Osteopathic Approach to the Cardiopulmonary Patient Flashcards
What biomechanical spine condition can hamper cardiopulmonary function? How is it measured?
Scoliosis
Measured by Cobb angle to determine mild (5-15), moderate (20-40), or severe (>50) — formed by intersection of line parallel to superior end plate of the most cephalad vertebra in a particular curve, with the line parallel to the inferior end plate of most caudad vertebra of the curve
______ function is compromised if the Cobb angle is >50 degrees
______ function is compromised if the Cobb angle is >75 degrees
Respiratory
CV
Correlation between gait and cardiac workload
Length of stride is reduced in pts with severe heart failure
The O2 cost associated with this short-stepping gait pattern is high
May contribute to limited exercise capacity in pts with heart failure
Lymphatic relationships relating to lung pleura
Parietal pleura —> internal thoracic and intercostal chains
Diaphragmatic pleura —> mediastinal, retrosternal, and celiac axis nodes
Visceral pleura —> deep pulmonary plexus
Lymphatic relationships in terms of drainage around the heart
Most drainage of pericardium is to the thoracic and right bronchopulmonary ducts
Lymphatic drainage from the heart and lungs is primarily carried back to the heart via the right lymphatic duct
Effect of MI on lymphatic relationships of the heart
MI —> dysfunctional lymphatic vessels —> development of chronic myocardial edema —> aggravation of cardiac fibrosis and dysfunction
Effect of VEGF-C on lymphatic relationships of the heart
VEGF-C —> cardiac lymphangiogenesis, may lead to improvement of cardiac function
The thoracic duct is functionally under ______ control
Sympathetic
thus hypersympathetic tone may lead to decreased lymph flow
SNS innervation of the heart consists of preganglionic axons from intermediolateral column of _____ which synapse on corresponding upper thoracic sympathetic ganglia and cervical ganglia through ascension
Postganglionic fibers form the sympathetic cardiac nerves which converge at the _____ _____
T1-5
Cardiac plexus
Parasympathetic preganglionic axons frmo the dorsal nucleus of the vagus nerve and the ____ ____ synapse on the cardiac plexus
Nucleus ambiguus
The cardiac plexus can be divided into superficial and deep cardiac plexi. The deep cardiac plexus can further be divided into a right and left half. What structures are associated with right vs. left half of the deep cardiac plexus?
Right half = right coronary plexus, left coronary plexus, SA node
Left half = AV node
[cholinergic and adrenergic fibers passing through the cardiac plexus are most strongly concentrated in the SA and AV nodes, and to a significantly lesser extent in the myocardium]
In terms of the right half of the deep cardiac plexus, sympathetic hyperactivity at the SA node —> increased risk of ______; and right vagal hyperactivity at the SA node —> __________
SVT
Sinus bradyarrhythmias
In terms of the left half of the deep cardiac plexus, sympathetic hyperactivity at the AV node —> increased risk of ______ and ______; and left vagal hyperactivity at the AV node —> _______
Ectopic foci; V.fib; AV blocks
Convergence of sympathetic and parasympathetic tone affect __________ of the pacemaker action potential
Phase 4 rate (diastolic depolarization)
[the slope of phase 4 in SA node determines HR; imbalance of homeostatic control of SA node may lead to nodal dysfunction and arrhythmias]
Innervation of costal and peripheral diaphragmatic parietal pleura
Intercostal nn
Innervation of mediastinal and central diaphragmatic parietal pleura
Phrenic nn
Innervation of the lungs
Branches of vagal nn
Sympathetic cervical cardiac nn
Sympathetic cardiac branches from T1-7
Innervation of trachea and bronchi
Branches of vagal nn
Recurrent laryngeal nn
Sympathetic trunks
Smooth muscle tone of the airways is predominantly ______
Parasympathetic
[cholinergic innervation —> bronchoconstriction, mucus secretion, bronchial vasodilation; non-cholinergic innervation (NO and VIP) —> bronchodilation]
Parasympathetic viscerovisceral reflexes affecting cardiopulmonary system
Irritation of the pulmonary branches of the vagus n. produce strong inhibitory reflexes on the heart
[ex: irritation of the larynx, pressure on carotid body, pressure on globe of eye]
Anterior chapmans points for myocardium, bronchus, upper lung, lower lung
Myocardium: 2nd ICS along sternal border
Bronchus: 2nd ICS along sternal border
Upper lung: 3rd ICS along SB
Lower lung: 4th ICS along SB
Posterior chapmans points for myocardium, bronchus, upper lung,lower lung
Myocardium: intertransverse spaces between T2-3
Bronchus: lateral to T2 spinous process
Upper lung: intertransverse space between T2-3 AND T3-4
Lower lung: intertransverse space between T4-5
OMT goal for biomechanical model in cardiopulm pt
Improve thoracic cage compliance and skeletal motion
OMT goal for neurologic model in cardiopulm pt
Normalize autonomic tone
OMT goal for respiratory-circulatory model in cardiopulm pt
Maximize efficiency of the diaphragm and ehance lymphatic return
OMT goal for metabolic/energetic/immune model in cardiopulm pt
Enhance self-regulatory and self-healing mechanisms
OMT goal for behavioral model in cardiopulm pt
Improve psychosocial components of health
In HTN, vascular and cardiac hypersensitivity to sympathetic stimuli is seen. Increase in BP leads to adaptation of homeostatic mechanism to maintain elevated BP. Due to widespread distribution of sympathetic nervous system, ______________ can be used to decrease SVR
Generalized paraspinal inhibition
5 model approach to HTN
Biomechanical: treat C/T/rib SDs
Neurologic: paraspinal inhibition, OA/AA
Resp/circ: tx any peripheral edema using lymphatics
Met/en/imm: diuretics, beta blocker, CCB, ACE/ARB
Behavioral: salt intake, exercise, weight loss, smoking cessation
CHF considerations from lymphatic standpoint
HF leads to decreased ability of thoracic duct to empty —> dilation and peripheral edema
Use caution as to not overwhelm circulatory system and exacerbate sx
5 model approach to CHF
Biomechanical: tx C/T/rib SDs
Neuro: OCMM, paraspinal inhib T1-6, subocc release, chapman’s pts
Resp/circ: rib raising, lymphatics
Met/en/imm: diaphragmatic and thoracic cage SDs, lymphatic pumps, effleurage for electrolytes, CHF meds
Behavioral: monitor fluid intake, diet and medication compliance
Osteopathic considerations for arrhythmias
Address ABCs always
OMT should be directed toward reduction of segmental facilitation in upper thoracics and modification of vagal tonicity
5 model approach to arrhythmia
Biomechanical: tx C/T/rib SD
Neuro: tx OA/AA, paraspinal inhib T1-6, chapmans
Resp/circ: valsalva, carotid sinus massage
Met/en/imm: Ca-channel blockers, anti-arrhythmics
Behavioral: med compliance, avoid caffeine and illicit drugs, tobacco cessation
3 main goals of PNA treatment
- Reduce congestion
- Reduce sympathetic hyperactivity to pulmonary parenchyma
- Reduce mechanical impediments to thoracic cage respiratory motion
5 model approach to PNA
Biomechanical: tx C/T/rib SD, percussion hammer
Neuro: paraspinal inhib T1-7, CV4, OA/AA
Resp/circ: rib raising, treat zink patterns, lymphatics
Met/en/imm: Abx, lymphatics, tapotement, sinus drainage, inhaled bronchodilators
Behavioral: hydration, good nutrition
5 model approach to COPD
Biomechanical: tx C/T/rib SDs
Neuro: T1-7, OA/AA, chapmans
Resp/circ: rib raising, treat zink patterns to improve diaphragmatic excursion
Met/en/imm: dome diaphragm, long acting beta agonists, anticholinergics, CPAP, O2, Abx, steroids
Behavioral: smoking cessation, regular exercise
What technique is contraindicated in COPD pts?
Thoracic vacuum
A 62-year-old woman comes to the emergency department after two weeks of shortness of breath. She gets out of breath easily when walking short distances and has felt more fatigued recently. She has a dry nighttime cough, which she attributes to a “cold.” She denies chest pain or pressure, palpitations, lightheadedness, or syncope. She was diagnosed with hypertension four years ago but does not take any medications. She has never smoked and rarely drinks alcohol. She has no family history of heart disease. Blood pressure is 165/92 mm Hg, and pulse is 99/min and regular.
If you suspect this patient has CHF, which of the following would you expect to hear on cardiac auscultation?
a. S4 gallop
b. fixed, split S2
c. systolic ejection murmur
d. S3 gallop
e. diastolic ejection murmur
d. S3 gallop
A 62-year-old woman comes to the emergency department after two weeks of shortness of breath. She gets out of breath easily when walking short distances and has felt more fatigued recently. She has a dry nighttime cough, which she attributes to a “cold.” She denies chest pain or pressure, palpitations, lightheadedness, or syncope. She was diagnosed with hypertension four years ago but does not take any medications. She has never smoked and rarely drinks alcohol. She has no family history of heart disease. Blood pressure is 165/92 mm Hg, and pulse is 99/min and regular.
Which of the following would be the most sensitive test for diagnosing CHF in this patient?
a. S3 gallop on cardiac auscultation
b. elevated plasma renin
c. lower extremity edema
d. cardiomegaly on CXR
e. elevated plasma BNP
e. elevated plasma BNP
A 62-year-old woman comes to the emergency department after two weeks of shortness of breath. She gets out of breath easily when walking short distances and has felt more fatigued recently. She has a dry nighttime cough, which she attributes to a “cold.” She denies chest pain or pressure, palpitations, lightheadedness, or syncope. She was diagnosed with hypertension four years ago but does not take any medications. She has never smoked and rarely drinks alcohol. She has no family history of heart disease. Blood pressure is 165/92 mm Hg, and pulse is 99/min and regular.
Which of the following osteopathic treatments would most significantly increase preload in this patient?
a. CV4
b. prone pressure to thoracic spine
c. effleurage of upper extremities
d. MET to lower cervical spine
e. rib raising
c. effleurage of upper extremities
A 62-year-old woman comes to the emergency department after two weeks of shortness of breath. She gets out of breath easily when walking short distances and has felt more fatigued recently. She has a dry nighttime cough, which she attributes to a “cold.” She denies chest pain or pressure, palpitations, lightheadedness, or syncope. She was diagnosed with hypertension four years ago but does not take any medications. She has never smoked and rarely drinks alcohol. She has no family history of heart disease. Blood pressure is 165/92 mm Hg, and pulse is 99/min and regular.
Which of the following osteopathic treatments would most significantly decrease afterload in this patient?
a. suboccipital release
b. rib raising
c. CV4
d. paraspinal inhibition to T and L spine
e. thoracic inlet direct MFR
d. paraspinal inhibition to T and L spine
