If we hear Tracheal, Broncovesicular or bronchial sounds distally to normal, what should we expect?
We should expect replacement of air-filled lung by fluid filled or consolidated lung tissue
With Transmitted Voice Sounds, what is Egophony?
E to A changes in periphery
With Transmitted Voice Sounds, what is Bronchophony?
When spoken words may or may not become intelligible but the sound becomes louder
With Transmitted Voice Sounds, what is Whispering Pectoriloquy?
When words become clear and intelligible
When doing Mediate Percussion on a patient, what do Normal/Resonant sounds mean?
The tissue is rich in air and poor in solid/fluid
When doing Mediate Percussion on a patient, what do Dull/Flat sounds mean? What cases may we hear this in?
The tissue ratio between air and fluid/solid is low
- Hear with patients with:
-Pneumonia (Alveolia are filled w/ fluid and blood cells)
-Pleural Effusion (Serous fluid in pleural space)
-Hemothorax (Blood in pleural space)
-Abnormal Tissue (Fibrous, tumor)
When doing Mediate Percussion on a patient, what do Hyperresonant sounds mean? What cases may we hear this in?
The Air is more abundant than normal
- Hear with patients with:
-Pneumothorax (Air in pleural space: uni- or bi-lateral)
-Lung Hyperinflation (e.g., with COPD, asthma)
What does it mean when the contents of the thorax shifts Toward the affected side?
This happens when the lung volume or intrathoracic pressure on that side is decreased. This can happen after a lobectomy or pneumonectomy or a large degree of atelectasis
- When the shift goes to the affected side in the patient after a lobectomy or pneumonectomy, the patient should be cautioned against lying on the affected side because this would only increase the mediastinal shift
What does it mean when the contents of the thorax shifts to the unaffected side?
When there is increased pressure on the same side, as happens in a pleural effusion, a tumor, or an untreated pneuomothorax
How do we palpate for a Tracheal Shift?
Palpation proceeds with the tip of the index finger being placed in the suprasternal notch, first medially to the left sternoclavicular joint and pushed inward toward the cervical spine. Then the index finger is placed medial to the right sternoclavicular joint and pushed inward toward the cervical spine
What does it mean when there is a Significant shift to the unaffected side? What happens if the shift is caused by Pneumothorax or a Pleural Effusion?
Aggressive Treatment is usually indicated
- If the shift is caused by a pneumothorax, a chest tube is usually inserted immediately. In the case of the large pleural effusion, a thoracentesis may be performed to drain the fluid or to evaluate the contents of the fluid or both
What does it mean when there is a tracheal shift to the Affected side after a lobectomy or pneumoectomy?
The patient should be cautioned against
lying on the affected side because this would only increase the mediastinal shift
With Breathing sounds, what is the Quality, I:E Ration and Location of Bronchovesicular Sounds?
- Quality: Medium in loudness and pitch
- I:E Ratio: I = E
- Location: Next to the sternum, between scapulae
With the Segments circled in black, what part of the lungs are being Auscultated?
Anterior Segments of the Upper Lobes (R side)
(1 ,2, 3 Intercostal space)
With the Segments circled in black on the R side, what part of the lungs are being Auscultated?
Right Middle Lobe (Spaces 4 and 5)
With the Segments circled in black, what part of the lungs are being Auscultated?
Anterior Basal Segments of the Lower Lobe (6th Intercostal space)
With the Segments circled in black on the L side, what part of the lungs are being Auscultated?
Lingula (4th and 5th intercostal space)
With the Segments circled in black, what part of the lungs are being Auscultated?
Posterior Basal Segments of the Lower Lobs
(T10-T12)
With the Segments circled in black, what part of the lungs are being Auscultated?
Lateral Basal Segments of the Lower Lobe
(Lateral to Inferior Lobe)
With the Segments circled in black, what part of the lungs are being Auscultated?
Superior Basal Segments of the Lower Lobes
(Medial to Inferior Angle)
With the Segments circled in black, what part of the lungs are being Auscultated?
Posterior Segments of the Upper Lobe
(Root of the spine of Scap)
With the Segments circled in black, what part of the lungs are being Auscultated?
Posterior Apical Segments of the Upper Lobe
What is Hypoxemia?
When the partial pressure of oxygen in arterial blood (PaO2) falls below ~55-60 mmHG
- A subsequent increase in minute ventilation occurs as well as a decrease in partial pressure of Carbon Dioxide (PaCO2). This results in a compensatory rise in HR/CO to increase O2 delivery to tissues
What are the S/S of Hypoxemia?
- Impaired judgement
- Progressive loss of cognitive and motor functions as the hypoxemia progresses
- Decreased exercise tolerance
- Loss of consciousness develops with severe hypoxemia
- Other S/S include headache, breathlessness, or severe dyspnea, palpitations, angina, restlessness and tremors
What will Long-Term Hypoxemia lead to?
Pulmonary Hypertension, Increasing the work on the Right Side of the heart, leading to Right Heart dysfunction and subsequently failure (cor pulmonale)
When is Supplemental O2 therapy indicated?
- PaO2 < 55 mmHG or SaO2/SpO2 < 88% on room air
or
- PaO2 56-59 or SaO2/SpO2 89-90% with one or more:
-Pulmonary Hypertension
-Cor Pulmonary or Edema due to heart failure
-Hematocrit >56%
Supplemental O2 Therapy Algorithm
If you are monitoring a patients SpO2 and you notice that its ≥ 90%, what should you, the PT do?
Monitor and continue plan of care
Supplemental O2 Therapy Algorithm
If you are monitoring a patients SpO2 and you notice that its NOT ≥ 90%, what should you, the PT do?
Decrease/Stop activity, Position change, deep breathing, pursed-lips breathing, coughing
Supplemental O2 Therapy Algorithm
When monitoring your patients SpO2, you notice that its NOT ≥ 90%, so you Decrease/Stop activity, Position change, deep breathing, pursed-lips breathing, coughing. After, you re-assess and you notice that their SpO2 is ≥ 90%. What should you do?
Monitor and continue plan of care
When monitoring your patients SpO2, you notice that its NOT ≥ 90%, so you Decrease/Stop activity, Position change, deep breathing, pursed-lips breathing, coughing. After, you re-assess and you notice that their SpO2 is still not ≥ 90%. However you notice that the patient is on O2 and the MD ordered to Titrate O2. What should you do?
- Adjust the flow as needed
- Change O2 delivery method
When monitoring your patients SpO2, you notice that its NOT ≥ 90%, so you Decrease/Stop activity, Position change, deep breathing, pursed-lips breathing, coughing. After, you re-assess and you notice that their SpO2 is still not ≥ 90%. The patient is NOT on O2 and you do not have an MD order to titrate after consulting the MD and they did not revise the order. What should you do?
If the Consult MD for revised order was denied, decrease activity level
- If the SpO2 IS ≥ 90%, monitor and continue plan of care
- If the SpO2 IS NOT ≥ 90%, stop activity and discuss with MD
What is FiO2? What is the equation for this?
This is Fraction of Inspired air, this represents the percentage of oxygen in atmospheric air
- FiO2 = (Flow Rate x 0.04) + 0.20
What is the General Information do we need to know about Nasal Cannula (NC)?
- Delivers flows from 0.25 to 6 L/min
- Generally recommended low flow NCs NOT used for flows > 6 L/min due to patient discomfort
What is the General Information do we need to know about High Flow Nasal Cannula?
- Best for patients needing > 6 L/min
- More comfortable, can eat/drink/talk easier than with mask
What is the General Information do we need to know about Simple Face Mask?
Covers mouth and nose, useful for patients unable to breath through nose
What is the General Information do we need to know about Venturi System?
- O2 system providing more specific O2 concentration than other devices
- Easy system for mobilizing patients
- Can provide O2 via face mask or tracheostomy tube
What is the General Information do we need to know about Non-rebreather Mask?
- Mask with O2 reservoir (bag) providing higher FiO2
- Advantage: Requires a lower flow of FiO2 from the tank for the FiO2 needed
What is the General Information do we need to know about Ambo Bag?
- Can be used to manually ventilate patients during ambulation when a portable ventilator is not available, give supplemental O2 for suctioning etc.
- For mobility, atracheostomy swivel connector with expandable tubing should be used to prevent extubation
With the Nasal Cannula, based on the O2 Tank Flow, what is the Approximate FiO2?
O2 Tank Flow - Approx FiO2
1 L/min - 0.24
2 L/min - 0.28
3 L/min - 0.32
4 L/min - 0.36
5 L/min - 0.40
6 L/min - 0.44
FiO2 goes up by 0.04; Maxes at 0.44
With the High Flow Nasal Cannula, what is the Approximate FiO2?
Highest % O2 is up to 0.75 FiO2 at 15 L/min
With the Simple Face Mask, what is the Approximate FiO2?
O2 Tank Flow - Approx FiO2
6 - 10 L/min - 0.35-0.50 (can vary)
With the Venturi System, what is the Approximate FiO2?
O2 Tank Flow
- Turn dial and provide O2 as stated on dial for need FiO2
Approx FiO2
- 0.24 - 0.50
With the Non-Rebreather Mask, what is the Approximate FiO2?
O2 Tak Flow - Approx FiO2
6 L/min - 0.60
7 L/min - 0.70
8-10 L/min - 0.80+
With the Ambo Bag, what is the Approximate FiO2?
Up to 1.00 FiO2
What is the Dean’s Hierachy for Treatment of Patients with Impaired Oxygen Transport?
The premis: The Position of Optial Physiologic function is Upright and moving
1. Mobilizaton and Exercise
2. Body Positioning
3. Breathing control maneuvers
4. Coughing maneuvers
5. Relaxation and energy Interventions
6. ROM exercises (Cardiopulmonary indications)
7. Postural drainage positioning
8. Manual Techniques
9. Suctioning
With Dean’s Hierachy for Treatment of Patients with Impaired Oxygen Transport, what is the goal of Mobilization and Exercise?
To elicit an exercise stimulus that addresses one of the three effects on the various steps in the oxygen transport pathway or some combination
Mobilizations and exercise, reduces stress on the pulmonary system during mobility and exercise
With Dean’s Hierachy for Treatment of Patients with Impaired Oxygen Transport, what is the goal of Body Position?
To elicit a gravitational stimulus that stimulates being upright and moving as much as possible: Active, active-assist, passive
With Dean’s Hierachy for Treatment of Patients with Impaired Oxygen Transport, what is the goal of Breathing Control Maneuvers?
To augment alveolar ventilation, to facilitate mucociliary transport, and to stimulate coughing
With Dean’s Hierachy for Treatment of Patients with Impaired Oxygen Transport, what is the goal of Relaxation and Energy-Conversation intervention?
To minimize the work of breathing and of the heart and to minimize undue oxygen demand
With Dean’s Hierachy for Treatment of Patients with Impaired Oxygen Transport, what is the goal of ROM exercise?
To stimulate alveolar ventilation and altre its distrubution
With Dean’s Hierachy for Treatment of Patients with Impaired Oxygen Transport, what is the goal of Postural Drainage position?
To facilitate airway clearance using gravitational effects
With Dean’s Hierachy for Treatment of Patients with Impaired Oxygen Transport, what is the goal of Manual Techniques?
To facilitate airway clearance in conjunction with specific body positioning
With Dean’s Hierachy for Treatment of Patients with Impaired Oxygen Transport, what is the goal of Suctioning?
To facilitate the removal of airway secretions collected centrally
With Dean’s Hierachy for Treatment of Patients with Impaired Oxygen Transport, what is the considerations for Mobilization and Exercise?
- Dyspnea on exertion – Use Dyspnea Scale with target of 4-6/10 rating during activity
- Use pulse oximetry and monitor for signs of hypoxemia / respiratory distress
- Consider physician orders for titrating supplemental oxygen to maintain SpO2 above > X%
- Consider bronchodilator therapies before exercise training
- Resistance training emphasis on function and musculature that support anti-gravity function and ADLs
- Balance training due to common observation of falls in some populations with chronic pulmonary diseases (COPD, for example)
With Dean’s Hierachy for Treatment of Patients with Impaired Oxygen Transport, what is the benefits of Body Position?
- V/Q Matching
- When standing, gravity pulls the mediastinal and abdominal structures down, creating more space in the thoracic cavity, which allows further expansion of the lungs and greater lung volumes. This, along with the decrease in compression on the lung bases, allows for greater alveolar recruitment.
- Sitting often leads to the somewhat reduced lung volumes compared with standing due to abdominal organs being higher, interfering with diaphragmatic motion. Second, the abdominal muscles are in a less optimal point in the length-tension curve, since the combination of hip flexion and higher position of the abdominal contents exert upward pressure. Third, the back of the chair may limit thoracic expansion.
- Supine position negatively affects diaphragmatic strength and an increase in blood volume within the thoracic cavity can lead to congestion of the pulmonary vasculature, which reduces lung compliance. This makes the lungs stiffer and harder to expand during inspiration
With Dean’s Hierachy for Treatment of Patients with Impaired Oxygen Transport, what are examples of Breathing Control Maneuvers/Ventilatory Strategies?
- Pursed-Lip Breathing
- Paced Breathing (Controlled exhalation during effortful movement)
- Diaphragmatic Breathing
- Lateral Costal Breathing
- Inspiratory Hold Technique
With Breathing Control Maneuvers/Ventilatory Strategies, what are the indications of using Pursed-Lip Breathing?
Dyspnea at rest and/or with exertion, wheezing
With Breathing Control Maneuvers/Ventilatory Strategies, what are the indications of using Paced Breathing?
Low Endurance, Dyspnea on exertion, tachypnea, fatigue, anxiety
With Breathing Control Maneuvers/Ventilatory Strategies, what are the indications of using Diaphragmatic Breathing?
Dyspnea, impaired lower lung expansion, hypoxemia, tachypnea, atelectasis, anxiety, excess pulmonary secretions.
- Note: individuals with severe hyperinflation and flattened diaphragms will most likely not benefit from this technique because the muscle length tension relationship is abnormal and will not result in an appropriate movement of the diaphragm
With Breathing Control Maneuvers/Ventilatory Strategies, what are the indications of using Lateral Costal Breathing?
Asymmetric Lateral chest wall expansion, localized lung consolidation or secretions
With Breathing Control Maneuvers/Ventilatory Strategies, what are the indications of using Inspiratory Hold Technique?
Hypoventilation, Atelectasis, Ineffective cough
What positions are best for those patients practicing Diaphragmatic Breathing?
- Initially we can start the patient in supine, although this requires the patient to breath against increased visceral organ resistance. Consider the sidelying position as better alternative for some
- When the pt has mastered the breathing pattern in supine or sidelying progress to sitting, then standing then walking and finally stairs
What are the Indications of using Airway Clearance Techniques?
Impaired mucociliary transport, excessive pulmonary secretions, ineffective or absent cough
What are the considerations of Airway Clearance Techniques?
- Pain Management
- Inhaled Bronchodilaters ~30 minutes prior
- Meal Timing: Before or at least 30 min after end of meal or tube feeding
What is the Simplest form of airway clearance? Which patients should use these techniqes?
- Simplest form is deep breathing and applying techniques to improve coughing function
- These techniques should be used with ALL patients in inpatient care (e.g., acute care, skilled nursing facilites) to improve airway clearance or prevent pulmonary dysfunction.
-However, IF an individual has retained secretions or has an ineffective cough, THEN alternatative airway clearance techniques should be used to mobilize the secretions and expel them from the airways to prevent futher pulmonary dysfunction
Mobility (e.g. ambulation) is an additional airway clearance technique that should be used early
What are the Stages of an Effective Cough?
- Adequate Inspiration (greater than tidal volume)
- Glottic Closure
-Otherwise, its called a huff - Building up of intrathoracic pressure and intraabdominal pressure
-Facilitated by abdominal and intercostal muscle contraction - Glottic opening and expulsion
With Cough Interventions, what takes place in the Extension Position?
- Consider cueing for upward gaze, scapular retraction, UE elevation as needed
- “Take a deep breath in…in…in…in…in… and now hold it”
With Cough Interventions, what takes place in the Flexion Position?
- Consider cueing for downward gaze, scapular protraction, UE depression and squeezing chest as needed
What is the Suggested Sequence for Active Cycle Breathing (ACBT)?
Breathing Control (BC):
- Relaxed, diaphragmatic breathing, normal tidal volume, 15-30 seconds
Thoracic Expansion Exercises (TEE):
- Deep, slow breathing in the vital capacity range
This cycle alternates until the patient feels prepared to expectorate the accumulated secretions, then:
Forced Expiratory Techniques (FET):
- 1 or 2 Huffs
- Huffs may be better for airways prine to collapsing
When is Active Cycle Breathing performed?
This is performed at rest and can be combined with breathing strategies (e.g., inspiratory hold) and/or performed in a postural drainage position with or without an application of percussion/vibration
With Postural Drainage, how should the bronchi be positioned?
- Segmental bronchi positioned perpendicular to the floor
- If used exclusively, each affected segment position should be maintained 5-10 minutes
-Prioritize most affected segment
Note some general trends:
- The more caudal the lung segment to be drained, the lower the head of bed is to be positioned
- The lung segment to be drained is often positioned superiorly so it can drain toward to proximal airways at the midline
What are the Precautions for Postural Drainage?
- Pulmonary Edema
- Hemoptysis
- Massive Obesity
- Large Pleural Effusion
- Massive Atelectasis
What are the Contraindications for Postural Drainage?
- Increased ICP
- Unstable hemodynamics
- Recent esophageal anastomosis
- Recent spinal fusion or injury
- Recent head trauma
- Diaphragmatic hernia
- Recent eye surgery
How do you do Percussion and Vibration?
- Lumbrical hand positioning with firm hands and loose wrists
- 2-5 minutes per segment followed by vibration (exhalation only) and coughing/huffing
When doing Percussion and Vibration, what are signs of Intolerance and Decompensation?
- Marked increase in RR or BP
- Decrease in SpO2
- Dyspnea or increased work of breathing
- Mental status change
- Cyanosis
When doing Percussion and Vibrations, what should we consider?
- Meal Timing: before or way after eating
- Nebulizer treatment may assist
- Can coordinate with nursing /RT in the event that is needed for suctioning is anticipated
RT = Respiratory therapist
What are the Precautions for Percussion and Vibration?
- Uncontrolled bronchospasm
- Osteoporosis
- Rib fx
- Metastatic CA to ribs
- Tumor obstruction to airway
- Anxiety
- Coagulopathy
- Convulsive or seizure disorder
- Recent PM placement
- Chest tube
What are the Contraindications for Percussion and Vibration?
- Hemoptysis
- Untreated Tension Pneumothorax
- Platelet count < 50,000
- Unstable hemodynamic status
- Open wounds, burns in the thoracic area
- PE
- Subcutaneous Emphysema
- Recent Skin grafts or flaps on thorax
What is Inspiratory Muscle Training? What S/S may indicate this?
This is intended to improve on impaired strength and/or endurance of the respiratory muscles
S/S of those impairments include:
- Decreased (chest expansion, breath sounds, tidal volumes)
- Dyspnea
- Uncoordinated breathing
The Concepts of IMT are the same as muscles, we incorporate the concepts of overload, specificity and reversibility
WIth IMTs, a major discrepancy may exist in the diagnosis for which this treatment is applied
What is the Normative Range of pH?
7.35 - 7.45
What is the Normative Range of PaCO2?
35 - 45 (40) mmHg
What is the Normative Range of PaO2?
80 - 100 mmHg
What is the Normative Range of %SaO2?
96 - 100%
What is the Normative Range of HCO3?
22 - 26 (24) mEq/L
HCO3 is bicarbonate, its a buffer against acididty. It will raise pH if its too low
With ABGs, what typically happens when CO2 levels go up?
(Arterial Blood gases)
Blood becomes more acidic and pH goes down
With ABGs, what typically happens when HCO3 levels go up?
(Arterial Blood gases)
pH goes up, the blood becomes more alkaline (basic), because there is more buffer introduced in the blood
What are the Primary Regulators of Acid-Base balance?
The kidneys and lungs
- The kideys are considered slow and the lungs fast
What is Respiratory Acidosis?
A condition of blood acidity due to a primary respiratory phenomenon
- Causes the blood pH to go down
What may cause Respiraory Acidosis?
- Respiratory Depression (Anesthesia, Overdose, increased ICP)
- Airway obstruction, decreased capillary diffusion (Pneumonia, COPD, ARDS, PE)
What are the S/S of Respiratory Acidosis?
- Headache
- Hyperkalemia
- Dysrythmias (increased K+)
- Drowsiness, dizziness, disorientation
- Muscle weakness, hyperreflexia
What is Repsiratory Alkalosis caused by?
- Hyperventilation (anxiety, fear, PE)
This will acutely lower CO2 in the blood
What are the S/S of Respiratory Alkalosis?
- Hypokalemia
- Numbness and tingling of extremities
- Hyper reflexes and muscle cramping
- Seizures
What may cause Metabolic Acidosis?
- Diabetes Ketoacidosis
- Severe diarrhea
- Renal failure
- Shock
What are the S/S of Metabolic Acidosis?
- Headache
- Hyperkalemia
- Nausea, vomiting, diarrhea
- Changes in LOC (confusion, increased drowsiness)
- Kussmaul respirations (compensatory hyperventilations)
What causes Metabolic Alkalosis?
- Severe vomiting
- Excessive GI suctioning
- Diuretics
- Excessive NaHCO3
What are the S/S of Metabolic Alkalosis?
- Dysrhythmias (Tachycardia)
- Compensatory Hypoventilation
- Confusion (decreased LOC, dizzy, irriatble)
- Tremors, Muscle cramps, tingling of fingers and toes
- Hypokalemia
What is the difference between normal and obstructive lungs in terms of Total Lung Capacity and Residual Volume?
Both are higher with the obstructive lungs
- Residual Volume is a key characteristic finding with obstructive lung disease
What is COPD?
A progressive disease which features chronic airflow limitations that are typically caused by a mixture of parenchymal alveolar disease (emphysema) and small-airway disease (obstructive bronchiolitis) which commonly occur in combination, with proportions varying from individual to individual. However, in some cases, either emphysema or chronic bronchitis is clearly dominant
Parenchymal: functional tissue of an organ (e.g. lung alveoli) as distinguished from the connective and supporting tissue
What are the 2 Primary Causes of COPD?
- Inhalation Factors
- Genetics
The Pathophysiology of COPD includes what? What do these 4, all do?
- Hyperplasia of the mucus-secreting cells
- Reactive airways
- Terminal bronchiole destruction
- Alveolar sac destruction
All of which reduce airflow out of the air sacs and the airways and result in hyperinflation and poor gas exchange resulting in ventilation/perfusion (V/Q) mismatch, hypoxemia, and oftentimes hypercapnia
With COPD, what is Inhalation Exposure?
How can smoking impair the lungs?
Inhalation exposure is often the primary contributing factor to the cascade of airway and alveoli inflammatory responses that lead to disease, especially in genetically susceptible individuals.
Cigarette smoke impairs cilia function, and alveolar macrophages within the lung parenchyma can be permanently destroyed, increasing the risk of infection
With the GOLD Staging of COPD, what is stage 2?
COPD Severity, FEV1/FVC ratio, FEV range
- COPD Severity: Moderate
- FEV1/FVC Ratio: < 0.70
- FEV Range: 50 - 79% of normal
With the GOLD Staging of COPD, what is stage 1?
COPD Severity, FEV1/FVC ratio, FEV range
- COPD Severity: Mild
- FEV1/FVC Ratio: < 0.70
- FEV Range: ≥ 80% of normal
With the GOLD Staging of COPD, what is stage 3?
COPD Severity, FEV1/FVC ratio, FEV range
- COPD Severity: Severe
- FEV1/FVC Ratio: < 0.70
- FEV Range: 30 - 49% of normal
With the GOLD Staging of COPD, what is stage 4?
COPD Severity, FEV1/FVC ratio, FEV range
- COPD Severity: Very Severe
- FEV1/FVC Ratio: < 0.70
- FEV Range: ≤ 30% of normal OR < 50% of normal with chronic respiratory failure present
What are the Characteristics Emphysema-Dominant Phenotype of COPD (“Pink Puffer”)?
- Typically characterized by a thin appearance due to weight loss, which is a result of the increased energy expenditure from the effort of breathing.
- May appear to be taking more effort to breathe, Using accessory muscles to compensate for impaired diaphragmatic function secondary to lung hyperinflation.
- Lips and nail beds may not show signs of cyanosis hence the term “pink”, which indicates relatively well- oxygenated blood despite the difficulty in breathing.
- The “puffer” part of the term comes from the pursed-lip breathing that alters respiratory mechanics by increasing airway pressure, which helps to prevent airway collapse during expiration
What are the Characteristics Bronchitis-Dominant Phenotype of COPD (“Blue Bloater”)?
- Exhibit persistent coughing and produce large amounts of sputum
- Typically presents with an overweight body type due to a combination of factors including a reduction in exercise capacity and the body’s attempt to increase its oxygen reserve capacity.
- Often exhibit signs of cyanosis, which gives rise to the term “blue”.
- The term “bloater” refers to the bloating seen in the body, including potential fluid retention and swelling, particularly in the lower extremities, due to right-sided heart failure that can complicate chronic bronchitis.
What do Mucous Plugs and Unstable Airways cause?
- Air trapping and hyperinflation on expiration
- During Inspiration, the airways are pulled open, allowing gas to flow past the obstruction
Emphysema
During Expiration, what does decreased elastic recoil of the bronchial walls result in?
Results in collapse of the airways and prevents normal expiratory flow
Emphysema
What is Flattened Hemi-Diaphragmatic contours considered?
- When is this best seen?
Its considered on of the most sensitive indicators of Hyperinflation
- Best seen on the lateral chest radiograph and consist of a loss of height of the convexity of the hemidiaphragm
- Draw a line connecting the sternophrenic angle and this arch height should be ≥2.5 cm
- It is considered clearly pathological when measured less than 1.5 cm
How is Muscle Composition affected with COPD?
- There is a shift from Type 1 to Type 2 Skeletal muscle fibers.
- There is a reduction in aeroic metabolism and poor muscle endurance
Emphysema
As COPD progresses, how can it affect the diaphragam and Pelvic Floor?
As the disease progresses, exhalation can become forced instead of passive, increasing intraabdominal pressure and putting more stress on the pelvic floor. This can lead to pelvic floor dysfunction that can manifest as urinary incontinence in both males and female
What are the Clinical Manifestations for Emphysema?
- Use of Accessory Muscles to breath
- Pursed-Lip breathing
- Minimal or absent cough
- Leaning forward to breath
- Dyspnea on exertion (late sign)
What is Chronic Bronchitis Defined as?
The presence of a chronic productive cough for 3 months in each of 2 successive years, provided that other causes of chronic mucus production (CF, bronchiectasis, and tuberculosis [TB]) have been ruled out
What are the Clinical Manifestations for Chronic Bronchitis?
- Excessive Body Fluids
- Chronic cough
- Shortness of breath on exertion
- Increased sputum
- Cyanosis (late sign)
What is the Pathophysiology of Emphysema “Pink Puffer”?
- There is decreased Elastic recoil, which increases lung compliance and decreases ventilation -> increases work of breathing
- There is destruction of capillary bed which decreases perfusion
The decrease in perfusion and ventilation causes a Matched V:Q Defect (relatively well-oxygenated blood unit late stages)
- There is Alveolar detachment which causes air trapping on expiration (we will see Pursed-lip breathing) -> we will see an increase in End-respiratory volume and an increase in RV and TLC and a decrease in VC -> then causes barrel chest
Also with Emphysema, the people will breath in normally and then they will have an issue getting the air out. Air trapping happens.
What is the Pathophysiology of Chronic Bronchitis “Blue Bloaters”?
- There is Airway obstruction, leads to Alveolar hypoxia. This then leads to V:Q Mismatch and/or Pulmonary Vasoconstriction
-With V: Q Mismatch we will see Hypoexamia (may also cause cyanosis) -> Polycythemia. Also we will see Hypercarbia leading to respiratory acidosis
-With Pulmonary Vasoconstriction we’ll see Pulmonary Hypertension and this leads to Decreased Left Ventricle output leading to decreased circulating volume and Activation of RAAS, also we will see Right Heart failure leading to Cor pulmonale - There is Mucus Hypersecretion, leads to productive cough with copious sputum
With Obstructive lung disease, what is the Vicious Cycle Hypothesis?
- This starts off with an initiating factor (e.g., smoking, childhood repsiratory disease)
- Leads to impaired innate lung defense, which exposes the lungs to infection, microbial colonization
- If the Microbial Colonization becomes large enough and the immune system responds, the body creates Microbial Antigens
- This then leads to Airway Epithelial injury, which will further damage the innate lung defense
And the cycle will continue to worsen
During the Physical Exam, what breath sounds may we hear with those patients with Chronic Bronchitis?
Vesicular, but likely diminished, prolonged expiration
During the Physical Exam, what Adventitous sounds may we hear with those patients with Chronic Bronchitis?
likely wheezing or rhonchi, possible crackles
During the Physical Exam, what Transmitted Voice sounds may we hear with those patients with Chronic Bronchitis?
None
During the Physical Exam, what Percussion Note may we hear with those with Chronic Bronchitis?
Resonant (Normal)
During the Physical Exam, where may we find the trachea when observing those patients with Chronic Bronchitis?
In midline
During the Physical Exam, what breath sounds may we hear with those patients with Emphysema?
Vesicular, but likely diminished, prolonged expiration
During the Physical Exam, what Adventitous sounds may we hear with those patients with Emphysema?
None, maybe wheezes during exacerbations (less than chronic Bronchitis)
During the Physical Exam, what Transmitted Voice sounds may we hear with those patients with Emphysema?
None
During the Physical Exam, what Percussion Note may we hear with those with Emphysema?
Diffusely Hyperresonant
During the Physical Exam, where may we find the trachea when observing those patients with Emphysema?
In Midline
Those with Lung Disease, what are other Examination Domains that we should assess?
- Walking ability (Endurance and speed): 2 or 6 MWT, ISWT, Incremental treadmill test, Seated or standing step test, 10 MWT, etc
- Balanc/Fall Risk: BBS, FGA, DGI, TUG, 5xSTS / 30 sec chair rise
- Strength and Power: Dynamometry, MMT, OMs like 5xSTS / 30 sec chair rise
-
QOL: Chronic Respiratory Questionnaire (CRQ), COPD Assessment Test (CAT), Saint George Respiratory Questionnaire
(SGRQ), and Living with COPD questionnaire (LCOPD)
The exercise prescription for individuals with lung disease, particularly those with moderate to severe disease, should be based on exercise testing
Considerations for Exercise Testing for Obstructive Lung Disease
Those with Obstructive Lung Disease should do Incremental Exercise Test to assess function. What is the difference in duration based on the severity of COPD? (Mild to Moderate compared to severe disease)
A test duration of 8– 12 min is optimal in those with mild-to-moderate COPD, whereas a test duration of 5– 9 min is recommended for individuals with severe and very severe disease.
Considerations for Exercise Testing for Obstructive Lung Disease
For those with Moderate to Severe Obstructive Lung Disease (COPD), what may they experience with exercise?
Individuals with moderate-to-severe COPD may exhibit oxyhemoglobin desaturation with exercise
What is the Aerobic FITT Principle for Individuals with COPD?
F: Minimally 3 days/wk ; perferably up to 5 days/wk
I: Moderate to Vigorous Intensity (50-80% peak work rate or 4-6 on the Borg CR10 scale)
T: 20-60 min per day at moderate to high intensities as tolerated. If the 20 to 60 min durations are not achievable accumulate ≥ 20 min of exercise rest periods of lower intensity work or rest
T: Common Aerobic modes including walking (free or treadmill), stationary cycling and upper body ergometry
UE activity is associated with high metabolic and ventilatory demand, and activities involving the arms can lead to irregular or dyssynchronous breathing. This is because some arm muscles are also accessory muscles of inspiration.
What is the Resistance FITT Principle for Individuals with COPD?
F: At least 2 days/wk performed on non-consecutive days
I:
- Strength: 60-70% of 1RM for beginners; ≥80% for experienced weight trainers
- Endurance: < 50% of 1RM
T:
- Strength: 2-4 sets, 8-12 reps
- Endurance: ≤ 2 sets, 15-20 reps
T: Weight machines, free weights, or body weight exercise
From the ACSM, what are the Considerations for Exercis training (1) for those with Obstructive Lung Disease?
- Interval training may be an alternative to standard continuous endurance training for those who have difficulty in achieving their target exercise intensity/volume due to dyspnea, fatigue, or other symptoms. Several randomized, controlled trials and systematic reviews have found no clinically important differences between interval or continuous training protocols in exercise capacity, HRQOL, and skeletal muscle adaptations following training.
- Intensity targets based on percentage of estimated HRmax may be inappropriate, particularly in individuals with severe COPD where resting heart rate is often elevated and ventilatory limitations, as well as the effects of some medications, prohibit attainment of the predicted HRmax and thus its use in exercise intensity calculations. Most individuals with COPD can accurately and reliably produce a dyspnea rating obtained from an incremental exercise test as a target to regulate/monitor exercise intensity.
- The use of oximetry is recommended for the initial exercise training sessions to evaluate possible exercise-induced oxyhemoglobin desaturation and to identify the workload a which desaturation occurred
From the ACSM, what are the Considerations for Exercis training (2) for those with Obstructive Lung Disease?
- Maximizing pulmonary function using bronchodilators before exercise training in those with airflow limitation can reduce dyspnea and improve exercise tolerance.
- Inspiratory muscle weakness is a contributor to exercise intolerance and dyspnea in those with COPD. Inspiratory muscle training (IMT) may prove useful in those unable to participate in exercise training or can be used as an adjunct for those who participate in an exercise program. IMT improves inspiratory muscle strength and endurance, functional capacity, dyspnea, and QOL, which may lead to improvements in exercise tolerance in those with COPD and asthma.
- Individuals suffering from acute exacerbations of their pulmonary disease should limit exercise until symptoms have subsided and rather focus on functional mobility
From the ACSM, what are the Considerations for Exercis training (3) for those with Obstructive Lung Disease?
- Exercise for individuals with associated Pulmonary Arterial Hypertension should consider:
–Using ECG monitoring if there significant right ventricular dysfunction
–Using supplemental oxygen to avoid hypoxemia which can worsen pulmonary artery pressures due to vasoconstrictive processes
–Caution with higher-intensity exercise – particularly those involving the UE - that may increase intrathoracic pressures (e.g. through Valsalva maneuvers) - Flexibility exercises may help overcome the effects of postural impairments that limit thoracic mobility and therefor lung function during activity
With COPD what is the FITT for Inspiratory Muscle Training? What should PTs consider with this principle?
– F: 3 day/week build to 6-7 days/week
– I: 30-40% of Maximal Inspiratory Pressure (1 RM), build toward 60-70%
– T: 15-30 min/day
– T: Threshold, x, etc.
Considerations:
* Reduce load back 30-40% in context of exacerbation
* Consider interval training if better tolerated
What is the Hallmark of Asthma?
The Reversibility of airway obstruction following the use of bronchodilator medications
What are the Characteristics of Asthma?
An “episodic” obstructive lung condition with periods of relatively normal lung function between episodes of wheezing, dyspnea, chest tightness, and coughing
What is Asthma?
A Chronic inflammatory disorder of the airways where
hyperresponsiveness and inflammation are key
components and acute exacerbations due to viral or
allergen exposures can accumulate over time to induce
airway remodeling
During the Physical Exam, what breath sounds may we hear with those patients with Asthma?
Depends on severity, maybe diminished or absent during asthma attack, prolonged expiration
During the Physical Exam, what Adventitous sounds may we hear with those patients with Asthma?
likely wheeze, particularly during asthma attack, may also have rhonchi in the presence of mucus
During the Physical Exam, what Transmitted Voice sounds may we hear with those patients with Asthma?
None
During the Physical Exam, what Percussion Note may we hear with those with Asthma?
Resonant (Normal) to hyperresonant during severe asthma attack
During the Physical Exam, where may we find the trachea when observing those patients with Asthma?
In midline
What is the most important treatment for asthma management?
It involves the use of appropriate medications to educe inflammation, stabilize airways and relieve bronchospasm
Exercis Testing and Prescription
Asthma Sx are often precipitated by what?
Exercise (i.e., exercise-induced bronchioconstriction {EIB}), Inhalation of cold air, and exposure to allergens or viral respiration infections
Differentiation of EIB from exertional angina is performed by assessing the individual’s degree of difficulty in breathing (i.e. EIB would likely produce greater work of breathing compared to exertional angina)
With Asthma, what should we consider with Exercise Test and Prescriptions?
- Consider HR effects of asthma control medications (e.g., when using HR zones for exercise prescription)
- Use of short-acting bronchodilators may be necessary before or after exercise to precent or treat EIB
- Peak-flow meters can be used as a guide for medication management and medical care
What is Bronchiectasis characterized by?
Irreversible dilation of one or more bronchi with chronic inflammation and infection
Associated with Cystic Fibrosis
What are 3 common mechanisms of Bronchiectasis that can lead to development of the permanent, pathological dilation and damage of the airways?
- Bronchial wall injury/structural weakness of bronchial walls
- Traction from adjacent lung fibrosis
- Bronchial lumen obstruction
With Bronchiectasis Physical Examination, what may we find with Auscultations?
(Breathing sounds, Adventitious soudns, Mediate percussion)
Breathing Sounds:
- Bronchial (with episodes of pneumonia) ; Diminished or absent (with mucus plugging)
Adventitious Sounds: Crackles over involved lobes ; Rhonchi during mucus retention
Mediate Percussion
- Dullness
- It’s common for individuals with bronchiectasis to breathe very shallowly when their lungs are being auscultated to avoid triggering coughing episodes. As a result of shallow breathing, diminished breath sounds are detected in all lung fields
What is the Goal of Bronctiechasis Management?
To reduce the number of exacerbations and improve QOL
With Bronchiectasis, what takes place during Interventions?
- Airway Clearance Techniques as needed
- Controlled breathing techniques coordinated with activity
- Strength training, especially quadriceps muscle strength and endurance
- Aerobic conditioning exercise
- Inspiratory muscle training to improve strength and endurance of accessory muscles
What does Cystic Fibrosis affect?
Affects every organ that has epithelial tissue
What is the Clinical Presentation with Cystic Fibrosis when its affecting the Pulmonary System?
Chronic airway obstruction and inflammation, thick tenacious
mucus, and recurrent bacterial infections
What is the Clinical Presentation with Cystic Fibrosis when its affecting the Intestines?
Thick mucus that interferes with nutrient absorption and results in malnourishment and low weight
What is the Clinical Presentation with Cystic Fibrosis when its affecting the Pancreas?
Exocrine pancreatic insufficiency, which affects both gastrointestinal function (fat maldigestion) and the growth and development of individuals with CF
What is the Clinical Presentation with Cystic Fibrosis when its affecting the Upper Airway?
Sinus Infection
What is the Clinical Presentation with Cystic Fibrosis when its affecting the Male Reproductive Tract?
Obstructive Azoospermia
What is the Clinical Presentation with Cystic Fibrosis when its affecting the Sweat Glands?
Elevated sodium chloride levels in sweat
What is the Primary Pathophysiologic event in CF?
Failure of the airways to clear mucus normally
With CF, what is mucus stasis, adhesions and obstructions responsible for?
For severe and unrelenting chronic bacterial infections
With CF, what happens as lung disease (chronic bacterial infection) progresses?
Submucosal glands hypertrophy, goblet cells become more numerous, and small airways often become completely obstructed by secretions. Bronchiolectasis and finally bronchiectasis are the outcome of repeated obstructive infection cycles
What are the Sx of CF?
- Salty-tasting skin
- Frequent lung infections
- Wheezing and/or shortness of breath
- Poor growth and slow weight gain despite a healthy appetite
- Frequent greasy, bulky stools and/or difficult bowel movement
What will we find in the Physical Exam with those with CF?
- Lung sounds are often unremarkable, except for diminution in the intensity of the breath sounds, which correlates with the degree of hyperinflation present.
- Adventitious breath sounds (e.g., crackles, wheezing) are usually heard first over the upper lobes
- Increased respiratory rate
- Digital clubbing occurs in virtually all patients with CF, and its severity generally correlates with the severity of lung disease
What are the Exercise Considerations for Mild Lung Disease?
- > 80% FEV1, normal ventilatory responses, possible slight reductions in arterial O2 levels
- Recommend using same testing and training principles that would be used for a normal population
What are the Exercise Considerations for Moderate Lung Disease?
- FEV1 between 50-80%, exercise tolerance is limited by ventilation, possible SOB with ADLs or activities ~3-4 METs, mild-to-moderate hypoxemia at rest that worsens with exercise, may be restricting/modifying activity levels to prevent exacerbation of symptoms
- Exercise tolerance should be assessed with exercise test to assess for vitals and ventilatory responses
- Supplemental oxygen should be considered if there is exercise-induced hypoxemia
What are the Exercise Considerations for Severe Lung Disease?
- FEV1 < 50%, dyspneic with most daily activities, may require intermittent or continuous supplemental oxygen at rest or with activity, may have elevated CO2 levels and/or right ventricular dysfunction
- Exercise tolerance should be assessed with exercise test to assess for vitals and ventilatory responses
- Interval training should be considered to build toward more continuous forms of exercise that may translate into daily activates that require sustained effort
What is Restrictive Lung Disease?
A group of disorders characterized by a reduction in lung expansion, leading to decreased lung volumes and impaired pulmonary ventilation. This reduction is due to various factors such as stiffness of the lung tissue, limitations in chest wall movement, or neuromuscular dysfunction, all of which increase the effort required for breathing.
What are the Hallmark SIGNS of Restriactive Lung Disease?
- Decreased lung volumes
- Decreased breath sounds
- Tachypnea
- Increased work of breathing
- V/Q mismatching (with hypoxemia when severe)
What are the Hallmark SYMPTOMS of Restriactive Lung Disease?
- Dyspnea
With Restrictive Lung Disease, associated SIGNS depend on when etilogy such as?
- Dry inspiratory crackles
- Decreased diffusing capacity
- Cor Pulmonale
With Restrictive Lung Disease, associated SYMPTOMS depend on when etilogy such as?
- Cough (often dry)
- Wasted, emaciated appearance
-Normally, ~ 5% of O2 is used to support work of breathing; in RLD, this can increase to ~ 25%.
-This larger fraction of total body metabolic energy diverted to respiratory muscles leaves a smaller fraction available for working limb muscles during exercise
WIth Restrictive Lung Disease, with age, what happens when there are Changes in the Chest Wall?
- There is decrease strength of respiratory muscles, this increases O2 consumption in respiratory muscles and a decrease in MVV (Max. voluntary ventilation).
- There is a decrease in chest wall compliance, this also increases O2 consumption in respiratory
- The incresae in O2 consumption in respiratory muscles lead to increase minute ventilation, an increase in work of breathing, and may increase respiratory muscle fatigue
This all leads to a Decrease in Pulmonary Efficiency, this signifies a decline in the respiratory system’s capability to meet the bodies demands, especially during stress or illness
WIth Restrictive Lung Disease, with age, what happens when there are Changes in the Lungs?
- As Alveolar compliance decreases, the elastcity of the alveoli diminishes, this results in an increase RV
-There is trapped air that contirbutes to higher physiological dead space (where gas exchange does not happen). With this air trapping, VC also decreases. s trapped in the lungs. This reduction in vital capacity signifies decreased lung efficiency and capacity for ventilation. Poor V/Q matching occurs as areas of the lung become under-ventilated relative to their blood supply, leading to hypoxemia. - There’s also a noted decrease in the diffusing capacity of the lung for carbon monoxide (DLco), which implies that the transfer of gases from the alveoli to the blood is less efficient, often due to a loss of alveolar surface area. With these changes comes a decrease in the optimal V/Q matching. Consequently, there’s a mild but significant reduction PaO2
During the Physical Exam, what breath sounds may we hear with those patients with Atelectasis (Obstructive Type)?
Diminished over absent
During the Physical Exam, what Adventitous sounds may we hear with those patients with Atelectasis (Obstructive Type)?
If obstruction is partial, wheezing or crackles may be heard due to air passing through or around the obstruction
During the Physical Exam, what Transmitted Voice sounds may we hear with those patients with Atelectasis (Obstructive Type)?
None
During the Physical Exam, what Percussion Note may we hear with those with Atelectasis (Obstructive Type)?
Dull
During the Physical Exam, where may we find the trachea when observing those patients with Atelectasis (Obstructive Type)?
Possibly shifted toward the affected side if severe
During the Physical Exam, what breath sounds may we hear with those patients with Atelectasis (Compressive Type)?
Diminished over absent
During the Physical Exam, what Adventitous sounds may we hear with those patients with Atelectasis (Compressive Type)?
Typically absent, as the lung tissue is compressed and is not moving through the area
During the Physical Exam, what Transmitted Voice sounds may we hear with those patients with Atelectasis (Compressive Type)?
None
During the Physical Exam, what Percussion Note may we hear with those with Atelectasis (Compressive Type)?
Dull
During the Physical Exam, where may we find the trachea when observing those patients with Atelectasis (Compressive Type)?
Possibly shifted away the affected side if severe
What affects of Obesity have on breathing?
- Obesity requires additional oxygen
- Produces additional CO2
- Decreases the compliance of the thorax and therefore increases the work of breathing
- (In the abdominal) exerts pressure on the abdominal contents and diaphragm
-Results in decreased lung expansion and early closure of the small airways and alveoli, especially at the bases or the dependent regions of the lung. These areas are hypoventilated relative to their perfusion, which can markedly increase the ventilation–perfusion mismatching and result in hypoxemia
With patients with Kyphoscoliosis, if the patient has < 70° of spinal curvature, how would this affect respiration?
< 70 degrees do not tend to produce pulmonary Sx
With patients with Kyphoscoliosis, if the patient has >120° of spinal curvature, how would this affect respiration?
> 120 degrees are commonly associated with severe RLD and respiratory failure
With patients with Kyphoscoliosis, if the patient has 70-120° of spinal curvature, how would this affect respiration?
May cause some respiratory dysfunction, and respiratory sx may increase with age as the angle increases and as the changes associated with aging affect the lung
With Crush Injuries, how can Rib Fractures impact breathing?
- Breathing will be shallow due to pain and muscular splinting
- Underlying hemothroax (if present) can lead to acute and chronic restriction
With Crush Injuries, what is Flail Chest? What are some long-term disabilites that may come from this?
- Injury to the free-floating segment ribs
- Long-term pulmonary disability following flail chest wall deformity, dyspnea on exertion, and mild restrictive pulmonary dysfunction for months to years
With Crush Injuries, what is Lung Contusion?
– Bruising of the lung tissue, which can lead to inflammation, edema, and hemorrhage within the lung parenchyma. The injured lung tissue may become stiff and less compliant, making it more difficult for the lungs to expand, leading to a restrictive pattern on pulmonary function tests.
– ~50-70% develop pneumonia
What is the Main Goal for Crush Injuries?
(Rib Fx, Flail Chest, Lung Contusion)
Pain management and reestablish normal breathing or at least a level of ventilation that can support necessary activities (e.g. ADLs) using deep breathing, positioning, and supported coughing
What is Pneumonia? What does this lead to?
An inflammatory process of some part of the lung where gas exchange occurs that usually begins with an infection in the lower respiratory tract
- Leads to decreased functional lung volume as consolidated air spaces do not inflate as easily (reflecting decreased compliance)
What are the 4 categories of Pneumonia (PNA)?
- Community-acquired PNA
-Streptococcus PNA or pneumococcus is the most common type - Hospital-acquired PNA (HAP)
-Represents the second most common type of nosocomial infection in USA (exceeded by UTI) - Health-care-associated PNA (HCAP)
- Ventilatory-associated PNA (VAP)
What are the Presentations of Bacterial Pneumonia (PNA)?
Abrupt onset, Lobar consolidation, high fever, chills, moderate-to-severe respiratory distress, focal auscultatory findings,productive cough, pleuritic pain, and elevated WBC
What are the Presentations of Viral Pneumonia (PNA)?
Gradual onset, preceding upper airway symptoms, diffuse/bilateral auscultatory findings, low-to-moderate fever,
and normal WBC, nonproductive cough
During the Physical Exam, what breath sounds may we hear with those patients with Lobar Pneumonia?
Bronchial
During the Physical Exam, what Adventitous sounds may we hear with those patients with Lobar Pneumonia?
Crackles, maybe a pleural friction rub if pneumonia has extended to pleural surface
During the Physical Exam, what Transmitted Voice sounds may we hear with those patients with Lobar Pneumonia?
(+) Test for transmitted voice sounds
During the Physical Exam, what Percussion Note may we hear with those with Lobar Pneumonia?
Dull
During the Physical Exam, where may we find the trachea when observing those patients with Lobar Pneumonia?
Midline
Applying the Hierarchy to a case of Pneumonia, what are the Acute Effects of Mobilization and Exercise?
- Mobilization can help redistribute blood flow to better Ventilated areas of the lungs, improving the match between ventilation and perfusion and thereby enhancing oxygenation.
- Movement and increased respiratory rate help in mobilizing secretions, facilitating their clearance from the respiratory tract.
- Exercise can increase the need for deeper breaths and subsequently stimulate the cough reflex to clear mucus
Applying the Hierarchy to a case of Pneumonia, How can Body Positions be beneficial?
- Consider the role of positioning to optimize V/Q matching, such as sitting up or lying on the side that is less affected to maximize air entry into the healthier lung segments.
- Educate the patient on the importance of frequent changes in position to prevent atelectasis and to promote lung expansion and secretion clearance.
Applying the Hierarchy to a case of Pneumonia, How can Breathing Control Maneuvers be beneficial?
- Consider techniques to enhance alveolar ventilation (diaphragmatic breathing, lateral costal breathing, etc.)
- Paced breathing might be used during activities to reduce dyspnea and improve efficiency.
Applying the Hierarchy to a case of Pneumonia, How can Coughing Manuvers be helpful for those patients?
Effective coughing techniques can be taught to help clear secretions, as pneumonia often leads to increased mucus production
Applying the Hierarchy to a case of Pneumonia, How can Postural Drainage Positioning be beneficial?
Positioning the patient to facilitate gravity-assisted drainage of secretions from different lobes of the lungs can help to clear mucus that may be obstructing airways, especially in bacterial pneumonia where there is often a significant productive cough
This is used when Mobilization, Body position, Breathing/Coughing manuvers dont work
Applying the Hierarchy to a case of Pneumonia, How can Manual Techniques be beneficial?
Manual chest physiotherapy, including percussion and vibration, can be utilized to loosen pulmonary secretions, making them easier to expectorate
This is used when Mobilization, Body position, Breathing/Coughing manuvers dont work
With Pulmonary Surgical Therapy, when do the lungs volume decreases reach their greatest values?
- When do these values return to relative normal and when is full recovery?
These decreases reach their greatest values 24-48hrs after surgery
- Lung Volumes then return to relatively normal values in 5 days
- Full recovery may take 2 weeks
Algorithm
What should be done when a patient is s/p thoracic or abdminal surgery?
We assess Static Functioning of Respiratory System: SpO2, RR, Dyspnea and Work of Breathing
Algorithm
A patient is s/p thoracic or abdminal surgery, We assess Static Functioning of Respiratory System: SpO2, RR, Dyspnea and Work of Breathing. What would happen if the patient is Favorable?
- Mobilize the patient out of bed
- Teach patient deep breathing exercises and huff/cough with wound support as needed
Algorithm
A patient is s/p thoracic or abdminal surgery, We assess Static Functioning of Respiratory System: SpO2, RR, Dyspnea and Work of Breathing. What would happen if the patient is Unfavorable (but clinically stable)?
- Position the patient in a stable, supported upright posture
- Teach patient deep breathing exercises andn huff/cough with wound support as needed
- We then Reassess Static Functioning of Respiratory System: SpO2 RR, Dyspnea, and Work of Breathing
Algorithm
A patient is s/p thoracic or abdminal surgery, We assess Static Functioning of Respiratory System: SpO2, RR, Dyspnea and Work of Breathing. The patient was found unfavorable (but clinically stable). What happens when we reassessed the Static Respiratory system and they are found to be favorable?
We progress toward the LIPPSMAck POP ambulation protocol
Algorithm
A patient is s/p thoracic or abdminal surgery, We assess Static Functioning of Respiratory System: SpO2, RR, Dyspnea and Work of Breathing. The patient was found unfavorable (but clinically stable). What happens when we reassessed the Static Respiratory system and they are still found to be Unfavorable?
Consider Positive Expiratory Pressure Device and/or Nebulization. If this fails, consider postural drainage +- P&V and/or consult with RT or nursing for suctioning
- If ineffective, contact physician
What is Pneumothorax?
When air is in the pleural space communicates freely with the outside environment
- Effective negative pleural space pressure cannot be maintained, the patient’s ability to move air into the lungs is severely diminished.
What is Tension Pneumothorax?
This means air can enter the pleural space BUT cannot escape into the external environment. This is an acute life-threatening situation
- As air continues to enter and becomes trapped in the pleural space, the intrapleural pressure rapidly increases. This causes the lung on the involved side to collapse. The mediastinal structures are pushed away from the affected side
During the Physical Exam, what breath sounds may we hear with those patients with Pneumothorax?
Decreased or absent
During the Physical Exam, what Adventitous sounds may we hear with those patients with Pneumothorax?
None, maybe a pleural rub
During the Physical Exam, what Transmitted Voice sounds may we hear with those patients with Pneumothorax?
None
During the Physical Exam, what Percussion Note may we hear with those with Pneumothorax?
Hyperresonant
During the Physical Exam, where may we find the trachea when observing those patients with Pneumothorax?
Possibly shifted away from affected side if severe
What is Pleural Effusion?
Although not a primary lung parenchyma disease
- This can lead to RLD pattern due to the physical limitation on lung expansion caused by the presence of fluid
With Pleural Effusion, what is Physical Restriction?
The fluid in the pleural space exerts pressure on the lungs, preventing them from fully expanding during inhalation and reducing the volume available for the lung to expand, leading to a reduction in lung volume such as vital capacity (VC) and Total lung capacity (TLC)
With Pleural Effusion, what may cause Impaired Gas Exchange?
The compression of the lung tissue can also adversely affect the efficiency of gas exchange by collapsing alveoli, further contributing to the Sx of dyspnea
During the Physical Exam, what breath sounds may we hear with those patients with Pleural Effusion?
Decreased or absent
During the Physical Exam, what Adventitous sounds may we hear with those patients with Pleural Effusion?
None, maybe a pleural rub
During the Physical Exam, what Transmitted Voice sounds may we hear with those patients with Pleural Effusion?
None
During the Physical Exam, what Percussion Note may we hear with those with Pleural Effusion?
Dull
During the Physical Exam, where may we find the trachea when observing those patients with Pleural Effusion?
Possibly shifted away from affected side if severe
What is Cardiogenic Pulmonary Edema?
An increase in the pulmonary capillary hydrostatic pressure, often secondary to left ventricular failure
What causes Noncardiogenic Pulmonary Edema?
Has a multitude of causes, including:
- increased capillary permeability
- lymphatic insufficiency
What is the effect of Pulmonary Edema?
What breath sounds would we hear?
With fluid in the alveoli and the interstitium, lung compliance is decreased ➡️ ventilation–perfusion mismatching is increased ➡️ gas exchange is disrupted ➡️ the work of breathing is increased ➡️ and there is RLD and in severe cases acute respiratory failure.
- Breath sounds usually reveal crackles.
What is a Pulmonary Emboli?
- This is a complication of venous thrombosis in which blood clots or thrombi travel from a system vein through the right side of the heart and into the pulmonary circulation where they lodge in branches of the pulmonary artery
With Pulmonary Embolism, many events go unnoticed because they are clinically silent. What are the classic Triad Sx they may experience?
Dyspnea, Hemoptysis, and Pleuritic Chest Pain
Hemoptysis, meaning coughing up blood or blood-tinged sputum from the respiratory tract
What is Interstitial Lung Disease? What does this cause?
A group of lung diseases affecting the interstitium (the tissue and space around the air sacs of the lungs)
- This causes interstitial fibrosis and impairment of lung function
With Interstitial Lung Disease, what are the 4 Buckets this disease can be grouped to?
- Connective tissue related
- Sarcoidosis
- Hypersensitivity
- idiopathic
Individuals with Idiopathic Pulmonary Fibrosis (IPF) may experience what? What is the significance of this?
May experience acute respiratory deteriorations, with development of new or worsening dyspnea and increased oxygen requirements
- Typically referred to as “Acute Exacerbations”, with a median survival of only 3-4 months post-event
What are the Goals for Idiopathic Pulmonary Fibrosis (IPF)?
The goals of treatment in IPF are essentially to reduce the symptoms, slow disease progression, prevent acute exacerbations, and prolong survival
- Meticulous attention to breathing techniques and verbal reinforcement during activity may help reduce subject anxiety and enhance the quality of the measurements
What is Sarcoidosis? What is the effect of this over time?
When idiopathic granulimatous inflammatory disorder affects many systems (multi-system disease) in the body, especially the lung.
These granulomas can be found in the lungs, lymphs, eyes and skin
- Over time, these granulomas can lead to fibrosis, which is the formation of scar tissue. Fibrosis is less elastic than healthy lung tissue, leading to a decrease in lung compliance
How does Sarcoidosis affect the lungs?
Reduces lung compliance, impairs gas exchange, and contributes to restrictive lung disease, often leading to hypoxemia and dyspnea
With Sarcoidosis, what are 3 distinctive features in the lungs?
- Alveolitis (earlies feature found)
- Formation of round or oval granulomas
- Pulmonary Fibrosis
How does Acute Respiratory Distress Syndrome (ARDS) occur?
When the lungs become less elastic, this occurs as a result of a disease that causes inflammation, leading to increased pulmonary vascular permeability, increased lung weight and loss of aerated tissue
How does Acute Respiratory Distress Syndrome (ARDS) affect the lungs?
- The lungs become less elastic due to inflammation, edema and the eventual development of fibrotic tissue, making them more difficult to expand during inhalation
- A ⬇️ in VC, functional residual capacity (FRC) and TLC) follows,.
- Furthermore a build up of fluid, inflammatory cells and fibrotic tissue within the alveolar space impairs gas exchange, leading ultimately to hypoxemia and hypercapnia and respiratory failure
With Acute Respiratory Distress Syndrome (ARDS), what is Alveolar Injury?
Type 1 pneumocyte, which are essential for the gas exchange process, are injured, disrupting the alveolar-capillary barrier, allowing fluid from the capillaries to leak into the alveolar space
With Acute Respiratory Distress Syndrome (ARDS), what is Endothelial Cell Injury?
Injuries to the endothelial cells of the blood vessels leads to increased permeability
What is Non-Invasive Positive Pressure Ventilation (NPPV)?
This is mechanical ventilation that uses a mask instead of an artificail airway with the purpose of assisting the patient with the ventilatory needs when short-term venilatory support is needed
What are the 2 most commonly used Non-Invasive Positive Pressure Ventilation (NPPV) support systems?
- Continuous Positive Airway Pressure (CPAP)
- Bilevel Positive Airway Pressure (BiPAP)
Both of these methods helps treat respiratory conditions by maintaining airway patency, improve oxygenation, reduce respiratory effort, and/or enhance sleep quality. Neither are a contraindiation against mobilization and/or exercise
With a CPAP, what are setting used and with what pathologies is this common with?
With a BiPAP, what are setting used and with what pathologies is this common with?
What are Invasive Ventilatory Devices?
Airway Adjuncts are used to provide a conduit for ventilation, oxygenation, and suctioning and can be used with bag-mask ventilation.
With Invasive Ventilatory Devices, describe Oropharyngeal Airway management.
Oropharyngeal airways can hold the tongue away from the back of the throat and maintain airway patency
With Invasive Ventilatory Devices, describe Nasopharyngeal Airway management.
Nasopharyngeal Airways are positioned to the base of the tongue and are generally better tolerated because it is less likely to stimulate gag reflex in the semiconscious or alert patient
With Invasive Ventilatory Devices, what are the indications to use a Endotracheal Tube (ETT)?
Can be inserted through oral cavity of nose
Indications include:
- Inability to maintain airway patency for adequate ventilation and secretion clearance
- Risk of aspiration
- Anticipation of deteriorating course leading to respiratory failure
The position and security of the ETT should be considered before, during, and after mobilization
