Cardiopulmonary-Vascular Flashcards
What is cardiomyopathy
- heart with increase mass but difficulty with pumping
- common risks: alcohol, 3rd trimester
What is hypertrophic cardiomyopathy? + s/s?
Hypertrophied heart, abnormalities in filling
- young athletes at risk of dying
- s/s: cheat pain, SOB, sudden
What is Cardiac Tamponade? s/s?
- Compression of the heart due to blood/fluid in the pericardial sac
- may be due to puncture wound from a heart procedure
S/s: jugular distension, hypotension, muffled heart sounds
What is arteriosclerosis? (Simple pathology, effects & it’s risks)?
Stiffening of arteries, thickening, dec elasticity, hardening
Type:
- Atherosclerosis: artery thickens due to accumulation of atheromas (WBC + Cholesterol + triglycerides) in lumen
- Effect: weakens underlying artery
Risk for: MI, stroke, aneurism
- What is aortic stenosis?
- it’s consequences?
- Calcification due to age or lipid accumulation
Consequences:
- heart murmur, hypertrophy, angina, syncope
What is an aneurism?
- causes, sites, result, s/s
- localized abnormal dilation of the wall of a blood vessel (may rupture)
Causes: atherosclerosis, trauma, congenital defect
Sites: aorta
Result: Aortic distension
- tear in inner wall of aorta, so blood flow b/w layers of wall and forces them apart.
S/s: chest or abdominal pain, dissecting aneurism = tear within wall)
What is a “Flail Chest”? + associated conditions + Rx
When rib segments break/ move independently due to fracture
- accompanied by “pulmonary contusion” (then respiratory failure), paradoxical breathing
Rx: pain control, intubation/ventilation, O2, airway clearance
Features of paradoxical breathing?
Inspiration:
- flail segment sucks in: lung, heart, mediastinum SHIFT AWAY, reducing air entry into the unaffected lung
Expiration:
- flail segment pushed outward: lung, heart, mediastinum are PUSHED TOWARDS the flail segment
Rx: pain control, intubation, o2, secretion clearance
What is a pneumothorax? Sound on percussion
Collapse of lung due to air in the pleural space from a chest wall puncture, or spontaneously bursts
Percussion: hyperresonant
Types of pneumothorax + Rx
Rx: aspirate or insert chest tube
1) Open: stab wound, air into pleural space
2) Tension: (v. Serious): causes increased pressure on the heart
- on expiration the open wound becomes sealed; air goes from affected lung into pleural space
- inspiration, air will stay in the pleural space
3) Spontaneous: rupture of air containing space of the lungs
4) Hemothorax: collapse of lung due to blood in pleural space
- ax: decreased breath sounds
3 features of the myocardial terrible triad and ECG finding
1) Ischaemia:
- inverted T waves = poor blood supply + hypoxia
- occurs seconds of onset, is reversible
2) Injury:
- Elevated ST segment: during MI (20-40 min), is reversible
- Depressed ST segment: during angina
3) infarction:
- abnormal Q waves + QRS complex
- increase R waves
- Not reversible, occurs 2 hrs after onset
Bradycardia and tachycardia values
Brady: 100
Tachycardia: 100
What is the result of Ventricular fibrillation + Rx:
Incompatible with life
Rx: requires defibrillator
Features of valvular heart disease?
1) Stenosis: failure of valve to open completely, decreased forward-flow
2) Regurgitation: failure of valve to close: reverse blood flow
Differentiate degree AV blocks types and characteristics
1st: Prolonged conduction in AV node (PR), P-wave normal
2nd:
a) Mobitz type 1: transient AV node block
- PR lengthens until totally QRS blocked, causing a missed beat
b) Mobitz type 2: Bundle branch block/bundle of His
- PR interval is normal with abrupt block of QRS
3rd: Block at AV node, bundle of His or bundle branches
- complete disassociation b/w atria and ventricles (independent rates, atrial faster)
- Bundle branch block = wide QRS
What is CHF?
- Types + Risk factors + s/s
- inability of heart to pump blood at rate required by tissues, or able to but at elevated filling pressures
Types:
- L sided: can’t pump blood out, results in fluid build up in lungs
- R sided: Can’t pump blood to lungs, back up in blood vessels causes fluid retention in extremities
Risk factors: HTN, CAD, Valve conditions, DM, thyroid
S/s: fatigue, swelling, weight gain, SOB, cough, wheeze, Dyspnea, etc
What is Left sided Heart failure
- can’t pump blood out of heart leading to damming of blood in pulmonary circulation
S/s:
- SOB when lying, gasp of breath when sleeping, decreased kidney and brain perfusion, exertion all dyspnea
- pulmonary congestion: cough, crackles, wheeze
What is right sided heart failure + causes + effects
Aka: Cor pulmonale (altered structure of RV), causes left sided heart failure
Causes: long term pulmonary HTN + R ventricle, emphysema, COPD, cystic fibrosis
Resultant effects:
- decrease flow in periphery
- Pitting edema (increase peripheral Venous pressure)
- congestion of portal system (liver damage, enlarged spleen)
- kidney and brain issues, fatigue
What is Ischemic heart disease + s/s
Causes = myocardial ischemia
S/s: Angina, MI, sudden cardiac death
- 90% due to atherosclerosis
What is Angina Pectoris?
+ causes + types
- Paroxymal (sudden attack, short and frequent) recurrent episodes of chest discomfort
Cause:
- transient ischemia of heart muscle due to obstruction/spasm of coronary arteries.
- types: Stable, unstable, prinzmetal (variant) at rest.
What is an MI?
Blood not flowing to part of the heart muscle due to injury from lack of O2.
Risk factors: CAD, age, smoking, cholesterol level
Cause: coronary artery blocked due to unstable atheromas (WBC, cholesterol, triglycerides)
S/s of MI, + Ax + Rx
S/s: sudden chest pain, L UE/neck pain, SOB, sweating, nausea, anxiety,
Ax:
- blood test: Troponin + Creatine kinase
- ECG: STEMI = elevated ST segment
Rx:
- Aspirin (immediate) = prevents further blood clotting
- Nitroglycerin = treat chest pain + O2 delivery
- Angioplasty = open artery back up
- Thrombolysis = blockage removed with med
- bypass surgery = especially if have DM or multiple blockages
Types of lung cancers
1) small cell (20-15%)
- develops in bronchial cell mucosa
- spreads rapidly & metastasizes early
2) Non-small cell:
a) Squamous cell = arise centrally near hilum, slow spread/ late metastases
b) Adenocarcinoma (30-45%) = mod spread, early mets to brain/ organs
c) Large cell = rapid spread + wide mets to liver, kidneys, etc, poor prognosis
PT Rx: manage fatigue
What are the types Brain cancer? + s/s
a) Intracerebral Primary = tumor neurons don’t proliferate
b) “ Metastic = from lungs, breast, prostate
- compensate by decreasing brain volume, CSF vol + blood flow vol
c) Other:
- Medulloblastomas = metastases to spine etc,
- Neuronomas = Schwannoma (Cranial nerve 8, vestibular)
S/s: N. Root pain, worse at night, pain with cough, radicular pain, head ache, seizure, nausea, cognition, behaviour
What is Pneumonia + its causes?
Inflammation of parenchyma of lungs
Causes:
- bacterial, viral, fungal (airborne pathogens)
- inhalation of toxic chemicals (smoke, dust, gas)
- aspiration: leads to impaired consciousness via ACHL abuse, post sx, neuro disease
What are the types of Pneumonia
Typical:
- sudden onset due to bacterial infection
- fever, sputum, physical consolidation signs
Atypical:
- No symptoms, little sputum, minimal chest signs
Pneumonia S/s + Rx
S/s:
- most preceded URTI, followed by sudden + sharp chest pain
- Productive green sputum
- Tachypnea ( increased RR)
- SOB
Rx: antibiotics/virals, airway clearance techniques, O2 support, positioning
What is Atelectasis + causes + distribution?
- Collapse of normally expanded and aerated lung tissue, either patchy, segmental, or lobar distribution
Causes:
- blockage of bronchus/bronchioles: paralysis, diaphragmatic disorders, mucous or airway obstruction, hypoventilation
- Compression due to pneumothorax, pleural effusion, tumor preventing alveoli from expanding
- Postanesthetic: effects of drugs and recumbency
Atelectasis s/s + Rx?
S/s:
- CXRAY: shifting of lung structure towards collapse, or shadow if entire lobe affected.
- Quiet breath sounds
- Dyspnea
- Tachypnea
- Cyanosis (low O2 saturation)
Rx:identify cause
- suction if from secretions
- chest tube if pneumo/hemo thorax or extensive pleural effusion
Define Acute respiratory distress syndrome? + pathology
- Acute respiratory failure w/ severe hypoxemia due to pulmonary or systemic problems
Pathology:
- lung injury characterized by increased permeability on alveolar capillary membrane, causing a leakage of fluid and blood into lung interstium + alveoli
ARDS: causes, results, Rx?
Causes:
- severe trauma, aspiration, embolism, infection/pneumonia
Result:
- inflammatory cascade, alveolar edema and colapse
- CXRAY: White out
Rx:
- PEEP: keep airways open
- position in prone
What is Severe acute respiratory syndrome? + S/s + result
Viral respiratory illness caused by SARS coronavirus
S/s: flu-like: fever, myalgia, cough, sore throat, lethargy
Result: can lead to pneumonia
What is a lung abcess + its causes
Infection leading to necrosis of lung tissue and cavity formation w/ necrotic debris
Cause:
- aspiration, predisposition if an alcoholic
What is Infant respiratory distress syndrome? + risks factors + Tx
- Lack of surfactant makes alveolar sacs prone to closing
- in infants with underdeveloped lungs
Risk factors:
- prematurity, c-section, blue baby, grunts, stops breathing
Tx: artificial surfactant
What is hypoxemic respiratory failure? + causes?
Gas exchange failure = arterial hypoxemia
- low blood O2 or can’t clear CO2
Causes:
- Pneumonia, ARDS, Obstructive lung disease, pulmonary embolism
What is hypercapnic respiratory failure? + causes?
++ CO2 in the blood, low blood O2
Causes:
- decrease ventilation from drugs or reduced respiratory control
- acute airway obstruction
- weak/ impaired respiratory mm
- SCI
What is asthma, what are its features?
- Spasm of airway from chronic inflammation of lungs/ airways causing airflow limitation + hyper-responsiveness
- airway hyper-responsiveness
- wheezing, breathlessness, chest tightness, coughing
- smooth mm contraction
What are the two types of asthma categories?
1) Extrinsic: allergic or atopic
- mast cells release mediators = bronchospasm + hypersecretion
2) Intrinsic:
- hypersensitivity to bacteria, drugs, cold, stress
What happens in lungs during an asthma attack + Rx?
- narrowed airway (tightened mm) + inflamed + thickened
- normal gas exchange
- lungs hyperinflated
- normal elastic recoil
- —- results in reduced exercise capacity
Rx:
- prevent triggers, inhaled corticosteroids
- if EIB: smooth mm constriction: upright, lean forward & purse lip breathing
Characteristics of COPD
Progressive airway obstruction that is not fully reversible:
- Hyper inflated
- normal gas exchange
- decreased elastic recoil
- onset: mid-old adult
Rx:
- pharmacology focus: smooth mm relaxation + reduce airway inflammation
- O2 therapy: except if patient has pulmonary HTN or CHF
What is bronchiectasis? causes, characteristics, Rx?
Irreversible destruction (necrosis) + dilation of airways with chronic bacterial infection
Caused by: CF, TB, endobronchial tumors
- Features: ++mucous, alveoli replaced with scar tissue (chronic inflm)
- Rx: bronchodilators, antibiotics, secretion clearance
What is Bronchitis?
Excess mucous production due to inflamed mucous membrane
What is Emphysema?
1) Destruction of air spaces distal to terminal bronchioles + alveolar septa = merging of alveoli into larger air spaces thereby decreasing SA for gas exchange
2) loss of airway and capillaries
What is the impact of emphysema during exhalation
+ Rx Impact?
Exhalation:
- damaged alveoli = old air becomes trapped, no space for new O2 air
- Hyperventilation flattens diaphragm = mechanical disadvantage
Rx: can slow progression but not reversible
What is interstitial lung disease? S/s, Rx?
Stiff, decreased lung compliance (not airway obstruction)
S/s: dyspnea, sever O2 desaturation, finger clubbing, scaring (CT)
Rx: O2 therapy, lung transplant, pulmonary rehab
What is pulmonary fibrosis? Causes + Rx?
- Fibrosis b/w alveoli from inhaling harmful particles, results in decreased gas exchange
Cause: 2/3 idiopathic, 1/3 TB
Rx: radiation, meds
What is idiopathic pulmonary fibrosis?
Scarring and fibrosis of alveoli
What is asbestosis?
“Restrictive” disease caused by inhaling asbestos
What is Pneumoconiosis
Aka: Coal workers lung
What is tuberculosis?
Infectious, inflammatory systemic disease that affects lungs via air borne particle
- may disseminate to involve kidneys, growth plates, meninges, avascular necrosis of hip joint
How to determine if you have TB?
TB skin test into forearm
- determines if body’s immune response has been active to TB before
TB s/s, result, Rx, PT precautions
S/s: productive cough 3+ weeks, weight loss, fever, night sweats, fatigue, bronchial breath sounds
Result: granulomas in lung tissues
Rx: medication
PT: Hx self protection (mask)
What is pleura effusion? + causes?
Accumulation of fluid in the pleural space due to disease can lead to Atelectasis
Causes:
1) Transudate: do to heart failure
- low protein, clear
2) Exudate: fluid from inflammation or disease
- opaque
Pleural effusion s/s + xray feature
S/s:
- SOB, chest pain, dull percussion, decreased or absent breath sounds, maybe pleural rub
CXRAY:
- silouhette signs
- mediastinal shift if large
What is pulmonary edema?
Increase fluid in extravascular spaces of the lungs
Causes:
- increases hydrostatic pressure due CKD or HF (fluid pushed out of vessels)
- increased alveolar permeability from drugs, ARDS, gas
Pulmonary edema s/s + auscultation sounds
S/s:
- stiff lungs = increase WOB
- Dyspnea
- productive cough with frothy pink sputum
O/A: fine crackles
What is a Pulmonary embolism + s/s?
blood clot in the lungs
S/s:
- bloody sputum
- Dyspnea
- Tachypnea
- SOB
- cyanotic
What is cystic fibrosis and its effects?
Inherited autosomal disorder affecting all exocrine glands
Effects:
- defective CI = excretion and sodium absorption = thick mucus
- recurrent chest infections
- consolidation
- atelectasis
- thickened bronchial wall
CF Dx?, s/s? Rx?
Dx: fam Hx, gene testing (two copies of bad gene), sweat test (measure chloride content)
S/s:
- respiratory symptoms, finger clubbing, breathlessness, delayed puberty, skeletal maturity, infertility in males, DM, liver diseas, Osteoporosis
Rx:
- airway clearance techniques, bronchial dilators, antibiotics
What is peripheral artery disease + s/s + effect
Underlying cause is atherosclerosis
S/s: distal to site of narrowing or obstruction
- intermittent claudication (pain in legs w/ activity)
- acute ischemia (pallor, pain paralysis, pulseless)
- ulceration and gangrene
- skin (shiny/hairless) often in feet
Result:
- decreased mobility due to pain + loss of function or limb
What is peripheral vascular disease?
Sites of obstruction and pain + s/s?
Obstruction of blood vessels supplying extremities
Sites:
- often in IF iliac, femoral, popliteal arteries of legs
- pain during activity, most often in the calf
S/s: intermittent claudication, decrease pulses, ulcer, cool skin, limit mobility and pain
What is thrombophlebitis?
Partial or complete occlusion of a vein by a thrombus with secondary inflammation
What is a DVT? Why is it bad?
+ s/s + test?
Blood clot in deep veins that can become a pulmonary embolism
S/s:
- tender calf ( thrombus in calf vein)
- fever
Test: Homan’s sign (passive DF), wells score
Define chronic venous insufficiency + causes + effects
Inadequate venous return over a prolonged period
Causes: DVT, obstruction via tumor
Effects:
- damaged valves lead to venous stasis
- edema
- thickening brown skin + ulcer
What are varicose veins? + result/risk?
Faulty valves cause abnormal dilation of veins
Result:
- twisting and turning of the vessels
- increased thrombosis risk
List of important lung volumes
- Tidal volume: 500mL
- inspiratory reserve volume: 2-3L
- expiratory reserve volume: 1L
- residual volume: 1L
Define tidal volume?
- volume inspired or expired with each normal breath
- 500mL
Define inspiratory reserve volume
- Max volume that can be inspired (on top of tidal volume)
- used during max exercise
- 2-3 L
Define expiratory reserve volume
- Maximum volume that can be expired after the expiration of tidal volume
- 1L
What is residual volume
Volume that remains in the lungs after maximum expiration
- cannot be measured by Spirometry
- 1L
Important lung capacities?
- Inspiratory capacity: 2.5-4 L
- Functional Residual capacity: 2 L
- Vital capacity: 3-4.5L
- Total lung capacity: 4-6L
Define inspiratory lung capacity?
- volume of max inspiration
- IRV + TV = 2.5- 4L
Define functional residual volume?
Volume of gas remaining in lung after normal expiration
- ERV + RV = 2 L
Define vital capacity?
Volume of max inspiration + expiration
- IRV + TV + ERV = IC + ERV = 3-4.5 L
Define total lung capacity:
Volume of the lung after max inspiration
- the sum of all four lung volumes:
- IRV + TV + ERV + RV = IC + FRC
What is lung dead space
Volume that does not participate in gas exchange
- 300mL / 2
Anatomical DS = volume of conducting airways
Physiological DS = volume of lungs that does not participate
What is normal FEV1
Amount of air expired in 1 second after maxinspiration
Normal: 80% of the forced vital capacity = FEV1/FVC
Restrictive disease: dec FEV1, dec FVC = ratio >0.8
Obstructive disease: dec + FEV1, dec FVC = ratio
Findings based on post bronchodilator FEV1 test
Stage 0:
- risk factors + chronic symptoms but normal Spirometry
Stage 1:
- FEV1/FEV ratio 80% predicted + symptoms
Stage 2:
- FEV1/FEV ratio
S/s of cardiopulmonary disease
- pain in chest, neck, jaw
- SOB
- dizzy, syncope
- Orthoptera (SOB when lung flat)
- ankle edema
- palpitation/ tachycardia
- intermittent claudication
- known heart murmur
- unusual fatigue
What are the 3 phases of cardiac rehab?
1) inpatient
2) outpatient 12 week program
3) in the community
3 goals of cardiac rehab?
1) Restore optimal function
2) Prevent progression of underlying processes
3) Reduce risk of sudden death and re-infarction
Exercises to avoid during cardiac rehab?
1) Valsalva
2) extensive upper body activity
3) isometric or static exercises
Cardiac rehab FITT prescription
+ modification for beta blocker or pacemaker, angina
F: 3-5days/week
I: 60-80% HRR (RPE 4)
- except if you have a beta blocker or pacemakFor pacemaker stay 30 bpm below level that it starts at or 10-15 beats below onset of abnormal symptoms or angina
T: work up to 45-60min in 5-10min intervals
T: who body dynamic movement
What does a beta blocker do?
What conditions is it suitable for?
Decreases : HR, contraction force, conduction velocity b/w SA and AV node, myocardial O2
- CAD, Angina pectoris, HTN, irregular rhythm
Considerations when patient is using beta blockers
- blunted HR/ BP response
- decreased resting BP and with exercise
- postural hypotension,
- decreased ischemia with exercise
- increase exercise tolerance in ppl either angina
- use RPE not age predicted HR.
Nitrate/nitroglycerin function + conditions it used for
Fx: Relaxes smooth muscle in blood vessels, increases flow and decreases workload + O2 supply of heart muscle.
Uses:
- CHF, Angina, MI
Considerations when patient is on nitro?
- Increased resting/exercise HR
- decrease resting/exercise BP
- postural hypotension changes
- increased exercise capacity either angina patients
What to tell a patient about nitro Rx and handling.
Doses 3-5 mins apart
Say:
- storage, expiry date, cool dry place, prime before taking 1st dose, sit down, wait 5min X 3 then go to hospital or return of lower HR.
What is the function of a ACE inhibitor, what conditions is it used for?
Angiotensin converting enzyme:
- blocks conversion of angiotensin I to II
- prevents vasoconstriction, decreases peripheral resistance, increased urine output
Use: HTN, CHF, CVD, MI, Kidney fxn in DM
Helps patients with CHF exercise more
Anti-cholesterol agents fxn
- decreased mortality in CAD patients even if cholesterol is normal, lowers cholesterol (LDL) and triglycerides.
Anti-platelet agents function, uses, contraindications + cautions.
- Decreased platelet aggregation at site of tissue damage
Use: reduces risk of MI, TIA, Brain attack or Ischemia
No contraindications to exercise or effects on HR or BP
Caution regarding bruising, or bleeds
Symptoms to ask for during lung disease Ddx?
- Dyspnea
- Cough
- Wheeze
- Cyanosis
- finger and toe clubbing (seen in COPD, CF due to chronic hypoxia)
- decreased O2 saturation
When is a flow volume loop test contraindicated?
In any condition prohibiting a max maneuver
When is simple spirometry contraindicated?
- recent MI, stroke/abdominal/thoracic sx, uncontrolled HTN, recent pneumothorax
When is spirometry testing indicated?
Dx lung disease, quantify extent of known disease, measure effect of occupational/ environmental exposure, Ax for risk of respiratory complications, evaluate impairment
What do we expect to see after a bronchodilator spirometry test?
Obstructive pattern:
Increase lung volume, decreased FVC, decreased ++ FEV1, decreased ratio
Restrictive pattern:
Decreased lung volumes, decreased FVC, decreased FEV1, ratio Is normal
Why would you measure diffusion capacity?
Provides Dx of emphysema
When would you perform a methacholine challenge test?
Dx asthma
- same as histamine… Causes inflammation
When would you do a VQ scan?
Used for perfusion disorders (pulmonary embolism)
What does IPPA stand for?
Inspection, palpation, percussion, auscultation
What to look for during Inspection of IPPA
1) Lines: HR, BP, SP02, RR
2) position of patient
3) head: facial expression, orientation X 3, speech, skin (color, sweat, temp), lips, nose (flaring), neck (accessory mm, distended jugular), chest (shape, deformity), breathing type (apical, diaphragmatic, accessory mm), limbs (color, clubbing, edema), cough (strong?, productive?), sputum (color, amount,smell)
What to do during palpation of IPPA
- Chest wall expansion (upper, mid, lower [front and back])
- tactile fremitus: ulna border of hand, feel vibrations
- trachea position at base of sternum
- Vitals: HR, BP, RR
What to do doing percussion of IPPA?
- middle finger over intercostal space, ax L & R upper mid and lower lobes anteriorly and posteriorly.
Sounds:
1) resonant (normal)
2) Dull = consolidation, pleural fluid
3) hyper-resonant = air
What is the difference b/w the sides of the stethoscope?
- Diaphragm picks up high pitch better
- Bell picks up low pitch better
What to do during auscultation of IPPA?
Points: 6 front, 10 back (look up diagram of lobes)
Breath sounds:
- bronchial = Hollow, short pause between inspiration and expiration, normal sound over trachea
- Adventitious = crackles inspiratory vs. Expiratory (early [airway obstruction], late [edema, fibrosis, partial consolidation]
- Wheeze: inspiratory vs. Expiratory, high (uniformly narrowed) or low pitched (intermittent narrow)
- Stridor: loud musical constant pitch with laryngeal or trachea obstruction
- pleural rub = creaky, leathery
11 steps of a chest X-ray
- Is it AP or PA?
- if AP, mediastinum is larger, dec inspiration, positioning compromised - Over or under exposed?
- Satisfactory inspiration?
- 9 ribs post, 6 anteriorly above dome of diaphragm - It the patient rotated?
- line from T1-4 & measure distance to end of clavicle
5) Is the heart enlarged?
- A/B ratio should not be >50%, A = width of heart, B = width of lung cavity
6) are both domes of diaphragm clearly seen?
- angles, costocardiac, right dome help indicated what lobe the pathology is in
7) position of mediastinum?
- tracheal shift in line with T1-4, it shifts towards the dec volume
- shoulder be 2:1 , R:L
8) landmarks in the mediastinum?
- pulmonary artery, cobweb appearance of blood vessels
9) Are the hila and fissure normal?
- should be at same height
10) are the bones normal? Fractures?
11) clinical reasoning:
CXR presentation of Atelectasis
- Shifting of land marks
- silhouette signs
- lobar collapse can be white b/c no air is in it/ full or secretions
Consolidation or pleural effusion on CXR
- lung fields opaque
- usually signs of Atelectasis with consolidation
- pleural effusion may have bunting of the costophrenic angle, and sometimes mediastinal shifts to opposite side
Pneumothorax findings on CXR?
- Dark area because of air
- absence of lung markings,
- fine line showing outline of the collapsed lung
Pulmonary edema on CXR?
- Enlarges peripheral vessels
- Opacities
- fluffy shadows
COPD on CXR
- Flattened diaphragm
- pear shaped heart
- enlarged chest cavity
- hyper-inflated/ flat ribs
What does PO2 measure
what determines PO2?
- measures free unbound 02 molecules, is the driving force for Hb saturation with O2.
- PO2 is determined by:
1) alveolar ventilation 2) V/Q 3) FiO2
What are normal ABG ranges
pH: 7.35-7.45 PaCO2: 35-45 HCO3: 22-28 PaO2: 80-100 mmHg SaO2: 95-100%
What is going on during metabolic or respiratory acid/alkalosis
Metabolic and respiratory acidosis = the pH is lower than normal
Metabolic and respiratory alkalosis = the pH is higher than normal
Resp acid: pH dec, PaCO2 inc, HCO3 normal
Resp alkal: pH inc, PaCO2 dec, HCO3 normal
Meta acid: pH dec, PaCO2 normal, HCO3 dec
Meta alkal: pH inc, PaCO2 normal, HCO3 inc
Rules when interpreting ABG’s
1) look at pH first to see what the primary process is
2) respiratory compensation can take minutes to hours
3) renal compensation takes 1-5 days
- for alveolar hypoventilation the PO2 should only decrease 1 mmHg for each 1 mmHg of PaCO2
Indications for Oxygen therapy
- SaO2 40%, ARDS, transport with O2, artificial airway
PaO2
Details of uses between: Low flow, high flow,
FiO2 of 1 L/min
1) Low flow: supplemental O2 to tidal volume
- NP (6L max), simple mask, partial rebreathing mask, non rebreathing mask
High flow:
2) Enough O2 to supply the entire TV
- Venturi face mask, face tent, tracheostomy mask
3) 24% 02 = goes up 4% every L
Incentive spirometry: purpose, method, contraindications
Purpose: Patient with Atelectasis: provides visual input/incentive goal
Method: sustained inspiratory effort ~3sec, relaxed expiration
Contraindications:
- cognitive impairment, patient unable to take deep breathe effectively due to pain, diaphragmatic dysfunction,
Inspiratory mm training:
- purpose
- needed Ax
- type of device
- first session FITT
- contraindications
- Purpose: retrain mm of inspiration for CHF, COPD, SCI, athletes
- Need: measure max inspiratory pressure + max expiratory pressure, - Device: threshold trainer
- Initial FITT: start w/ 5 min, progress over 2-3 weeks 2 x 15min -30, 4-5 days/week. Begin at 20-30% MIP, progress to 50%MIP as tolerated
- Contraindications: Acute respiratory failure, cognitive impairment
How to use V/Q matching for an Atelectasis
- encourage re-expansion, put diseased lung in the non-dependant (up) position and do unilateral breathing exercises in this position.
Discuss V/Q matching for “Ventilation”
- Normal: greatest in dependant regions
- Abnormal: usually preferentially will vent the diseased areas of lung
- Effect of mech vent: air flow path of least resistance, usually non-dependant region
Discuss V/Q “perfusion” principles
- Normal: greatest on dependent regions
- Abnormal: Unless restricted it will flow to gravity dependent regions
- Effect of mech vent: increased pressure can restrict blood flow to non dependent regions
Treatment principles for V/Q
- normal
- abnormal
- mech vent
- Normal: lower regions of lungs has greatest VQ matching in upright lung
- Abnormal: generally place affected area in the non dependent position to increase VQ matching
- mech vent: whatever works best do it.
Why perform breathing exercises?
- increase ventilation, prevent Atelectasis, dec WOB and O2 consumption, remove secretions, inc chest wall mobility
Diaphragmatic breathing: indications, why, how, additions?
Indications: post op, Resp failure, chronic respiratory distress
- Why: inc lung expansion and compliance, reduces V/Q matching, increase respiratory mm strength
Additions: end inspiratory hold, lateral costal, sniff
List of breathing exercises
- diaphragmatic
- pursed lip
- Segmental
- breath stacking
Assisted Cough: indications, contraindications, precautions, procedures
- indications: an ineffective cough seen in patient SCI, NMD, chemically paralyzed, weak respiratory
- contraindications: Ruptured diaphragm
- precautions: IVC filter, rib #, abdominal/thoracic sx, pneumothorax, perforated bowel.
- on 4th big breath, assist cough via xiphoid, catch secretions
Huffing technique
= Forced expiratory technique
- DB followed by 2 reps of huff, with “O” shape mouth
Contraindications of postural drainage?
- untreated pneumothorax, hemoptsis, unstable CV, increased ICP, esophageal anatomosis, aneurism, PE, CHF, recent laminectomy, agitated
Strange postural drainage positions
RUL: supine, hips ER
LUL: semi-prone, left side elevated with pillows, HOB at 30
LLL lateral & RLL medial: right side lying, bed inverted 30 degrees
Proning: indication + contraindications
Last effort for a patient with ARDS to get VQ matching
Contraindications: facial trauma, chest wound, unstable SCI
Contraindications to percussion
- rib #, prone to hemorrhage, metatastic bone Ca, osteoporosis, burns, subcutaneous emphysema of neck and thorax, unstable CV, skin graft, tumor, pneumothorax
Manual hyper-inflation:
- indications
- needed equipment
- contraindications/ precautions
Indications: Acute lobar collapse & sputum clearance
- Need: ambu bag, O2 tubing, pressure manometer (can’t go >30-40), skill?
- Contraindications: acute pneuectomy, untrained pneumothorax, proximal tumor, head injury, HFOV
Precautions: hemoptsis, bulae, high RR or PEEP, bronchospasm, CVS instability.
Active cycle breathing technique:
- indications
- technique
Indications: secretion removal, allow increased pressure behind the huff
How:
- deep breathing X 3 + hold, normal breathing X 3, Huff, medium breathing
Autogenic drainage: indications, phases, procedure
Alters rate and depth of breathing to produce highest possible airflow in bronchi
Phases: unsticking, collection, evacuating
Procedure: normal breath X 10, bit DB, DB +++, cough
What is PEP device?
What patients use this the most?
Positive expiratory pressure device:
Handheld device that oscillated during inspiration that will help dislodge mucous in the small and large airway
Very common in CF
Indications for secretion suctioning
- contraindication
- can’t clear secretions, loss of airway control, lung pathologies, sputum sample
Contra:
- getting worse, nasopharyngeal basal skull #, nasal bleeding , epiglottitis, croup, CSF leakage, nasal stenosis
Pulmonary rehab aerobic FITT
1-2x/day to 3-5 days/week, interval training (5-10 min, 2 min rest, 10-40 mins of continuous exercise
1,3, 10reps. Respiratory mm retraining, functional (tug, berg), 5lb X 19 reps X 50-89max
