Osteopathic Approach to the Cardiopulmonary Patient

Question 1

What biomechanical spine condition can hamper cardiopulmonary function? How is it measured?

Answer 1

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

Question 2

______ function is compromised if the Cobb angle is >50 degrees

______ function is compromised if the Cobb angle is >75 degrees

Answer 2

Respiratory

CV

Question 3

Correlation between gait and cardiac workload

Answer 3

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

Question 4

Lymphatic relationships relating to lung pleura

Answer 4

Parietal pleura —> internal thoracic and intercostal chains

Diaphragmatic pleura —> mediastinal, retrosternal, and celiac axis nodes

Visceral pleura —> deep pulmonary plexus

Question 5

Lymphatic relationships in terms of drainage around the heart

Answer 5

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

Question 6

Effect of MI on lymphatic relationships of the heart

Answer 6

MI —> dysfunctional lymphatic vessels —> development of chronic myocardial edema —> aggravation of cardiac fibrosis and dysfunction

Question 7

Effect of VEGF-C on lymphatic relationships of the heart

Answer 7

VEGF-C —> cardiac lymphangiogenesis, may lead to improvement of cardiac function

Question 8

The thoracic duct is functionally under ______ control

Answer 8

Sympathetic

thus hypersympathetic tone may lead to decreased lymph flow

Question 9

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 _____ _____

Answer 9

T1-5

Cardiac plexus

Question 10

Parasympathetic preganglionic axons frmo the dorsal nucleus of the vagus nerve and the ____ ____ synapse on the cardiac plexus

Answer 10

Nucleus ambiguus

Question 11

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?

Answer 11

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]

Question 12

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 —> __________

Answer 12

SVT

Sinus bradyarrhythmias

Question 13

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 —> _______

Answer 13

Ectopic foci; V.fib; AV blocks

Question 14

Convergence of sympathetic and parasympathetic tone affect __________ of the pacemaker action potential

Answer 14

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]

Question 15

Innervation of costal and peripheral diaphragmatic parietal pleura

Answer 15

Intercostal nn

Question 16

Innervation of mediastinal and central diaphragmatic parietal pleura

Answer 16

Phrenic nn

Question 17

Innervation of the lungs

Answer 17

Branches of vagal nn

Sympathetic cervical cardiac nn

Sympathetic cardiac branches from T1-7

Question 18

Innervation of trachea and bronchi

Answer 18

Branches of vagal nn

Recurrent laryngeal nn

Sympathetic trunks

Question 19

Smooth muscle tone of the airways is predominantly ______

Answer 19

Parasympathetic

[cholinergic innervation —> bronchoconstriction, mucus secretion, bronchial vasodilation; non-cholinergic innervation (NO and VIP) —> bronchodilation]

Question 20

Parasympathetic viscerovisceral reflexes affecting cardiopulmonary system

Answer 20

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]

Question 21

Anterior chapmans points for myocardium, bronchus, upper lung, lower lung

Answer 21

Myocardium: 2nd ICS along sternal border

Bronchus: 2nd ICS along sternal border

Upper lung: 3rd ICS along SB

Lower lung: 4th ICS along SB

Question 22

Posterior chapmans points for myocardium, bronchus, upper lung,lower lung

Answer 22

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

Question 23

OMT goal for biomechanical model in cardiopulm pt

Answer 23

Improve thoracic cage compliance and skeletal motion

Question 24

OMT goal for neurologic model in cardiopulm pt

Answer 24

Normalize autonomic tone

Question 25

OMT goal for respiratory-circulatory model in cardiopulm pt

Answer 25

Maximize efficiency of the diaphragm and ehance lymphatic return

Question 26

OMT goal for metabolic/energetic/immune model in cardiopulm pt

Answer 26

Enhance self-regulatory and self-healing mechanisms

Question 27

OMT goal for behavioral model in cardiopulm pt

Answer 27

Improve psychosocial components of health

Question 28

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

Answer 28

Generalized paraspinal inhibition

Question 29

5 model approach to HTN

Answer 29

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

Question 30

CHF considerations from lymphatic standpoint

Answer 30

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

Question 31

5 model approach to CHF

Answer 31

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

Question 32

Osteopathic considerations for arrhythmias

Answer 32

Address ABCs always

OMT should be directed toward reduction of segmental facilitation in upper thoracics and modification of vagal tonicity

Question 33

5 model approach to arrhythmia

Answer 33

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

Question 34

3 main goals of PNA treatment

Answer 34

1. Reduce congestion
2. Reduce sympathetic hyperactivity to pulmonary parenchyma
3. Reduce mechanical impediments to thoracic cage respiratory motion

Question 35

5 model approach to PNA

Answer 35

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

Question 36

5 model approach to COPD

Answer 36

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

Question 37

What technique is contraindicated in COPD pts?

Answer 37

Thoracic vacuum

Question 38

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

Answer 38

d. S3 gallop

Question 39

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

Answer 39

e. elevated plasma BNP

Question 40

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

Answer 40

c. effleurage of upper extremities

Question 41

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

Answer 41

d. paraspinal inhibition to T and L spine