Medical Management & rehabilitation of cardiopulmonary diseases Flashcards
week 5 (126 cards)
1
Q
laboratory values
Troponin
A
protein that increases in presence of heart damage (myocardial infarction)
2
Q
lab values
brain natruiretic peptide (BNP)
A
hormone secreted with increased ventriuclar stretch (congestive heart failure CHF)
3
Q
C-reactive protein (CRP)
A
an inflammatory marker used todetrmine cardiovascular disease presence
4
Q
prothrombin time
A
duration of time from clot to form in body. increased time = increased bleed risk
5
Q
tissue plasminogen activator (tPA)
A
“clot buster”; dissolving clots in coronary or cerebral arteries (TNK - tenecteplase - new genetically modified tPA - lower risk of bleeding)
must be adminstered early on! like 2 hours or less from onset of symptoms
6
Q
labratory values
Electrolytes (Na+, K+)
A
impact cognitive function, heart rhythmicity; can be dilauted if pt is on diuretic
dieretics: some are potassium sparing some are potassium dumping
7
Q
lab values
blood urine nitrogen (BUN)
A
assessed heart and renal failure; paired with creatinine (Cr) = best combo for renal function
think heart and renal failure
8
Q
cardiovascualr diagnositic testing: non- invasive
waht are some non invasive diagnostic tests
A
- holter monitor
- echocardiogram
- PET
- CT scan
- SPECT
- MRI
- MRA
- exercise testing
9
Q
what is holter monitor
purpose:
A
- portable, samll ECG device for 24 hr monitoring
purpose: cardiac arrythmias” life-threatening; hemodynamic instabilty: syncope, dizziness, SOB
worn at all time except in water
10
Q
what are teh abnomrla/non life threatening findings of a holter monitor:
A
exercsie test and or ECG is performed
life threatening findings: electrophysiologic mapping invasive) - determine area of suspected arrhthmic concern
technique: attempt to induce the area of arrhythmic concern; if successful, area is restosred with anti-arrhythmic medication; if unable to restore, cardiac ablation (intentional cauterization/scarring of involved tissue by use of electricity or cryotherapy to form a wound)
11
Q
echocardiogram (ECHO)
A
ultrasound (US) device that uses sound waves to produce images of heart by using a transducer
12
Q
purpose of ECHO
A
evaluates integrity of heart hfunctionality - chamber size (dilated), wall thickness (hypertrophic) and motion (akinetic, hypokinetic, dyskinetic), valvular function (stenosis/regurgitation/prolapsed), ejection fraction (reduced/preserved)
13
Q
what are the different types of ECHO
A
transesophageal (TEE), transthoracic ( TTE), stress echo, contrast echo
14
Q
what is the echo “TEE”
A
transducer probe is attached to thin tube, inserted into mouth> esophagus; better heart visualization than TTE but IS INVASIVE
15
Q
what is echo “TTE”
A
tranducer placed on chest wall at point of maximal impulse
- contrast provided via IV; improved accuracy of diagnosis; gives real time assessment of blood flow (invasive)
16
Q
what is echo “STRESS”
A
echo performed pre and post exercise to determine ischemic-induced heart wall motion abnormalities
17
Q
what is positron emission tomography (PET) scan
A
- nuculear tracer deposits in organ tisseu and gives off positrons; camera creates pictures from the positrons
areas with high blood flow will show up - high metabolically active areas
18
Q
what is purpose of PET scan?
who is it it best for?
A
purpose: evaluate metabolic function and blood flow - gold standard; diagnose coronary artery disease, left ventricular dysfunction; can stage canger
best for: women with ischemic heart disease due to increased sensitivity to microvascular disease
very expensive, needs highly trained person
cancer
19
Q
CT scan
A
series of x-ray images, viewing organs in 1-3 mm slices
20
Q
purpose of CT scan
A
purpose: diagnose masses, aneurysms, pericarditis; gold-standard for diagnosing pulmonary embolism (PE)
21
Q
what is SPECT?
purpose?
A
- nuclear chemical injected, resulting in gamma rays being emitted and recorded by a camera; computer translates recording into 2 dimensional cross sections
purpose: quantify myocardial perfusion and contractility deficits (less accurate than PET scan, but more availability)
22
Q
magnetic resonance imaging (MRI)
A
scan that uses magneticfields and radio-pulsed waves to produce images
23
Q
purpose of MRI
A
assesses coronary blood glow, morphology, myocardial contractility/ diagnose valve disease, masses, thrombi
24
Q
when is ECHO more common than MRI?
A
more common or a cardiac catheterization (under the “invasive” section)
25
magnetic resonance angiogram (MRA)
similar to MRI but more dynamic assessment; showing movement of blood within veins and arteries
26
purpose of MRA
evaluate blood vessels, location of blockage, severity of blockage. diagnose aneurysms, atherosclerosis, vasculitis
27
what is exercise testing
purpose of exercise testing
- non-invasive exertional procedure to diagnose and treat coronary artery disease
purpose: progressively increase oxygen demand to reproduce symptoms under continuous monitoring
exercise can occur by treadmill, stationary bike, etc.
28
goal of maximal stress test
goal of patient exercising at end-point range; only stopping test if symptoms limite continuation
29
What is bruce treadmill protocol
- most common type of maximal stress testing
- average time of 6-12 min becasue of initial and progressing grade % despite slow speed
- usually done in the outpatient setting; ordered by MD; appropriate medical emergyency/equipment/personnel must be present
30
what are some absolute contraindication for bruce treadmill protocol
- myocardial infarction occurance < 4-6 weeks ago
- acute pericarditis
- resting or unstable angina
31
what are some indications for exercise stress testing
- eval of chest pain suggestive of coronary disease
- eval of atypical chest pain
- determination of prognosis and severity of CAD
- eval of effects of medical or surgical therapy or intervention
- eval of arrhythmias
- eval of hypertension with activity
- assessment of functional capacity
- screen to provide exercise prescription
- provides motivation for lifestyle change
32
what are the stages, speed, grade and duration of bruce treadmill protocol
33
exercise testing
type: submaximal stress test
endpoint is predetermined and exercise is terminated at this point or before (symptoms)
34
how is submaximal stress test end point predetermined?
by predicted maximal heart rate
220-age x 65% (min)
or
220-age X 85% (max)
35
when is submaximal stress testing typically done and what can it help predict?
done: after a cardiovascular incident (after myocardial infarction or post surgery
predict: incident recurrence; moinitor for abnormalities on ECG; optimal medical management
36
what is submaximal stress testing a good screening tool for?
what are the absolute contraindications:
- great screening tool for cardiac rehab candidates (phase II - outpatient)
absolute contraindications:
- severe CHF with/without presence of S2 sound; resting or unstable angina
37
modified bruce protocol is commonly performed by physical therapists
what are the
stages
min
MPH
grade
## Footnote
submaximal stress test
stage 1 --> 0.0 min --> MPH 1.7 --> grade 0%
stage 2 --> 3.0 min --> MPH 1.7 0% grade
stage 3 --> 6min --> 1.7 -->10% grade
stage 4 --> 9 min --> 2.5 MPH --> 12% grade
stage 5 --> 12 min --> 3.4 MPH --> 14% grade
38
# exercise testing with imaging techniques
Radioactive nuclide perfusion imaging - what is injected?
purpose:
how it works:
interpreting:
## Footnote
"nuclear stress test"
- thallium 201 - perfusion tracer injected IV
purpose: assesses coronary perfusion and cell membrane integrity. viable myocardium. predict risk of reccurent myocardial infarction
how: tallium injected. uptake in myocardium (cellular integrity) versus uptake in blood. if cells aren't well perfused and metabolically intact, "cold spots" appear
test in time sensitive: requires immediate assessment and 4 hour reassessment
interpreting:
- cold spots on immediate read but not on 4 hour read = reversible/ischemic/viable tissue
| cold spots = nonperfused or dead myocardium
## Footnote
primarily seen for pharmacologic-induced stress test when aptient acnnon perform an exercise stress test
39
what is the gold standard testing for diagnosing pulmonary embolism (PE)?
CT scan
40
# cardiovascular diagnostic testing: invasive
cardiac catheterization
catheter insersted into heart via arterial or venous system to measure chamber pressures and hemodynamicfunction
41
# cardiothoracic surgical appraoches
posterolateral thoracotomy
primarily for pulmonary procedures; risk of inercostal nerve damage
42
# cardiothoracic surgical approaches
median sternotomy
primarily for cardiac procedures
- midline incision - below suprasternal notch to distal xiphoid
## Footnote
seen with CABG
43
for a median sternotomy
what are the sternal precautions:
what are post-operative complications:
sternal precautions: no lifting > 10lbs; no reaching both arms up/out/back; no pushing/pulling
post operative complications: atelectasis, pneumonia, pneumothorax
| these are old precautions - new is MOVE IN TUBE
## Footnote
* wound dehiscence risk increasing if pt has history of smoking
44
what is the physical therapists role for median sternotomy
- splinting technqiues to reduce pain; with sneezing/coughing; educate to avoid smoking; use of incentive spirometer; initiate and progress mobility; discharge planning
45
sestamibi is a pharmacologic induced stress test where the pt cannot perform an exercise stress test - it differs from radioactive nuclide perfusion imaging how?
sestamibi is not time sensitive - in blood longer
46
# cardiothoracic surgical approaches
video-assisted thoracic surgery (VATS)
- minimally invasive
- common for lung, lymph nodes, pleura procedures
- ribs are spared (not spread apart, as is done forthe open thoracotomy procedure)
- decreased incision pain
- decreased hospital stay
47
Coronary artery Bypass graft (CABG)
when is it performed?
what is the goal?
performed: when coronary arteries are severely narrowed and blocked ( i.e. myocardial infarction)
goal: revascularize cardiac tissue by bypassing involved coronary arteries that are causing ischemia or infarct
## Footnote
typically involed multi-vessels (MD will document 2-vessel CABG, CABG x 3, etc)
will typically be done by median sternotomy and will have sternal precautions
48
what vein is most commonly used as the vascular graft in a CABG?
saphenous vein
or
internal mammary artery may be used
49
physical therapist role for chest tubes
- do not knock over chest tube box!
- must remain distal to entry site for effective, gravtiy assisted drainage
- pt can ambulate ~8 ft in room (stand -step, pivot transfer, seated/standing)
- cardiac rehab (phase I), edu on lifestyle changes
- edu on splinting techniques w/coughing/sneezing/breathing/pain
- mobilize, regain ADL's
- prevent DVT
- monitor incision and graft site
- reinforce sternal precautions, airway clearance, incentive spirometry, - posture re-edu
- assist with discharge plans
50
after a CABG when are patients usually out of bed?
within hours -24hrs (depends on facility)
they will remain in hospital for 5-7 days
51
how long does sternal healing take?
6-8 weeks
52
percutaneous coronary intervention (PCI)
performed?
goal?
performed to determine myocardial integrity in the presence of known or suspected coronary atherosclerosis, done in cardiac catheter lab (when intervention is deemed necessary)
goal: emergency room "door to ballon" intervention in <90 minutes
53
54
pts who had a PCI are placed on double antiplatelets, why?
due to restenosis risk from scar tissue formation or thrombi around stent
55
Intra-aortic balloon pump (IABP)
why is it performed?
intended to reduce cardiac workload by decreasing afterload
- technique also improves coronary perfusion
56
what is an IABP?
- balloon is inserted from axilllary or femoral artery into aorta and inflated at the srat of ventriuclar diastole (after aortic valve closure)
- results in increased intra-aortic pressure and diastolic pressure by allowing retrograde flow to coronary arteries > improved tissue oxygenation
- defalted just before systole to decrease afterload
57
what population do you see often have an IABP?
congestive heart fialure, unstable angina
## Footnote
pts are critically ill and often not seen by PT's
58
What is a pacemaker?
what pt population is it typically inserted for?
small, electronically-pulsed generator, controlling cardiac arrhythmias by creating an artifical action potential
- typically implanted for pts with chronic bradycardia (heart rate < 60 bpm)
59
can you mobilize a pt on a temporary pacemaker?
no - unless conductive lead wires are stabilized - talk to nurse/doc
60
what is a fixed pacemaker
heart rate will not change
should use RPE scale to gauge pt's fatigue
61
pacemaker type interpreting 3 letter abbreviation
first letter =
second letter =
third letter =
first letter = chamber being pace (atrial, ventriuclar, dual)
second letter = chamber being sensed
third letter = pacemaker respone (I= inhibits pacemaker discharge; T= triggers pacemaker discharge; D = both available)
62
permanent pacemaker - PT role
- may not see pt solely becasue of placement (usually secondary to concern)
- doc may order shoulder sling for 1 week (post-op: visual/tactile reinforcement of precautions)
- increase mobility and teach pt how to perform daily routine while maintaining precautions
## Footnote
doc will clear them for a shower not PT's
63
automatic implantable cardioverter defibrillator (AICD)
treatment for life threatening arrhythmias (ventrcular dysrhythmias)
| cannot drive for first ~ 6 mths
## Footnote
doc office has monitor to make changes, acts as a pacemaker and defibrillator - pt can feel shock from defibrillation PT should be aware of this
64
When is a valve repair or replacement necessary?
in the presence of plaque build up around leraflets of valve --> stiffness and decreased blood flow
usually seen during an ECHO or cardiac death
- pt will complain of (c/o) dyspnea on exertion, peripheral edema, paroxysmal nocturnal dyspnea, palpitations , heart murmurs present
65
valve replacement: two types
1. mechanical (metal) - ball or disc mechaism ; will have a permanent clicking sound on auscultation; lifetime durability but needs lifelong anticoagulation
66
after a heart transplant -
what is the most primary cause of death?
what is the second most common reason for death?
- primary: infection
- 2nd: organ rejection (needs to be caught early)
67
# heart transplant
cardiac denervation occurs -->
occurs --> loss of sympathetic and vagal influence --> delayed respone to exercise demand
68
when working with a heart transplant pt, what should we expect in regards to the heart rate?
will have higher resting HR, slow acceleration with activity and slow recovery HR
69
when working with heart transplant pt's, what is the most appropriate way to gauge their exercise intensity?
borg RPE scale
goal of <13 on scale
| HR is unreliable
## Footnote
monitor signs/symptoms of rejection, steroid induce myopathy, sternla precaustions, limited shoulder ROM
70
what are signs of heart transplant rejection?
fever, decreased exercise tolerance, hypotension
71
What is a ventricular assistive device?
- mechanical pump used when human heart pump is failing. portable option for transition to home
- working with pts heart to deliver optimal blood flow
72
a ventricular assistve device can be placed in various places including?
- left (LVAD)
- right (RVAD)
- biventriulcar (BI-VAD pump)
73
a left LvAD receives blood from the left ventricle and carries it?
mechanically to aorta
74
a RVAD receives blood from right ventricle and carries it?
mechanically to pulmonary artery
75
What can be a bridge to heart transplant or considered final treatment plan ("destination therapy")
ventricular assistive device
76
what should PT's be monitoring for those with a ventriuclar assistive device?
- borg RPE scale
- monitor vitals/hemoglobin hematocrit (cells destroyed in pump may result in anemic presentation)
- monitor dyspnea
77
what is the goal of vascular procedures?
goal of vascular proceudres is to treat atherosclerosis conservatively (non-invasively) first
78
# vascular procedures
critical stenosis
limb-threatening ischemia
## Footnote
- recall pain is occuring at rest; no longer intermittent claudication
- ABI=<.5
- infection or gangrene with high risk of limb loss
- surgery for preservation of viable tissue
79
in regards to vascular proceudres - critical stenosis what are the options for the patient?
- surgery for preservation of viable tissue
- bypass surgery
- stenting (PCI)
- amputation (last resort)
80
# vascular procedures
after a patient is treated for critical stenosis when can a PT get involved?
- once bedrest order is lifted
## Footnote
may have weight bearing as tolerated oreders and likely needs an ssitive device, temporarily
81
what are the two types of aneurysms?
- thoracic aortic aneurysm (TAA)
- abdominal aortic aneurysm (AAA)
## Footnote
can also ahve a peripheral arterial aneurysm
82
what are the different shape presentations of aneurysms?
saccular - ballooning on one side
fusiform - ballooons on all sides
dissecting and rupturing - life threatening (>50% dilated)
83
What is an aneurysm?
- weakneing and dilation/ballooning of aorta, resulting in > 50% increase in diameter; #1 risk = smoking
- pt is often asymptomatic and finding is usally accidental; routine ultrasound imaging; alternate diagnosis work up
84
what is the most common type of abdominal aortic aneurysm (AAA)?
infrarenal (below renal arteries)
85
# abdominal aortic aneurysm
palpable pulsatile abdominal mass
swishing murmur heard when auscultating abdominal cavity
86
for an abdominal aortic aneurysm
imaging shows < 5 cm
what is the intervention appropriate for this?
monitor and antihypertensive meds
87
for an abdominal aortic aneurysm
imaging shows > 5 cm
what is the intervention appropriate for this?
surgery
## Footnote
endovascular repair (EVAR) - miminally invasive
88
for those with AAA and no surgery- what activities are contra indicated?
- isometrics
- heavy lifting
- vasalva maneuver
89
patients with abdominal aortic aneurysm - what should the physical therapist start doing?
- splinting technique
- breathing training
- teach logroll technique
- ensure abdominal binder is use for out of bed mobility
- minotoir incision site at groin
- ensure JP drain remains intact
90
PT's should monitor for signs/symptoms of decompensating CHF (left)
which includes:
- increse dyspnea and or pulmonary congestion
- decrease activity tolerance
- unable to pass "talk test"
- hemodynamic instability (decrease systolic blood pressure, pallor)
- new S3 presence
- impaired cognition
91
what is used to determine the severity of CHF (left)
## Footnote
looking for severity of pump failure and if ejection fraction (EF) is reduced/preserved
ECHO
92
if a patient with CHF - Left has an EF < 35% what might they have placed?
ICD (implantable cardioverter defibrillator)
93
what is the medical management of those with CHF -left?
## Footnote
like 8 things
- sodium restricted diet (dash diet)
- diuretics
- inotropic medications - improves pump function (strength of contraction)
- aldosteron-antagonist "water pill"
- ACE - inhibitor (lower BP)
- beta-blocker (need bord RPE monitoring)
- dialysis to decrease burden on kidneys and assist w/fluid removal
- exercise; low intensity
94
What is the purpose of an Automatic Implantable Cardioverter Defibrillator (AICD)?
Treatment for life-threatening arrhythmias (ventricular dysrhythmias)
## Footnote
AICD can function as a pacer and a defibrillator.
95
How is the implantation method of an AICD similar to that of a pacemaker?
Similar to pacemaker, but a separate programmer remains at doctor’s office to monitor and make changes.
96
What sensation does a patient experience during defibrillation from an AICD?
Patient will feel the shock from the defibrillation, which can knock them to the ground.
97
What follow-up is necessary after several shocks from an AICD?
Follow up visit to MD; Physical Therapist must be aware of this necessity in the outpatient setting.
98
What are the typical state regulations regarding driving clearance after AICD implantation?
>6 months usually ok.
99
What condition necessitates valve repair or replacement?
Presence of plaque build-up around leaflets of valve → stiffness and decreased blood flow.
100
What symptoms might a patient exhibit that indicates valve issues?
* Dyspnea on exertion
* Peripheral edema
* Paroxysmal nocturnal dyspnea
* Palpitations.
101
What abnormal heart sound is known as a heart murmur?
Abnormal heart sound on auscultation.
102
What does a stenotic valve indicate?
Narrowing of the valve.
103
What is an incompetent/regurgitant valve?
Valve that allows backflow or is prolapsed from overstretched annulus or chordae tendinae.
104
What interventions can be performed for valve issues?
* Dilation (Valvulotomy)
* Repair (Mitral-MVR or Aortic Valve Repair-AVR)
* Replacement (Transcatheter Aortic Valve Replacement –TAVR).
105
What are the two types of valve replacements?
* Mechanical (metal) – ball or disc mechanism
* Tissue (Bi-prosthetic) – human (allograft) or animal (xenograft).
106
What is the primary characteristic of mechanical valve replacements?
Will have a permanent clicking sound on auscultation and requires lifelong anticoagulation.
107
What is the lifespan of tissue valve replacements?
<20 years; not recommended for younger populations.
108
What does S3 heart sound indicate?
Heard after S2; rapid ventricular filling/dysfunction; 'lub-dub-dub' - ventricular gallop sound.
109
What does S4 heart sound indicate?
Heard just before S1; increased resistance to ventricular filling; 'la-lub-dub' – atrial gallop sound.
110
What are systolic murmurs associated with?
Most common; due to aortic stenosis; heard between S1 and S2; 'swishing' sound.
111
What are diastolic murmurs?
Uncommon; heard after S2.
112
What is pericarditis?
Inflamed pericardium → fluid within pericardial space → pericardial effusion.
113
What can untreated pericarditis lead to?
Cardiac tamponade (compression).
114
What is myocarditis?
Inflamed myocardium that can lead to heart failure due to swollen heart muscle.
115
What is endocarditis?
Inflamed endocardium, usually including heart valves, due to bacteria.
116
What is the primary focus of a physical therapist for lung transplant patients?
Monitoring hemodynamics, improving cough, increasing mobility.
117
What is emphysema?
Chronic progressive disease caused by smoking, leading to irreversible loss of elastic recoil.
118
What is the classic symptom of chronic bronchitis?
Productive cough > 3 months for 2 years.
119
What is bronchiectasis?
Irreversible dilation of bronchial walls due to chronic inflammation and infection.
120
What is asthma?
Chronic airway inflammation from overreactive airway.
121
What is cystic fibrosis?
Pediatric obstructive disease due to genetic mutation affecting chloride channels.
122
What is a common symptom of cystic fibrosis in infants?
Infant tastes salty.
123
What are the roles of a physical therapist in cystic fibrosis management?
* Mucus clearance
* Breathing training
* Strength training
* Thoracic mobilization and stretching.
124
What are underlying causes of restrictive lung dysfunction?
* Musculoskeletal issues (e.g., kyphoscoliosis)
* Connective tissue diseases (e.g., rheumatoid arthritis)
* Trauma (e.g., rib fractures)
* Nutritional factors (e.g., obesity).
125
What is the goal of pulmonary rehabilitation?
Work up to 30 minutes of continuous aerobic exercise, 3-5 x/week for 4-12 weeks.
126
What is the RPE scale goal during pulmonary rehabilitation?
11-14 on a 6-20 scale.
