Cardiopulm Unit 4 Lecture Part B Flashcards
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 > 1.4 mean?
Abnormal, suggest incompressible tibial arteries due to calcification/atherosclerosis, obse lower limbs
With ABI, what does the value 1.00 - 1.4 mean?
Normal
- Adequate Blood supply
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
When doing Functional Assessment with patients with PAD, what Measurements should we consider? What should we monitor during the functional assessment?
- Measurements to consider include: time or distance to claudication symptoms, total walking distance, pain intensity and location, walking speed, and recovery time.
- Since the major risk factors are the same for PAD as they are for CAD, heart rate and blood pressure should be monitored. Patients with PAD may exhibit relatively large rises in BP due to atherosclerosis
What are the Implications of PAD for PT?
- The reduction of risk factors of atherosclerosis, particularly smoking, and exercise training are mainstay treatments for mild to moderate forms of PAD
Exercise testing should inform a tailored exercise prescription
- Supervised exercise training for individuals with PAD can provide a supportive environment that encourages the individual to overcome fear of claudication pain and falling, thus increasing intensity of exercise
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 are the 2 classifications of Aortic Aneurysms?
- Thoracic Aortic Aneurysms (TAA) occur along the part of the aorta running through the chest
- Abdominal Aortic Aneurysms (AAA) are found in the part of the aorta passing through the abdomen, with most arising below the renal arteries (infrarenal)
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 Risk Factors for Aortic Aneurysms?
- Smoking
- Age, particularly over 60
- Male gender
- Family Hx
- Hypertension
- Hyperlipidemia
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
What is the Rationale for Exercise Prescription?
- Increased levels of physical activity before hospitalization for heart-related conditions are associated with better short-term cardiovascular outcomes
- Pt with stable ischemic heart disease, each 1 MET increase in exercise is associated with an 8-35% reduction of mortality
- Increased Cardiorespiratory fitness in middle age is associated with a progressively lower risk of developing HF over time
What can Exercise Intensity be based on for Aerobic Conditioning/Endurance?
- Max HR
-Estimated
-Peak
-Found - %HRR
- RPE
- Workload (e.g., METs, Watts)
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)
With RPEs, why would this scale be useful for PTs?
This scale is used for steady state aerobic work (e.g., walking, biking). It provides a LINEAR correlation between perceived exertion and HR, ranging from 6-20, corresponding to a heart rate range of 60 to 200bpm in health individuals.
- So if a person says the exercise was a 11 on the scale, we would multiply by 10 and we would estimate their HR to be 110bpm.
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 MET?
The ratio of the rate of energy expended during an activity to the rate of energy exepnded at rest (Resting metabolic rate)
- This allows for quantification of exercise based on how much energy is required to perform a given task
What are the Strengths of the MET?
- Standardization: Provides a standardized measure to compare the energy expenditure of different activities across different people, regardless of their individual fitness level
- Simplicity and Ease of Use: METs offer a straightforward way to categorize and quantify exercise intensity that is easy to understand for both healthcare providers and patients
What are the Limitations for METs?
- Individual Variability: METs do not account for individual variations in metabolism or fitness level. The same MET value might represent different levels of exertion for different individuals
- Limited in Scope: while useful for aerobic activities, METs are less applicable for quantifying the intensity of strength training exercises
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
With Aerobic Exercise, where do we start?
- We should first perform an exercise test that ramps up to at least that intensity and verify that the patient displays safe vital signs responses and is without adverse reactions or other diseplays of things that would make the exercise unsafe
While the absolute risk of a cardiac event during vigorous intensity exercise is very low, the risk is highest in individuals who are habitually inactive, have low levels of fitness, and those with coronary artery disease - We should consider co-morbidities or other factors that may effect exercise tolerance
With Aerobic Exercise, How do we progress?
For severely deconditioned clients with chronic disease or disabilities, consider initiating exercise at low intensities within a conditioning phase with duration and frequency adjusted according to their individual capacity.
- It is crucial to start with a conservative exercise volume to avoid the development of overuse injuries. It is always easier to increase an overly conservative training load than to be forced to reduce training parameters or even abort the exercise program to allow for recovery from overuse injuries
What is the rationale of Resistance Training?
- Resistance training can be especially effective in patients that do not tolerate continuous or interval aerobic training or other therapeutic modalities
- Loss of muscle mass has been reported to explain approximately 50% of the decline in peak aerobic capacity with age and power and strength levels are positively associated with the cardiorespiratory capacity in elderly subjects.
- Targeting this loss of muscle function with RT (even without any aerobic exercise) has been shown to increase aerobic capacity by between 8-24% in older adults
Aerobic exercise alone does not improve strength thus is insufficient as a
single modality for older adults
With other factors to consider with when training, what are warm-ups important?
- Improves ROM and may reduce the risk of injury during the exercise session
-The warm-up emphasize the large muscle groups that are related to the trainingmovement
What are some conditions that may require a longer warm-up?
- CAD
- Cardaic Denervation (SCI, heart transplant)
- Autonomic Dysfunction (DM, PD)
With other factors to consider with when training, what is typically the Order of Exercise?
In general, begin with warm-up, then consider proceeding to strength/power training, balance exercises, or novel activities depending on priorities, and then finally aerobic/endurance training followed by a cool-down
With Exercise programs, why might a patient not adhere to the program?
- Socioeconomic status
- Education level
- Living alone has been reported to be associated with levels of adherence
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
What are the Key Goals for Phase 1 of Cardiac Rehab?
- Physiological Monitoring: Assess responses to self-care and mobility, particularly during early mobility with portable devices (e.g., pulse oximetry, ECG, arterial line).
- Feedback for medical team: Provide vital patient activity response data to medical team for informed care adjustments.
- Activity Guidelines: Offer safe, progressively adjusted activity plans based on daily reassessments.
- Patient & Family Education: Focus on disease understanding, risk modification, self-monitoring, and formal CR program awareness. Provide initial guidance and written materials for ongoing education post-discharge.
Phase 1 Cardiac Rehab
With a Chart Review, what are things we should look out for iin the Inital Assessment and Diagnostic Overview?
Primary and Secondary Diagnoses:
* Identify main diagnoses, admission reasons, and comorbidities affecting cardiovascular care.
* Track cardiovascular symptoms at admission and monitor trends during care.
* Identify and consider medications.
Cardiac Risk Factors:
* Assess risk factors to guide precautions during activity and identify needed referrals.
Laboratory and Diagnostic Data:
* Evaluate blood tests to assess cardiopulmonary dysfunction severity.
* Review chest radiographs and imaging for insights into lung/heart pathology.
* Consider cardiac catheterization and echocardiography results for targeted rehab strategies.
Phase 1 Cardiac Rehab
With a Chart Review, what are things we should look out for iin the Medical Management and Monitoring?
Surgical History:
* Review of surgical procedures informs PT precautions and potential complications.
* Consideration of graft locations, pacemaker implantation, and surgical complications impacts rehab approach.
Monitoring:
* Track trends in vital signs and hemodynamics to assess cardiovascular stability during activity.
* Continuous ECG and telemetry to monitor rhythm and respond to myocardial injury; typically using 3- or 5-lead systems.
Medications and Supplemental Oxygen:
* Review cardiac medications to anticipate effects on exercise tolerance.
* Consider oxygen therapy requirements and adjust activity intensity to maintain adequate oxygenation
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
Phase 1 Cardiac Rehab
Why is the patient interview important?
Effective patient interviews hinge on clear communication and rapport, using simple, open-ended questions to understand the patient’s symptoms and perspectives on their health issues.
- Active listening is key to comprehending the patient’s experiences and responses to their condition
Phase 1 Cardiac Rehab
What information should we gather during a patient interview?
- Patients complaint
- Hx of medical problems
- Report of Sx
- Risk factors
- Their understanding of problem
- Family situation
- Readiness to learn
- Goals for rehab
Phase 1 Cardiac Rehab
What does a System Review of the Cardiovascular system include?
- Vitals
- Cardiac rhythm
- Peripheral pulse
- Inspection of edema
- Cardiac and pulmonary auscultation
- Observation of breathing
Severe irregularities found in any of these examinations may reflect an unstable physiologic state that requires additional screening and/or urgent medical management
Phase 1 Cardiac Rehab
What are some Abnormailties we may find during a Systems Review?
-
Skin Color/Tone can reflect the efficiency of blood circulation and the oxygenation levels of the blood (e.g.,
pallor might indicate poor blood flow or anemia, bluish tint (cyanosis) suggests oxygenation impairment). -
Abnormal vital signs reflect an underlying physiology that may impact the patient’s capacity for movement
and exercise due to limitations in pumping and oxygen delivery to tissues. The patient may experience Sx like fatigue, dizziness, or shortness of breath during physical activity. -
Diminished pulses or cool extremities may indicate reduced blood flow, potentially causing tissue ischemia,
pain, and muscle weakness, especially in the lower limbs. This can severely limit a patient’s capacity for walking and weight-bearing activities. -
Symmetrical Dependent Edema may indicate fluid retention related to impaired cardiac pump function.
This can lead to increased limb weight, discomfort, and reduced joint mobility, affecting movement and exercise tolerance.
Phase 1 Cardiac Rehab
When should we do an Activity Evaluation Post-Uncomplicated MI? What should be monitored?
- Early activity evaluation is key after a cardiac event when the patient stable
-Typically 1-2 days post-uncomplicated MI - Monitor Vital signs continuously: HR, Rhythm, BP, SpO2, and Sx during activity
Phase 1 Cardiac Rehab
When should Activity Evaluation be terminated? What are some considerations?
- Terminate evaluation immediately if abnormal responses occur (e.g., severe dyspnea, arrhythmias)
- Safe progression guide progression to monitored, individualized activity
- Consider pre-hospital activity levels and patient-specific discharge goals
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
With the Discharge Planning of rehab for uncomplicated MI, what is done in this stage? What should you educate the patinet on?
Determine need for assistive device and follow up services
Education:
- Safe use of AD
- Benefits of follow-up services, such as home health PT, OP PT and cardiac rehabilitation programs
- Family/caregiver training if needed
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
With Phase 1 of Cardiac Rehabilitation, what should we Educate the patient on?
- Diease process and prognosis
- Self-monitoring techniques (RPE, pulse, BP)
- Sx recognition and reponse (Ischemia, dyspnea, arrythmias)
- General activity guidelines and home exercise prescription
- Med management
- Lifestyle modifications
- OP services
When can you Initiate “Phase 2” of Cardiac Rehab?
Current guidelines do not provide robust recommendations on when exercise should optimmaly commence after MI
- Most begin at least 4 to 6 weeks after hospital discharge by studies suggest that earlier initiation may lead to improved remodeling and cardiopulmonary capacity in patients who are clinically stable and without complicated course
When can you Initiate “Phase 2” of Cardiac Rehab with those with Smaller-sized Infarcts?
The risk of adverse events or complications (e.g., re-infarction) do not appear to be greater when exercise is initiated at one
week versus six weeks post-MI.
- This is consistent with findings that demonstrate that exercise stress testing is safe and feasible in the majority of post-MI patients 3 days after infarction
When can you Initiate “Phase 2” of Cardiac Rehab with those with Larger-Sized infarcts or complicated courses?
- Initiation of exercise may be more safely deferred or otherwise limited to low-level intensities until later phases
of healing when the newly laid scar tissue is less vulnerable to stress. - A relatively conservative approach is also advised after subendocardial MIs (NSTEMIs) due higher observed rates of
reinfarction.
What is the OP Cardiac Rehab Criteria for Candidacy?
- MI within the past 12 months
- CABG
- Stable Angina
- Heart or lung transplant
- Heart Valve repair or replacement surgery
- Stable CHF (Stable patients are defined as patients who have not had recent (< 6 weeks) or planned (< 6 months) major cardiovascular hospitalizations or procedures)
- PVD
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
If a patient has Arrhythimias (for PVCs) when exercising, what questions should we ask and when should we stop exercise and being treatment?
If a patient has Ischemia when exercising, what questions should we ask and when should we stop exercise and being treatment?
