CPT I - EXAM Flashcards
What is VO2? What units is it measured in?
The rate of oxygen consumption in aerobic metabolism.
Absolute: L/min
Relative: ml/kg/min
What is the average resting VO2?
3.5 mL/kg/min (1 MET)
What is the average Max VO2?
30-40 mL/kg/min (10 METs)
When does the anaerobic metabolism come into play?
It works a little bit at rest but starts to work harder when the oxygen transport system can’t keep up with demand.
What is VO2 a function of?
CO x (a-vO2)
Cardiac output x how much oxygen consumed
What is a-vO2?
Oxygen in arteries - oxygen in veins
Ie, how much oxygen consumed by mitochondria in muscles
What are the pleural cavities composed of?
Visceral pleura
Pleural fluid
Parietal pleura
What is parenchyma?
Spongy structure of lung surrounding airways
What are the functions of the upper airways? What are the complications if they can’t do those functions?
Gets air from outside to lower airways
Warm, filter, humidify air
Higher risk for aspiration, pneumonia, dried out secretions, inability to talk or cough
What is the purpose of the epiglottis?
Protects the airways by preventing food from entering the trachea when swallowing
Provides an effective cough (creates pressure after deep breath in)
What is the glottis?
The opening to the trachea from the larynx. Contains the vocal cords.
What is the carina?
The bifurcation point where the trachea splits into the right/left main stem bronchus.
Which lung (R/L) is more likely to have pathology? Why?
More likely on the right because the right main stem bronchus is more straight than the left (greater chance of aspiration).
What happens to the diaphragm in neuro/spinal cord injuries? Clinical indication?
No abdominal musculature to support organs that hold the diaphragm up - sits lower.
Patients can’t breathe effectively, at risk for pneumonia.
What happens to the diaphragm in COPD?
Patients have an expanded chest that forces the diaphragm to sit lower.
Primary muscles of inhalation?
Diaphragm, external intercostals
Accessory muscles of inhalation?
SCM, scalenes, abdominals
Muscles of active exhalation?
Internal intercostals, abdominals
How do we work speech and cough?
Speech - eccentric contraction of diaphragm to control flow
Cough - isometric epiglottis and abdominals to concentric contraction
Lung Volume: TV
Tidal Volume
Volume of air inspired or expired per breath
Lung Volume: IRV
Inspiratory Reserve Volume
From end of tidal inspiration to max inspiration
Lung Volume: ERV
Expiratory Reserve Volume
From end of tidal expiration to max expiration
Lung Volume: RV
Residual Volume
Volume of air in lungs after max expiration
Lung Volume: TLC
Total Lung Capacity
Volume in lungs at end of max inspiration
Lung Volume: VC
Vital Capacity
Volume from max inspiration to max expiration
Lung Volume: IC
Inspiratory Capacity
Volume from tidal expiration to max inhalation
Lung Volume: FRC
Functional Capacity
Volume after tidal expiration
FEV1/FVC ratio
What is the average? What is FEV1 indicative of?
Forced Expiratory Volume in 1 Second
Forced Vital Capacity
Reflects pulmonary expiratory power and overall resistance to air movement upstream in lungs. Measures ability to sustain a high airflow level.
Average should be 0.75-0.8 (75-80% of air in 1 second). FEV1 is air in upper airways.
FEF 25-75%
Forced Midexpiratory Flow
Average flow rate during middle phase of max expiration. Gives better idea about small airway disease (goes from upper –> lower airway flow)
What is anatomical dead space?
Normal/fixed area where no gas exchange occurs. Includes conducting zones and upper airways.
1/3 of individual’s resting tidal volume
What is physiologic dead space?
An area that could or should be exchanging gas, but is not.
Normal - alveolar sacs not in use at rest (IRV)
Abnormal - fixed disease (cystic fibrosis)
What is 2/3 resting tidal volume?
Air movement to alveoli
What are the 3 forms of resistance to lung airflow?
Compliance - ability to expand
Elasticity - back to original shape after deformation, no energy required
Airway resistance - radius/diameter
Healthy Work of Breathing (WOB) is low. This is affected by? (5)
Compliance Elasticity Resistance Ventilatory demand Number of intact alveoli
What is minute ventilation (VE)? What is maximum voluntary ventilation (MVV)?
VE = TV x RR
Volume of air moved in or out of lungs per minute.
MVV = TVmax x RRmax
What is V/Q matching? What is the average V/Q?
V/Q matching is attaining an adequate combination of V/Q for gas exchange.
Alveolar ventilation / cardiac output
4 L/min / 5 L/min = 0.8
What is Ventilatory Index?
VI = VE/MVV
Minute ventilation at any time divided by maximum voluntary ventilation. Should be very small at rest.
What is your breathing reserve?
MVV - VE
How much air is left at any time.
What is the VI during exercise? At VO2max? Dyspnea? Fatigue? Non-sustainable?
60% MVV at exercise, typically 80% at VO2max 50% for dyspnea 70% for fatigue 90% for unsustainable
Will a patient with pulmonary pathology have a higher or lower MVV? What does this do to their VI?
Have a lower MVV which gives them a high VI (SOB with walking)
What are the 4 factors of gas exchange (passive diffusion)?
Partial pressures
Surface area
Diffusibility of membrane
Time (1/4s at rest)
What is the hypercapnic drive?
Primary drive in healthy ppl. Central chemoreceptors in the medulla detect CO2 levels and increase ventilation when levels are high.
What is the hypoxic drive?
Secondary drive in which peripheral chemoreceptors in carotid bifurcation and arch detect low levels of O2 to increase ventilation.
What is the sympathetic response to the airways?
Bronchodilation with decreased mucus production.
When HgB is fully saturated (100%), how much oxygen will it carry?
How much HgB does a person have on average?
HgB carries 1.34 mL O2 / g HgB
Average HgB: 15 g/dL blood
What is the oxygen carrying capacity of blood (CaO2)? What does this measure?
CaO2 = (1.34) x (15) x (.98) CaO2 = Amount of O2 x Amount of HgB x Saturation of HgB
Measures how well gas is exchanged.
How much oxygen does the body extract from what is delivered to it (at rest)?
25%
What determines whether oxygen is picked up or dropped off? What affects this?
Affinity of HgB for O2 (high = picked up)
Affect Affinity: acidity, temp, level of O2
What is the main transport of metabolic CO2?
Bicarbonate
What creates non-metabolic CO2?
During anaerobic metabolism, the body accumulates lactic acid.
Lactic acid + bicarbonate = CO2
What is stroke volume? Average?
SV - volume of blood ejected by heart per beat
End Diastolic Vol - End Residual Vol
Avg: 70 mL
What is venous return?
Volume of blood that returns to heart per beat
What is cardiac output?
Volume of blood pumped by heart per minute
CO = HR x SV
What side of the heart is low/high pressure?
Right side: low pressure (pulmonary)
Left side: high pressure (systemic)
During exercise, we lose time in diastole (ventricular filling), how do we maintain stroke volume (cardiac output)?
Increased venous return (fill up ventricles faster)
What is the ejection fraction? What is the average?
Volume ejected from the amount available.
SV/EDV
Avg: 60-70%
What is the average cardiac output?
CO = SV x HR CO = 70 ml x 70 bpm = 5 L/min
What are the determinants of stroke volume?
Preload - tension before heart contraction; determined by EDV
Afterload - load against which heart contracts (right and left side); determined by vascular resistance (state of dilation/constriction)
Contracility - positive inotropic effect increases contractility
What happens to the 3 determinants of SV during exercise?
Preload - increases (venous return)
Afterload - decreases (vasodilation)
Contractility - increases (SNS)
What are the 3 determinants of HR?
Intrinsic conduction system (automaticity, rhythmicity, intercalated discs)
Autonomic NS - chronotropic effect
Chemical/hormonal response - norepi and epi from adrenal glands
What is the primary pace maker? How fast?
SA Node (60-100 bpm)
What is the secondary pacemaker? How fast? What else does it do?
AV Node (40-60 bpm). Delays impulse for fraction of a second which allows the atria to contract and complete ventricular filling.
What is the rest of the conduction system after the SV and AV nodes?
Bundle of His - left/right bundle branches through interventricular septum
Purkinje fibers - L/R ventricles; beats 20-40 bpm
What vessels determine vascular resistance?
Arterioles (resistance vessels)
What kind of vessels increase during aerobic training? Why?
Capillaries - to increase blood flow and O2 delivery and remove waste products.
What are the 2 main branches of the left coronary artery?
Circumflex
Left Anterior Descending (LAD)
Why does coronary perfusion decrease during exercise?
Heart gets its blood supply during diastole, which is shortened during exercise.
What is Mean Arterial Pressure (MAP)? What is the average?
MAP = DBP + PP/3
Pressure that maintains tissue perfusion, detected by kidneys.
PP is pulse pressure (SBP - DBP)
Avg = 93 mmHg
BP =?
BP = CO x TPR
If TPR decreases during exercise, why would SBP increase?
CO increases
What is the difference between the effects of the autonomic NS and hormonal response on cardiovascular function?
Autonomic has an immediate effect while hormonal takes time to kick in.
What is the parasympathetic influence on the heart? Sympathetic influence?
PNS: Negative chronotropic effect
SNS: Positive chronotropic and inotropic effects
What releases norepinephrine? Epinephrine?
Sympathetic NS releases NE from the adrenergic fibers.
NE stimulates adrenal release of epinephrine.
If the SNS causes vasoconstriction, why is their vasodilation during exercise?
Exercise (metabolism and PaO2) overrides the SNS response
What is the RPP?
Rate-Pressure Product
RPP = HR x SBP
Myocardial oxygen demand. This is why we measure both HR and BP to assess patient.
A patient has a BP of 150/84. What kind of HTN is this considered?
Stage I because of the SBP of 150.
Why is the Valsalva maneuver dangerous for cardiopulmonary patients?
It is an acute drop in blood pressure secondary to drop in venous return.
What are the 3 factors of assessing tissue perfusion?
Heart rate
Strength of pulse
Rhythm
How do you assess a patient’s reaction to exercise?
Before activity
During activity
After activity at 1 min intervals until back to baseline
What is the difference between the bell and the diaphragm on a stethoscope?
Diaphragm detects high frequency sounds
Bell detects low frequency sounds (better for diastolic BP)
How fast do you release air from the BP cuff?
2 mmHg per second
What are Korotkoff sounds?
Phase 1: 1st appearance of sounds (SBP) Phase 2: Murmur or swishing Phase 3: Crisp and louder Phase 4: Muffling Phase 5: Sounds disappear (DBP)
What are you assessing for respiration?
Rate
Depth
Rhythm
Quality
What is the average body fat % for males/females?
Males: 12-15%
Females: 25-28%
What is body mass index?
BMI = body mass (kg) / Stature (m2)
What are the body’s goals during exercise?
Deliver oxygen at a rate needed to meet energy demand
Eliminate waste products at rate equal or greater than production
Dissipate heat, regulate body temp
Deliver hormones
What is the difference between absolute and relative intensity?
Absolute - actual intensity person is tested at
Relative - % of max capacity; relative to the individual
What is APMHR?
Age Predicted Max Heart Rate
APMHR = 220 - Age
only use for healthier individuals
What is the state of vasodilation during aerobic exercise?
Vasodilation throughout workout
What is the state of vasodilation during anaerobic exercise?
No vasodilation until recovery. TPR and therefore BP rises.
During aerobic exercise, what kind of TPR drop occurs if you are just working out arms, just legs, or both?
Arms: less of a drop (less area to dilate)
Legs: higher drop (more mass than arms)
Both: lowest BP response
What is SaO2? Does it change at max exercise?
Saturation of HgB molecule - ability for diffusion across alveolar membrane. Does not change at max exercise except for a couple % points. Delivery/consumption decreases, however.
What is typical anaerobic threshold?
40-60% VO2 max (4-6 METS)
What is ventilatory efficiency?
How much CO2 released (the more the better)
What is the difference between VO2max and VO2peak?
VO2max - leveling of VO2 with increasing intensity
VO2peak - exercise is stopped before seeing the O2 consumption leveling off (reach APMHR, RER > 1.15, anaerobic metab., stopped exercise)
What are the 4 principles of training?
- Overload
- Specificity
- Individual differences
- Reversibility
What are the 5 (or 4) exercise prescription components?
Mode Intensity Duration Frequency Progression
Frequency
Intensity
Time
Type
Why aerobic training?
Enhance delivery and utilization of oxygen.
Physiologic effects of training
Increased VO2 max Decreased VE at submax intensity Decreased HR/BP at submax intensity Increased capillary density Increased anaerobic threshold Enhanced metabolism Reduction of risk factors Decrease morbidity/mortality
What is the respiratory quotient?
RQ = VCO2/VO2
CO2 production vs. O2 consumption during aerobic exercise (metabolic CO2).
What is respiratory exchange ratio?
RER = VCO2/VO2
CO2 production vs. O2 consumption during anaerobic exercise (metabolic and lactic acid buffering CO2)
If RER is > 1, what state is the person in?
Anaerobic metabolism
What non-exercise demands can stimulate the oxygen transport system?
Infection, disease, injury
If the quality of blood in SV is poor, what is the compensation?
HR increase (for CO)
If a patient has weakness if the cardiovascular system, what other systems should be improve to compensate and take away some physiologic stress on the body?
Ventilatory pump system
Neuromuscular system
(parts of the O2 transport system)
If there is an inability to increase CO and/or (a-vO2) is limited, what are the consequences?
Decreased VO2 max Early onset anaerobic metabolism Inability to reach anaerobic threshold (SOB) Increased physiologic stress System failure
What increases metabolic demand?
Movement Stress, fear, yelling Resistance/intensity Anticipation Anxiety Pain
What limits the Oxygen Transport System response?
Disease Deconditioning Inactivity Bedrest Medications Neural control
Where is a voluntary ventilator tube placed? Clinical implication?
At the jugular notch
Affects upper airways
Which ribs articulate with the manubrium?
1 and 2
What does the sternal angle articulate with? What lies directly behind it?
Rib #2 is on either side of it
Carina and T3 vertebra are directly posterior
How many true ribs / false ribs / floating ribs?
True: 7
False: 3
Floating: 2
Which ribs does the body of the sternum articulate with?
Ribs 2-7
Which ribs articulate at the junction between the sternum body and xiphoid process? What structures are directly lateral to this junction?
Articulate with ribs 6-7
Rib 5 and the apex of the heart are lateral to this junction
What is the clinical implication of ribs 8-10 articulating with cartilage only?
Gain mobility here for rib expansion
What is FRC? How are the ribs angled?
Functional Residual Capacity - volume of air left in lungs after normal resting exhalation.
Ribs are angled downward (sagittal view) less than 90 deg. Ribs are angled downward (posterior view) about 45 deg.
You palpate the T4 spinous process. Which vertebral body is anterior to that?
T5
Rib 7 articulates with what structures?
Inferior facet of T6
Superior facet of T7
Transverse process of T7
Why do connective tissue disorders (RA, lupus) impact ventilation? What is a good stretch to increase ventilation?
Joints are made up of connective tissue. If costovertebral/costotransverse joints are limited, their ability to expand is limited.
Stretch: deep breath with lateral side bend
What are the 3 steps of effective breathing?
Belly rise
Lateral expansion
Chest rise
What are Type 1 and Type 2 alveoli cells?
Type 1: anatomical structure of alveoli (stability)
Type 2: produce surfactant
What is surfactant? When does this start to develop in utero?
Fluid that breaks up the surface tension of the alveoli and allows them to expand.
Produced at 26-28 weeks but doesn’t mature until 36.
What do collateral ventilatory pathways do?
Bypass occluded airways
Decrease resistance to airflow
What are the 3 types of collateral ventilation?
Channels of Martin - 2 bronchioles
Channels of Lambert - bronchiole to alveoli
Alveolar pores of Kohn - 2 alveoli
How much of VO2max goes toward the work of breathing?
10% (increased surface area aids in diffusion)
What is PO2 in venous blood, alveolus, and arterial blood?
Venous: 40 mmHg
Alveolus: 100 mmHg
Arterial: 100 mmHg
What is PCO2 in venous blood, alveolus, and arterial blood?
Venous: 45 mmHg
Alveolus: 40 mmHg
Arterial: 40 mmHg
Arterial blood gas (at rest): pH range? PaCO2 range? PaO2 range? HCO3 range?
pH: 7.35-7.45
PaCO2: 35-45
PaO2: >80
HCO3: 22-26
Venous blood gas (at rest): pH range? PaCO2 range? PaO2 range? HCO3 range?
pH: 7.31-7.41
PaCO2: 41-51
PaO2: 35-40
HCO3: 22-26
Why does bicarbonate levels remain unchanged between arterial blood gas and mixed venous blood gas?
It is affected by kidneys, not ventilation
Why is there residual volume when you force air out of the lungs? What is the clinical implication of pulmonary disease?
When air is forced out, pressure around airways increases and collapses them.
Someone with pulmonary disease starts out with narrowed airways, so they are collapsed earlier which results in less total lung capacity.
Which volumes are studied to determine how well a patient can get air out of their lungs?
Forced Vital Capacity (FVC)
Forced Expiratory Volume in 1 Sec (FEV1)
Forced Midexpiratory Flow (FEF 25-75%)
Peak Expiratory Flow (PEF)
What happens to PEF in those with asthmatic attack?
Peak Expiratory Flow is a person’s maximum speed of expiration. PEF drops in those with pulmonary issues.
Why is increasing volume more effective than breathing faster?
Increased surface area (decreased physiologic dead space). Breathing faster decreases more anatomical dead space instead of physiologic dead space.
What is the inhale:exhale ratio at rest? During exercise?
At rest: 1:2 (elastic recoil slower)
Exercise: 1:1 (active exhale)
What is Work of Breathing? How is efficiency determined?
WOB: ventilatory requirement determined by VO2 demand and ventilatory efficiency.
Efficiency is how much air is moving per how much CO2 is removed (VE/VCO2)
What are the 3 types of V/Q mismatching?
- Ventilation in excess of perfusion (increased V without Q) - air is sent to area with no blood supply (ex: pulm embolism obstructs blood flow).
- Perfusion in excess of ventilation (increased Q without V) - send blood to area without ventilation (ex: secretions block airflow)
- Absence of perfusion and ventilation (ex: tumor obstructing V and Q).
Why should you assess someone’s vital signs when you reposition them?
Positioning can affect V/Q ratio. You need to make sure they are stable in the new position.
How does a patient with pulmonary disease develop secondary pulmonary hypertension?
If vasoconstriction does not occur in areas of dead space, they have perfusion in excess of ventilation which leads to pulmonary HTN.
What are the voluntary and involuntary CNS controls of ventilation?
Voluntary: motor cortex
Involuntary: Hypercapnic drive, hypoxic drive, peripheral mechanoreceptors (muscles)
Why is the yawn/sigh reflex so important?
It forces you to breathe into your reserve volume which prevents secretion buildup and subsequent infection.
What is pleural effusion?
Pleural fluid buildup in the potential space between visceral and parietal pleura. This can collapse the lung or prevent expansion.
What is the point of maximal impulse?
The apex of the heart
How does an increased afterload lead to heart failure?
The heart increases contractility to compensate which overloads the heart.
SBP reflects which determinant of SV? What else does it represent in regards to the heart?
Represents afterload
Also represents contractility (how hard the heart is working)
DBP is a good indicator of what? Why? High DBP indicates what?
DBP is good indicator of cardiac perfusion because it is the time that coronary arteries are supplied with blood.
High DBP can indicated trouble filling the arteries.
What is the normal increase in SBP during aerobic exercise? DBP?
SBP: 10 mmHg per MET level
DBP: rises very little
What is SpO2?
How well oxygen gets from alveolar membrane to the blood stream
What are the criteria for low, moderate, and high risk people for cardiopulmonary disease?
Low: asymptomatic, 0-1 risk factors
Moderate: asymptomatic, 2+ risk factors
High: symptomatic, known disease
What are symptoms of cardiovascular disease?
Angina Claudication Orthopnea/PND DOE/cough Dizziness/syncope Palpitations Edema/skin color
What is angina?
A conglomerate of symptoms, not just chest pain.
Can be any symptom above the waist as a result of an imbalance between myocardial oxygen supply (coronary circulation) and demand (HR and SBP).
What is claudication?
Lack of blood flow to peripheral muscles which causes cramping.
What is orthopnea? PND?
SOB, trouble breathing in supine. Associated with heart failure. Supine increases venous return which increases preload.
Orthopnea - happens as soon as lay down
Paroxysmal Nocturnal Dyspnea - can handle initial rise in preload but can’t over handle it over time.
What is DOE?
Dyspnea on Exertion
What is syncope? Caused by?
Fainting, transient loss of consciousness
Result of decreased BP, CO, blood flow to brain
What are symptoms of pulmonary disease?
SOB/DOE Cyanosis - nails, lips, eyes Wheezing Cough WOB Sputum production Pain