RCVII Essay Flashcards
purpose of prone positioning
The patient is kept in prone positioning to help increase lung volume, improve mucus clearance, improve ventilation perfusion mismatch and thereby manage any atelectasis and improve gas exchange.
precautions for prone positioning
attachments - oxygen, catheters
contraindications for prone position
only absolute contraindication is unstable spinal fracture. Relative contraindication haemodynamically unstable, unstable pelvic or long bone fracture, open abdominal wounds, raised intracranial pressure if head or neck obstructs cerebral venous drainage.
purpose and risk of IRV
reduce shunting, improve V/Q mismatch, reduce dead space ventilation, increase mean airway pressure. Risk of barotrauma, worsening of pulmonary oedema, patient must be sedated and paralysed.
contraindications of IRV
preexisting hemodynamic compromise or obstructive lung disease requiring a prolonged expiratory phase. (E Sembroski et al. 2018)
purpose of and definition of early Mobilisation
purpose - Early mobilisation which involves any physical activity that results in a physiological change with the first 2-5 days of illness, active mobilisation is preferred to prevent muscle atrophy and muscle weakness and to preserve physical function. (Kozu et al 2022).
precautions of early mobilisation
attachments, medications, NEWS score, nursing staff liaison, clinical notes to see if the patient is awaiting any further investigations or treatment e.g CT, dialysis
contraindications of early mobilisation
haemodynamically unstable, insufficient oxygen support, SpO2 of less than 80%, hypotensive, unstable angina, weakness in lower limbs
definition of pulmonary rehab
Pulmonary rehabilitation is a comprehensive intervention, based on a thorough patient assessment followed by patient-tailored therapies, which include, but are not limited to, exercise training, education, and behavior change, designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence of health-enhancing behaviors
indications of pulmonary rehabiltation
Bronchiectasis – improve exercise capacity and HRQoL but difficult to maintain (Lee et al. 2017)
ILD – Improve functional exercise capacity, dyspnoea and QoL (Dowman et al. 2014)
Asthma – improve exercise capacity, asthma control, QoL, reduce wheeze and bronchial inflammation (Zampogna et al. 2020)
Reduced hospitalisation, reduced symptoms of dyspnea, enhanced self efficacy and knowledge, improved limb muscle strength and endurance
screening for pulmonary rehab
COPD – MRC 3-5 or mMRC 2-4
Where capacity and skill-set allows, PR programmes should accept other chronic respiratory disease patients with a functional limitation due to breathlessness e.g. MRC 2 (mMRC 1) if referred.
Must be motivated to participate
Must be able to exercise independently and safely
Able to travel to venue and access to appropriate equipment for PRP
Exclusion criteria – uncontrollable cardiovascular conditions limiting participation, limited mobility due to orthopaedic, psychological, neurological conditions, suspected underlying malignancy.
outcome measures for pulmonary rehab
HR, SpO2, BP, BMI
Measures of Dyspnoea. (Modified BORG Score, mMRC)
Functional capacity - 6-minute walk test,
Quality of life: for COPD – COPD Assessment Tool, for asthma Asthma Quality of Life Questionnaire (AQLQ for Asthma), for bronchiectasis The Quality of Life-Bronchiectasis (QOL-B)
Agreed goals (SMART goals)
Where possible a measure of quadriceps muscle strength is highly recommended.
components of pulmonary rehab
Pt assessment
An initial center-based assessment by a health care professional
An exercise test at the time of assessment
A field exercise test
Quality of life measure
Dyspnea assessment
Nutritional status evaluation
Occupational status evaluation
Program components
Endurance training
Resistance training
Method of delivery
An exercise program that is individually prescribed
An exercise program that is individually progressed
Team includes a health care professional with experience in exercise prescription and progression
Quality Assurance
Health care professionals are trained to deliver the components of the model that is deployed
exercise prescription of endurance exercise in pulmonary rehab
Duration – at least twice weekly supervised session with minimum 12 wks
Frequency – ACSM minimum 3-5 times a week, ATS/ERS 3-5 times a week, AACVPR 3-5 times weekly
Intensity – ACSM light intensity; 30-40% peak work rate, vigorous intensity; 60-80% peak work rate, or dysnpea rate 4-6 Borg, ATS/ESR > 60% maximal work rate, AACVPR high intensity; 60-80% peak work rate
Time ACSM – non specific, ATS/ERS 20-60min per session, AACVPR – 20-60 min per session for 4-12 wks
exercise prescription for resistance exercise in pulmonary rehab
Frequency – ACSM > 2times/wk, ATS/ERS 2-3times/wk, AACVPR no standard
Intensity – ACSM light intensity; 40-50%, moderate intensity; 60-70%, ATS/ERS 60-70% 1RM or 100% 8-12 RM, AACVPR start with lower weights/resistance and higher reps for endurance, higher weights and fewer reps for strength
Time – ACSM 1-4 sets, 8-10 exercises, 10-15 reps, ATS/ERS not stated, AACVPR not stated.
haemodynamic monitoring definition
The ability of the body to maintain homeostasis and deliver oxygen to tissues via circulation is essential for healthy organs. Therefore it is essential to be able to assess this status and the effects of our treatments
how is BP measured invasive and non invasively
Invasive via arterial line sited in artery
Continuous Monitoring of Systolic, Diastolic and Mean Arterial Pressure
abnormal blood pressure in haemodynamic monitoring
normal range 120/80
hypotensive SBP <90, DBP <60
hypertensive SBP >180, DBP >100
Orthostatic hypotension 5 mins lying, 1 min standing, 3 min standing, > 20 SBP drop or > 10 DBP drop.
why is the transdeucer placement important for BP monitoring
Transducer position is important pressure displayed is pressure relative to position of transducer.In order to reflect blood pressure accurately transducer should be at level of heart. Over-reading will occur if transducer too low and under-reading if transducer too high
how is CVP measured
central venous pressure
Pressure in superior vena cava measured via central line
importance of Central Venous Pressure
CVP gives a crude estimate of left atrial pressure (LAP), measures venous return
LAP approximates to left ventricular end-diastolic pressure (LVEDP) which is related to preload
normal range CVP
5-12 cm H2O
Signs of elevated CVP
risk of heart failure, contractile dysfunction, valve abnormalities or dysrhythmias, fluid retention
signs of reduced of CVP
Hypovolemia, venodilation,
What is pulmonary artery wedge pressure
The pulmonary wedge pressure or PWP, or cross-sectional pressure, is the pressure measured by wedging a pulmonary catheter with an inflated balloon into a small pulmonary arterial branch. It estimates the left atrial pressure.
Important in shocked patients to correctly manage fluid balance
normal pulmonary artery wedge
4-12 mm Hg
elevated PCWP
severe left ventricular pressure, severe mitral stenosis
ECG purpose
An ECG (electrocardiogram) records the electrical activity of the heart. It provides information about heart rate and rhythm
abnormal sinus rhythm
Atrial fibrillation, left bundle branch block, right bundle branch block, sinus tachycardia
purpose of lengthening expiration in inspiration expiration ratio. example of lengthened inspiration:expiration
1:3-4
decrease gas trapping
normal PEEP
5cmH2O
Example of increased PEEP and its therapeutic effects
Increased PEEP is used therapeutically in attempt to increase open lung units
>8cmH2O minimise vent disconnection and take precautions to minimise loss of PEEP.
causes of hypoventilation
decreased level of arousal, CNS Depression, Fatigue
causes of hyperventilation
Asthma, Increased CNS activity, Anxiety
normal range of tidal volume
450-600ml
list pre-evaluation for CPET
informed consent , allow pariticipant questions to be answered
perform health screening
pre-exercise evaluation - medical Hx an CVD risk factor Ax
PAR-Q+
participant preparation
refrain from ingesting food, alcohol, caffeine ot tobacco 3h before test
avoid significant exertion or exercise on day of Ax
wear appropriate clothes
drink ample fluid 24 hrs prior
if the CPET is used for diagnostic purposes how is a patients prescribed cardiovascular medication taken and give your reasoning
purpose discontinue prescribed cardiovascular medications but only with physician approval. Currently, prescribed anti-anginal agents alter the hemodynamic response to exercise and significantly reduce the sensitivity of ECG changes for ischemia.
if the CPET is used for exercise prescription purposes how is a patients prescribed cardiovascular medication taken and give your reasoning
patients should continue their medication regimen
CPET assessment
Non -Invasive
Heart rate
Blood pressure
12 Lead ECG
Subjective ratings (RPE) / Chest Pain / Fatigue
Ventilatory expired gas analysis responses
Invasive
Arterial Blood gases – not always taken, may use radial artery catheter for continuous monitoring, take separately Pre/Post test
Lactate monitoring
indications of stopping CPET
Onset of angina or angina-like symptoms
Drop in SBP of ≥10 mm Hg with an increase in work rate or if SBP decreases below the value obtained in the same position prior to testing
Excessive rise in BP: systolic pressure >250 mmHg and/or diastolic pressure >115 mmHg
Shortness of breath, wheezing, leg cramps, or claudication pain.
Signs of poor perfusion: light-headedness, confusion, ataxia, pallor, cyanosis, nausea, or cold and clammy skin
Failure of HR to increase with increased exercise intensity
how is the CPET test terminated
An appropriate cool-down/recovery period should be initiated consisting of either:
Continued exercise at a work rate equivalent to that of the first stage of the exercise test protocol or lower or
A passive cool-down if the subject experiences signs of discomfort or an emergency occurs
All physiological observations (e.g., HR, BP, signs, and symptoms) should be continued for at least 5 min of recovery
physical fitness definition
Being physically fit is defined as ‘the ability to carry out daily tasks with vigor and alertness, without undue fatigue and with ample energy to enjoy leisure-time pursuits and to meet unforeseen emergencies’
how does cardiorespiratory fitness relate to physical fitness
Cardiorespiratory fitness is one of the health related components of physical fitness. Cardiorespiratory fitness is defined as the ability of the circulatory and respiratory system to supply oxygen during sustained physical activity.
the gold standard for assessing cardiorespiratory fitness
V˙O2max is the accepted measurement of cardiorespiratory fitness
VO2 max is the maximum amount of oxygen the body can utilize during exercise
V˙O2max is expressed as ml /kg-1/min-1
VO2 = CO x (a-v O2 difference) [cardiac output X the amount of O2 taken up from the blood by the tissues]
Measured using an open circuit spirometer
Cardiopulmonary exercise test using a cycle ergometer
parameters to be assessed in the interpretation of maximal test
HR
BP
12 lead ECG
ABG
Lactate
how is the HR interpreted in a maximal test
- A failure of the HR to decrease by at least 12 beats during the first minute or 22 beats by the end of the second minute of active post exercise recovery is strongly associated with an increased risk of mortality in patients diagnosed with or at increased risk for IHD
what BP values would be considered predictive future hypertension in a CPET test
A peak SBP >250 mmHg or an increase in SBP >140 mmHg during exercise above the pre-test resting value is predictive of future resting hypertension
what is considered abnormally low SBP in a CPET test
A decrease of SBP below the pre-test resting value by >10 mm Hg after a preliminary increase, particularly in the presence of other indices of ischemia, is abnormal and often associated with myocardial ischemia, left ventricular dysfunction, and an increased risk of subsequent cardiac events
what is considered abnormal DBP in a CPET test
A peak DBP >90 mmHg or an increase in DBP >10 mmHg during exercise above the pre-test resting value is considered an abnormal response and may occur with exertional ischemia.
A DBP >115 mmHg is an exaggerated response and a relative indication to stop a test
stages of cardiac rehab
- period in hospital stay post acute cardiac event. Comprise of risk assessment and risk stratification, early mobilisation and discharge planning.
- period 4-6 wks post d/c. health education and gradual resumption of PA
- period 6-8 wks post d/c. Cardiac rehab classes of aerobic exercises and resistance training classes 2-3 times/week. lifestyle intervention,education on nutrition, CVD, smoking cessation, medication and mental well being.
- Phase 3 end and beyond - long term maintainance and lifestyle changes. can chose community classes.
screening for cardiac rehab
symptomatic hypotension/hypertension, tachycardia, unstable arrhythmia, unstable diabetes, unstable angina, febrile illness
inclusion criteria for cardiac rehab
inclusion criteria -medically stable post MI, CABG, PCI, stable angina, HF, cardiomyopathy, post cardiac transplant ICD, valve repair, pacemaker insertion
exclusion criteria for cardiac rehab
unstable angina
ischemic changes on resting ECG
resting SBP > 200 mmHg/DBP > 110 mmHg
symptomatic hypotension
critical aortic valve stenosis
uncontrolled sinus tachycardia
uncompensated CHF
uncontrolled diabetes
