Respiratory Flashcards
What are the normative values for an ABG?
pH= 7.35 - 7.45
PaCO2= 4.7 - 6.0 kPa
PaO2= 11 - 13 kPa
HCO3= 22 - 26
BE= -2 - +2
What are the 4 Type of Respiratory problems we can influence?
- Sputum Retention
- Loss of Lung Volume
- Increased Work if Breathing
- Respiratory Failure
What are the key categories in a systematic Respiratory Assessment?
A - Airway
B - Breathing
C - Circulation
D - Disability
E - Exposure
In A-E Respiratory Assessment what things is A assessing?
- Is the airway patent? Is it their own? Are they able to talk? Are they self ventilating?
- Occluded/ Obstructed? (Added breath sounds: stridor, hoarse voice, orthopnoea, drooling, dysphasia)
- End of bed: paradoxical breathing, cynosis, added sounds, can feel the sounds
In A-E Respiratory assessment what is included in B section?
- Respiratory Rate (regular? over 25bpm=concern)
- Work if breathing? Using accessory muscles?
- Chest expansion? Even? Deviation of trachea?
- Saturation levels (95-98%, at least above 88%)? Are they on O2? How is it delivered?
- Have they had ABGs? Results?
- Chest X-ray findings?
- Auscultation- breath sounds throughout? Added sounds?
- Palpation- Secretions? Tactile fremitus? Hot/cold? Centrally/peripherally? Oedema?
- Cough- Strong/Weak, Dry/Wet, Productive/ Unproductive?
- Able to clear secretions?
In A-E Respiratory assessment what is included in C section?
- Heart Rate (60-100bpm)
- Blood Pressure (90-60mmHg to 120/80mmHg
-Capillary refill - Skin Colour
- Sweating
- Urine output (800 to 2000ml per day or 1.5 to 2 ml/kg per hour)
- Blood sugar levels(4-7mmol/l before eating and 8.5-9mmol/l 2 hours after eating)
In A-E respiratory assessment what is included in section D?
- Level of consciousness (Alert, Voice, Pain, Unresponsive)
-Glasgow Coma Scale - Are they sedated?
In A-E respiratory assessment what does section E include?
- Injuries/pressure wounds
-Are there any serious surgical wounds? Are these contraindications for any interventions?
-Do they have any drains? Are they swinging and bubbling? - Attachments: Catheter, Arterial line, NG tubes
What does SBAR stand for?
Useful format to deliver handovers/gather on call info:
Situation
-pts name?where they are? whos calling? help/advice needed?
Background
-pts arrival? current status/whats happened?PMH? normal status? previous physio? current obs (A-E)?
Assessment
-vital signs? clinical impressions? concerns? clinical reasoning?
Recommendation
-explain what you need? give advice/suggestions?
Normal urinary output?
0.5-1.0ml per kg of body weight per hour
Is a sensitive marker with poor output related to shock and risk of cardiovascular insufficiency
What are you assessing when using palpation for respiratory assessment?
Temperature- hot/cold, central compared to peripheral
Oedema- central/peripheral? impact on treatment?
Trachea- central? deviated due to collapse/mass?
Expansion- equal and consistent? insp and exp?
Tactile fremitus- crackles under hands? ausc and precussion
Chest X-Ray interpretation. What are we looking for
Patients name/date/orientation
A- Alignment (Film rotated? AP/PA? Airways- trachea)
B- Bones (all there and intact? #’s?)
C- Cardiac (correct position/size/clear borders?)
D- Diaphragm (correct position/clear contours/ angles)
E- Expansion (well expanded-5-7 ribs to pierce diaphragm in anterior midclavicular line? extra structures)
F- Lung Fields (fields clear? extend to edge of thorax?)
G- Gadgets (any lines, drains, tubes, sutures, clips?)
What can percussion indicate for chest physiotherapy?
Hyper-resonant (pneumothorax-air between pleura, or empysema-over expanded lung)
Dull (pleural effusion or consolidation)
What are normal breath sounds?
-Soft, muffled
-Louder on INSPIRATION and fade on expiration
-1:2 ratio for inspiration:expiration
What does bronchial breathing over the lung fields indicate?
Bronchial breathing= EXPIRATION louder and longer with pause between inspiration and expiration
-Consolidation
-Collapse without sputum plug
-Beginning of pleural effusion
What may be causing quiet or absent breath sounds?
-Poor expansion, low lung volumes, atelectasis
Also caused by:
-Shallow breathing
-Poor positioning
-Collapse with complete obstruction of airway
-Sounds reduced by hyperinflation
-Sounds reduced by pleura, chest wall (obese/muscular pts, pleural effusion/pneumothorax/haemothorax)
-Pneumothorax
What is a wheeze? and What does it indicate?
Wheeze= musical sound from narrowed airway, usually heard on EXPIRATION. Usually due to bronchcospasm or secretions in small airways.
- High pitched- bronchospasm-potential increased WOB
-Low pitched- Sputum- disrupted turbulant flow, change with coughing
-Localised- tumour/foreign body- one area on ausc
What does fine crackles indicate? and When does it occur?
Usually late INSPIRATON
Short, sharp at lung peripheries, lessens with deep breath
- Atelectasis
-Intraalveolar/pulmonary oedema
-Secretions small airways
What does coarse crackles indicate? and When does it occur?
May be during inspiration and expiration
Early EXPIRATORY- central airways
Late EXPIRATORY- peripheral airways
changes/clears with coughing
-Obstruction more proximal and larger airways with sputum.
What is a pleural rub? and its causes?
Creaking/rubbing (boots in snow) can be localised/genralised, soft/loud, EQUAL INSPIRATION AND EXPIRATION
- Inflammation of pleura
-Infection
-Tumour
What is stridor? and its causes?
Sound of constant pitch during BOTH INSPIRATION AND EXPIRATION in upper airways.
- Croup
- Laryngeal tumour
- Upper airway obstruction
*Alert medical staff!
What categories does NEWS measure?
What is a significant change?
A significant change in score of 3 in one or more categories, or 5+ in total can trigger critical care support
Measures:
-Resp rate
-SPO2
-Air/oxygen
-Systolic BP
-Pulse per min
-Consciousness
-Temperature
What is atelectasis and where can it occur?
Appearance on CXR?
-Atelectasis is a collapse! And is area of airless lung
- May involve small areas, an entire lobe or an entire lung (RUL-horizontal fissure/above whitness, RML (middle lobe)-indistinct heart boarder, RLL- whitness compared to L with visible heart boarder, LUL-all hazy, LLL-heart border)
-CXR= loss of lung volume, whiteness over area, shift of trachea/heart TOWARDS to fill space, elevation of hemidiaphragm compared to opposite site, less clear borders
What is consolidation?
Where can it occur/
Causes?
CXR appearance?
Consolidation is when air is replaced by fluid in the lung. May present patchy, or entire lobe/segment
CXR= whitness, poor/fluffy boarders, no loss of lung volume
- Pneumonia- infected fluid (most common)
- Aspiration- gastric contents/saliva (particularly RLL)
- Traumatic lung contusion- blood
-Alveolar pulmonary oedema- serus transudate (usually mid zones by hila)
What is a Pleural Effusion?
How does it present on CXR?
Fluid in pleural space= plural effusion
CXR= uniform density throughout which changes dependent on pts position (erect-lower zone/supine-posterior surface).
Blunting of costophrenic angle, large effusion= shift AWAY, white out
What is pulmonary oedema? Causes?
How does it present on CXR?
Pulmonary oedema usually caused by left ventricular failure
CXR:
- heart enlarged
- consolidation around the hila
-Shift AWAY
-Kerley B lines ( tiny, thin, horizontal lines seen in lower zones caused by oedema)
- Large distended veins in upper zones
-May be pleural effusions
What is a pnumothorax?
How does it present on CXR?
Can be normal or tension.
Tension pnumothorax= air in pleural space increases, increasing pressure inlungs, push mediastinum AWAY, can cause cardiac arrest
CXR: Blackness
- Lung edge seen as white line parallel to chest wall
- NO Lung markings
-Outside lung edge blacker than area inside line
*** DON’T USE POSITIVE PRESSURE VENTILATION!
How does emphysema (COPD) present on CXR?
-Lungs appear hyperinflated and blacker in emphysema because of damaged lung tissue
-Thin walled sacs/ bullae may be present as particularly black areas often at top of lung
-No visible edge and lung markings present throughout
What is sputum retention?
If not treated can lead to…?
Sputum retention is where pts cannot clear sputum adequately, either independently or with physio support
May contribute to:
- airway obstruction, respiratory infections, increased WOB, ventilation/perfusion mismatch and respiratory failure
Signs and Symptoms of sputum retention?
- Audible noise= crackles/bubbling/coarse wheeze during coughing, deep breathing, or forced expiration
- Palpation= crackles felt
- Auscultation= crackles/wheeze (may clear with cough)
- History= Pt says difficulty clearing secretions, PMH of sputum condition e.g. bronchiectasis/COPD
- Sputum= infected? colour? sticky/thick?
- CXR= Sputum plugging lead to atelectasis/patchy consolidation also seen
- Ventilator display= increased airway pressure and/ restrictive tidal volumes. Jagged edge waveforms indicating airway obstruction
Causes of sputum retention?
Impaired mucociliary clearance, excessive mucus secretion, impaired cough, or aspiration
What causes mucociliary clearance?
- Increased volume of secretions produced by the goblet cells
- Increased viscosity of secretions because of dehydration, infection, or abnormal secretion (e.g. cystic fibrosis)
- Paralysis of cilia because of smoking, general anesthetic, reduced fluid intake or dry oxygen therapy
- Damaged airways (e.g. brochiectasis)
- Intubation (presence of artificial airway)
Impaired cough and/or reduced expiatory flow rates may be caused by:
- Fatigue
- Breathlessness
- Immobility
- Muscle weakness or paralysis
- Low lung volumes
- Pain
- Reduced level of consciousness related to anaesthesia, analgesia or pathology
What medical interventions are available for sputum retention?
-Hydration= as dehydration causes inefficient cillia, intravenous fluids
-Humidification= deliver oxygen via humidification, cold water humidification systems with wide-bore tubing, heated systems for intubated and noninvasive ventilation patients, heated high flow systems
- Nebulised saline= (0.9%) may be used regularly through the day/immediately before active clearance techniques, hypertonic saline
- Brochodilators= to manage bronchospasm
- Pain control= ensure pain is adequately controlled before tretament, pt should take deep breaths/huff, and move comfortably
- Mucolytic drugs= carbocisteine may be useful for pts with thick sputum (e.g. cystic fibrosis, COPD)
Physiotherapy interventions for spontaneously breathing/ nonintubated patients?
- Good positioning (sitting upright, avoid slumped position)
- Supported cough (support any incisions/trauma to chest or abdomen to make cough effective)
- ACBT (adapt to pt with breathing control to include suitable rests)
- Mobilise (move pts when possible- side lying, sitting, standing and walking can help to mobilise sputum if safe to do so)
- Manual techniques (percussion, shaking, and vibrations can be for useful for patients with thick secretions when unable to clear secretions using ACBT and mobiliy alone, with postural drainage
- Positioning/postural drainage (side lying is useful when pts have generalised secretions, specific positions can be used if sputum is localised to a lobe or series of lobes)
- Positive expiatory pressure (PEP) or oscillatory PEP (Pts with chronic lung disease characterised by sputum retention e.g. cystic fibrosis, COPD, bronchiectasis)
- Autogenic drainage (only use in acute position if the pt knows the technique and both you and they are skilled in its use)
- Mechanical insufflation/exsufflation (used with pts who have ineffective cough caused by primary muscle weakness)
- Intermittent positive pressure breathing-IPPB (useful to improve tidal volumes on inspiration to facilitate expectoration
- Manual assisted cough-MIE (for pts with neurologic compromise e.g. SPI, MND, GBS)
-Suction-nasopharyngeal/oral (only use if secretions in central airways, pts is unable to cough effectively, other methods ineffective)
Lung volume loss usually occurs when one or both of the following is reduced…?
- Inspiratory reserve volume (IRV)
- Functional residual capacity (FRC)
What is inspiratory reserve volume?
IRV is the total volume of air that can be inspired beyond a normal tidal inspiration.
- Determined by amount thoracic cage and diaphragm can expand during inspiration
- Sufficient inspiratory muscle strength is required
- Leads to reduced total lung capacity (TLC), and vital capacity (VC). And reduced ability to increase inspiratory volume in response to increased demand for ventilation= increased risk of resp failure
Causes of reduced inspiratory capacity/ inspiratory reserve volume?
- reduced thoracic mobility
- reduced lung compliance
- inspiratory muscle paralysis
- significant weakness
What is functional residual capacity?
FRC= the volume of air that remains in the lung after a normal tidal expiration. Reaches close to residual volume.
- Can cause air to be trapped and rapidly absorbed leading to atelectasis, and reduced V/Q ratios
- Determined by balanced inward recoil of lungs and outwards recoil of chest wall, when both inspiratory/expiatory mm’s relaxed
-e.g. kyphoscoliosis, abdominal surgery
How is IRV and FRC measured?
Laboratory Spirometry
But can use FVC and FEV1 in clinic- as both will be reduced in pts with low lung volumes.
- Normal FEV1/FVC ratio is usually 70% (0.7)
- A pt with low lung volumes will have low FVC and a normal FEV1/FVC ratio= restrictive pattern
What problems can arise from low lung volumes?
- Reduced compliance
- Reduced diffusion
- Reduced V/Q ratios
Causing increased WOB, breathlessness and reduced exercise tolerance.
8 Type 2 respiratory failure may develop because fatigue leads to an inability to maintain adequate minute volume
Signs and symptoms of loss of lung volume?
- Difficulty taking deep breath
- Reduced thoracic mobility (bilaterally/unilaterally, may be associated with chest wall deformity or #)
- Reduced breath sounds
- Fine crackles possible during inspiration
- Bronchial breathing may be heard over areas of consolidation
- CXR may demonstrate increased opacity and reduced volume, resulting in shifted stuctures. These may be identified as consolidation, atelectasis, scar tissue, pleural effusion, pneumothorax
- Pain on inspiration
- Reduced exercise tolerance
- Restrictive pattern from spirometry
- Use of accessory mm’s, reduced oxygen sats –> resp failure can occur depending on severity and cause of volume loss
What is normal human body temperature?
36.5 - 37.5 degrees
Fever (pyrexia) is anything above 37.5 and is associated with an increased metabolic rate. As temp increases oxygen consumption and CO2 production increases. Results in increased HR and RR.
What is normal heart rate range?
What other heart rate ranges are of note?
- HR= 60-100bpm
- Tachycardia= HR greater than 100bpm at rest
(e.g. anxiety, exercise, fever, anaemia, hypoxia) - Bradycardia= HR below 60bpm
(e.g. athletes, cardiac drugs like beta-blockers)
What is normal blood pressure range?
What other BP ranges are of note?
95/60 to 140/90
- Hypertension= above 145/95 (due to changes in vascular tone/aortic valve disease)
- Hypotension= below 90/60 (normal during sleep, sign of heart failure whilst awake, blood loss, vascular tone)
What is postural hypotension?
Postural hypotension is a drop in BP of more than 5mmHg between lying and sitting, or standing.
- May be due to decreased circulating blood volume/loss of vascular tone
- If 10mmHg or more sudden drop with inspiration suspect pulsus paradoxus and severe airway obstruction
What is normal respiratory rate range?
What other RR ranges are of note?
-Adult normal RR= 12-16 breaths/min
- Tachypnoea= 20bpm RR or above (e.g. any form of lung disease, metabolic acidosis, anxiety)
- Bradypnoea= 10bpm RR or less (*uncommon finding, e.g. central nervous system depression by narcotics or trauma)
What are some causes of finger clubbing?
- Lung disease (infective- bronchiectasis, lung abcess, empyema), fibrotic, malignant- bronchogenic cancer, mesothelioma)
- Cardiac disease (congenital cyanotic heart disease, bacterial endocarditis)
-Other (familial, cirrhosis, gastrointestional disease- Crohn’s, ulcerattive collitis, coeliac disease)
What should a basic subjective assessment include for respiratory patient?
- Check medical records
- Breathlessness, cough, sputum, wheeze, chest pain
- Duration, Severity, Pattern, Associations
- Functional ability, Disease awareness
- Alongside PMH, FH, SH, DH, HPC, Sleep pattern, Aggs/Eases
What physiotherapy strategies are there to manage reduced lung volumes?
Strategies to increase lung volume:
- Pain management
- Controlled mobilisation
- Breathing exercises= focus on thoracic expansion, inspiratory holds and sniffs
- ACBT (if sputum retention reduce forced expiration and emphasise thoracic expansion exercises)
- Positioning= for optimal expansion and length tension relationship of diaphragm, postural drainage (sitting forward lean, side lying, prone-ICU?
- Continuous airway positive pressure (CPAP) to increase FRC
- Intermittent positive pressure breathing/ noninvasive ventilation to increase TV
- Neurofacilitation techniques = ventilated ensure positive end expiratory pressure is maintained throughout
What factors can result in reduced chest wall/ diaphragm mobility?
- Chest wall deformity= (kyphosis, scoliosis), ankylosing spondylitis, degenerative arthritis, trauma- # ribs, abdominal/thoracic surgery
- Lung compression= enlarged abdomen (ascites, pregnancy, obesity, constipation)
- Intrusion of abdominal contents into chest= e.g. diaphragmatic hernia/ hiatus hernia
- Pleural effusion, mass (e.g. tumour)
- Pneumothorax
- Obesity
What factors can result in reduced lung compliance?
- Interstitial lung disease
- Cystic fibrosis
- Atelectasis (secondary to sputum plugging, causing lobar collapse)
- Pulmonary oedema
- Pneumonia, consolidation
- Adult respiratory distress syndrome (ARDS)
What factors can result in inspiratory muscle weakness or paralysis?
- Neuromuscular disease (e.g. GBS, high spinal cord lesions, muscular dystrophy)
- Reduced respiratory drive (e.g. head injury, drugs)
What different respiratory problems can lead to low lung volumes?
- Consolidation
- Atelectasis
- Chest trauma
- Postabdominal/ thoracic surgery
- Pleural Effusion
- Pneumothorax
- ARDS
What are the components of “work of breathing”?
Other terms surrounding/describing this?
Increased WOB= Load (applied to resp mm’s), Capacity (efficiency of resp mm’s), Demand (drive to breathe)
- Dyspnoea, breathlessness, shortness of breath= pts perceived increased WOB
*Beware resp mm fatigue can lead to resp failure!!
Signs of increased work of breathing
- Increased RR (increased demand for gas exchange)
- Increased HR (improve circulation for O2 delivery)
- Altered respiratory pattern (Increased TV, Pursed lip breathing-prevents airway collapse during expiration)
- Mouth breathing (reduces airflow resistance)
- Accessory mm’s use (to improve ventilation)
- Decreased O2 sats (Pt no longer maintaining sufficient gas exchange causing hypoxemia)
- Dereanged ABG’s (no longer able to maintain adequate ventilation/gas exchange/ CO2 removal)
Signs of hypoxia
Hypoxia= low O2 in blood/tissues
- Increased RR
- Cough
- Cyanosis
- Shortness of breath
- Cerebral- confusion/anxiety
- Cardiac- increased/decreased pulse, cardiac arrest
- Sweating
- Reduced SPO2 and partial pressure of O2
Signs of hypercapnia
Hypercapnia= C02 retention/build up (common in COPD)
- Peripheral vasodilation
- Bounding pulse
- Tremor of hands
- Cerebral- restlessness/irritability, confusion, seizure, coma
- Cardiac- increased/decreased pulse & BP, cardiac arrest
- Fatigue
- Increased PaCO2
What treatment options are available to reduce the load of increased work of breathing?
Increased Load= extra thoracic load, airway load, lung tissue load (compliance)
- Positioning (for lung compliance and diaphragm unloading)
- Weight loss
- Address bronchospasm
- Clear sputum
- Reduce inflammation
What treatment options are available to reduce the demand of increased work of breathing?
Increased Demand= Hypoxic drive, metabolic demands, anxiety, hypercapnic drive
- Improve breathing pattern
- Rest
- Reassurance
- Support oxygenation
- Support ventilation
- Reduce metabolic demand
What treatment options are available to reduce the capacity of increased work of breathing?
Increased Capacity= muscle bulk, muscle innervation, muscle nutrition, level of muscle fatigue
- Optimise V/Q matching
- Optimise respiratory mechanisms
- Support oxygenation
- Support ventilation
- Strengthen respiratory mm’s
- Rest
What is respiratory failure?
Respiratory failure= results from inadequate gas exchange by the respiratory system, meaning arterial oxygen, carbon dioxide or both cannot be kept at normal levels
What are the signs of Type 1 Respiratory Failure?
- Oxygen arterial partial pressure below 8KPa (hypoxic)
- RR above 24 bpm (tachyponoeic)
- Partial pressure of CO2 (PaCO2) is normal/low
- Difficulty speaking in full sentences, using accessory mm’s
- Perform full ax: notes, ausc, CXR, ABGs, RR etc. before treatment
** If pt resp mm’s fatigue risk type 2 respiratory failure
What are the causes of Type 1 Respiratory Failure?
- V/Q mismatch (COPD, pneumonia, asthma, interstitial pulmonary fibrosis, bronchiectasis, pulmonary oedema, pneumothorax, pulmonary embolus, ARDS, lobar collapse)
- True pulmonary shunt (no response to O2 therapy- although CPAP/PEEP may help) = large pnumonias/consolidation, large atelectasis, ARDS/acute lung injury, small cell lung cancer
- Diffusion defects= thickened membrane (pulmonary fibrosis/sarcoidosis), reduced lung surface (emphysema)
- Hypoventilation of alveoli (will progress to T2)= dysfunction to ventilatory drive, weakness from neuromuscular dysfunction (SCI), mm fatigue- fixed thorax, worsening V/Q mismatch (severe kyphoscoliosis)
What 2 types of oxygen delivery devices are there?
Examples and brief description
1_ Variable Performance Devices
- e.g. Simple face mask, nasal cannulae
- Low O2 devices, where O2 delivery is dependent on minute ventilation (TV x RR)
2_ Fixed performance devices
- e.g. Venturi mask, nasal high flow
- High O2 flow rate, deliver known O2 dose, delivery rate may exceed minute ventilation even when pt tachypnoeic
When should humidification be considered?
- Any artificial airways (e.g. tracheostomy, laryngectomy)
- If dry O2 is uncomfortable for pt (to improve compliance)
- Hypoxemic pts with sputum retention
What are the effects of CPAP?
Continuous Positive Airway Pressure- maintained throughout resp cycle. Can be used with high concentrations of O2
IMPROVES OXYGENATION BY INCREASING FRC AND IMPROVING LUNG COMPLIANCE
- Assists alveolar recruitment (e.g. post-atelectasis)
- Reduces V/Q mismatch
- Improves gas exchange & arterial oxygenation
- Reduces WOB/ RR
- Aids secretion mobilisation
Contraindications for CPAP?
- Acute asthma/ severe air trapping COPD
- New onset of type 1 resp failure where no hx of previous lung disease e.g. perfuse pneumonia
- Uncooperative/ extremely anxious pt
- Reduced consciousness and inability to protect their airway. Unstable cardioresp status/resp arrest
- Trauma or burns involving face/ facial/esophageal/gastric surgery
- air leak syndrome (pneumothorax with bronchopleural fistula)
- Severe nausea/ vomiting/ copious secretions
What are the signs of Type 2 Respiratory Failure?
- PaO2 less then 8KPa
- PaCO2 greater than 6.5KPa
- pH is less than 7.35
- RR is more than 24bpm
Occurs as result of inadequate gas exchange and/or hypoventilation. Results in CO2 retention. The pt will be hypoxic and hypercapnic.
What are the common causes of Type 2 Respiratory Failure?
- Inadequate central drive (e.g. drugs/head injury)
- Weak or fatigued respiratory mm’s (e.g. neuromuscular disease, T1RF to T2RF due to mm fatigue)
- Fixed thoracic cage (e.g. kyphoscoliosis, obesity)
- Worsening of V/Q mismatch ( e.g. infective COPD exacerbation)
- Decreased lung surface area (e.g. exacerbation of CF, ARDS, pneumonia, bronchiectasis)
What are some treatment options for the management of Type 2 Respiratory Failure?
- Optimise alveolar ventilation and V/Q matching, reducing further fatigue of resp mm’s.
- NIV
- Treat reversible causes (e.g. atelectasis and sputum plugging- mechanical insufflation-exsufflation, assisted coughing techniques, positioning and manual techniques-use caution can worsen WOB)
- Reduce hyperinflation (pursed lip breathing)?
When should NIV be used?
What are the benefits of NIV?
- NIV used to treat acute/chronic Respiratory Failure
- Increased tidal volume with each breath (if pressure effective should improve chest wall mvt)
- Corrects pCO2 and pH
- Reduces RR
- Reduces WOB and breathlessness by offloading the inspiratory muscles ( delivers IPAP and lower EPAP)
Contraindications for NIV?
- Severe facial deformity (e.g. facial #’s, facial burns)
- Fixed upper airway obstruction
- Undrained pneumothorax
- Inability to protect the airway
Relative contraindications: (needs monitoring and trained professionals)
- excess bronchial secretions, confused & uncooperative, GCS less than 8, hypotension (systolic BP below 90)
What is ACBT?
When should it be used? How does it work?
ACBT- secretion clearance technique
- Breathing control interspaced with Thoracic expansion exercises (TEE) and Forced Expiration Technique (FET= HUFF- sputum mobilisation)
- Can be used with other treatments: e.g. manual techniques and positioning
* No contraindications or precautions
What is autogenic drainage?
When should it be used? How does it work?
AD= technique to mobilise secretions by breathing at different lung volumes to produce high airflow in the airways. Particularly used in chronic lung pathology.
* No contraindications or precautions
What is breathing control/ diaphragmatic breathing?
When should it be used? How does it work?
BC= relaxed breathing at TV, using minimal effort, relaxed shoulders/upper chest. Place hand on abdomen to ensure effective diaphragmatic breaths
- Indications: Increased WOB, shortness of breath, altered breathing pattern, panic attackes/anxiety, hyperventilation
* Enusre pt comfortable and not actively contracting abs. No contraindications
What is CPAP?
When should it be used?
Contraindications and precautions?
CPAP= Continuous Positive Airway Pressure. Used in spontaneously breathing pts who require high flow rate. Should be used with humidification. Can perform breathing exercises alongside.
Indications:
- Increased WOB, hypoxaemiacaused by atelectasis, reduced FRC, flail chest, poor gas exchange due to inflammation/pulmonary odema/chronic damage
Contraindications:
- Undrained pneumothorax, Frank haemoptysis, vomitting, facial #’s, nasal approach for neurosurgery, CVS instability, Raised ICP, Recent upper GI surgery,Active TB, Lung abscess
Precautions:
- Increasing PaCO2, Emphysema (bullae), pt compliance, Skin breakdown around mask, airways obstructed by tumour (air trapping), deranged platelets
When should cough be used?
Contraindications and precautions?
Effective Cough= pt effective breath in, closure of glottis to generate expiatory velocity.
Indications:
- Prevention and treatment of sputum retention
Contraindications:
- only for assisted cough-avoid pressure on abdomen/rib #’s/ chest wall injuries
Precautions:
- Normal: Pain (adequate analgesia), severe bronchospasm, discourage unnecessary coughing (pts with frank haemoptysis, oesopageal bleeding, raised ICP, recent cerebral bleed, major eye surgery), perussis (whooping cough)
- Assisted cough: immediately following surgery (abdominal, eye, cardiothoracic), paralytic ileus, rib #’s, raised intracranial pressure, undrained pneumothorax, osteoporosis, unstable spine.
What is High Flow Nasal Cannula?
When should it be used?
Contraindications and precautions?
HFNC= delivers up to 70L gas per min. Used with heating and humidification.
Indications:
- Increased WOB, High O2 requirement, Poor face mask tolerance, Pts where humidity may assist clearing secretions
Contraindications:
- Maxillofacial trauma, complete nasal obstruction, basal skull #, undrained pneumothorax
Precautions:
- Flow not too high for pt, No forced expiration if appropriate
What is Humidification?
When should it be used?
Contraindications and precautions?
Humidification= water vapour cooled/heated, delivered using wide diameter tubing (21mm) and mask, 10-15mins use.
Alternative= perscribed saline nebulisers (5mL of 0.9% saline)- only use humidification if these uneffective
Indications:
- Sputum retention (sticky/thick/difficulty expectorating/dry mouth), pts needing continuous O2 (dry gas), pts breathing via tracheostomy/endotracheal tube
Contraindications:
- None
Precautions:
- Pts prone to bronchospasm, crystallization of saline, airway/facial burns if heated humidification, can exacerbate fluid overload in cardiac conditions
What is Incentive Spirometry?
When should it be used?
Contraindications and precautions?
Incentive spirometer= gives visual feedback on slow breath performance (limited evidence)
Indications:
- Volume loss, pts with difficulty performing TEE
Contraindications & precautions: None
What is Manual Hyperinflation?
When should it be used?
Contraindications and precautions?
MHI= deep breaths delivered manually to mechanically ventilated pts by rebreathing bag. To recruit collateral ventilation, expand areas of atelectasis and improve ABGs.
Indications:
- Intubated pts with atelectasis/ sputum retention hypoxia
Contraindications:
- Undrained pneumothorax, CVS instability/arrythmias, Systolic BP (<80), severe bronchospasm, peak airway pressure >40cmH20, High PEEP requirement (>15), unexplained haemoptysis, raised ICP
Precautions:
- Use manometer monitor peak pressures, Don’t exceed 40 pressure and >10 PEEP, drained pneumothorax, recent lung surgery (14 days), arrythmias/unstable BP, On 100% O2 (risk desaturation), Reduced resp drive, Raised ICP within set limits
What is Manual Insufflation/Exsufflation (Cough Assist/Clearway)?
When should it be used?
Contraindications and precautions?
Device assists cough effort using positive pressure breath, followed by rapid switch to negative pressure
Indications:
- Prevention and treatment of sputum retention
Contraindications:
- Undrained pneumothrorax
Precautions:
- Oxygen dependency (include O2 in breathing circuit), Don’t use on-call if untrained, Bronchospasm
How does mobilisation help breathing?
When should it be used?
Contraindications and precautions?
Mobilisation= can induce deep spontaneous breathing, increases expiratory flow rates, helps loosen secretions, provoke coughing and increase respiratory muscle strength
Indications:
- Sputum retention, Volume loss, Limited previously mobile pts
Contraindications:
- CVS instability, Low BP, serious arrythmyia
Precaustions:
- Drips/drains/catheters, controlled pain through analgesia
What is Nebulised hypertonic saline/mucolytics?
When should it be used?
Contraindications and precautions?
Nebulised hypertonic saline (<7% sodium chloride) hydrates mucociliary escalator potentially reducing sputum viscosity & assists sputum clearance in pts with chronic airways disease.
Mucolytics= can be nebulised/oral which break down sputum, less thick and easier to expectorate
Indications:
- Sputum retention
Contraindications:
- Closely monitored pt with haemoptysis
Precautions:
- May cause bronchospasm, hypertonic saline must not be mixed with other drugs, avoid giving inhaled medication beforehand
What is NIV?
When should it be used?
Contraindications and precautions?
Noninvasive ventilation= aims to increase minute volume (TV x RR) to stabilise/reduce PaCO2. Inspiratory postive airway pressure (IPAP) greater then expiratory positive pressure (EPAP). Acutely unwell pts.
Indications:
- Increased WOB causing ventilatory failure (e.g. increased CO2, fatigue, neuromuscular disorders)
Contraindications:
- Undrained pneumothorax, Frank haemoptysis, Vomiting blood, Facial #’s, CVS instability, Raised ICP, Recent upper GI surgery, Active TB, Lung abscess
Precautions:
- Emphysema (bullae), Pt compliance, Skin compromise around mask, Tumour obstructing airways (air trapping)
What is Ocillating Positive Expiratory Devices?
When should it be used?
Contraindications and precautions?
Ocillating Positive Expiratory Devices
(Acapella, AerobiKA, Flutter, RC-Cornet, Bubble PEP)
- Devices can be used alone or with other techniques for retained secretions.
- Exhaling through device = Positive Expiratory Pressure (PEP) and vibration within airways to loosen secretions. Used for 5-15 mins with interspaced FET
Indications:
- Sputum retention
Contraindications & precautions: None
What is oxygen therapy?
When should it be used?
Contraindications and precautions?
Delivering O2 at concentrations between 24%-100%. Give minimum does to reach target sats as toxic if used unnecessarily. Ensure adequate humidification for high concentrations and continuous use, or for tracheotomy/laryngectomy pts.
Indications:
- Hypoxemia, before & after suction
Contrainidcations:
- None
Precautions:
- Hypercapnic COPD pts dependent on hypoxemia for resp drive (use ABGs to assess)
What is Percussion/ Shaking/Vibrations?
When should it be used?
Contraindications and precautions?
Percussion= rhythmic cupped handed clapping on pts chest
Shaking= oscillations through therapists hands to compress and release on chest wall only on exhalation
Vibrations= fine oscillations through therapists hands to pts chest wall during expiration
To assist secretion clearance. Use with TEE. Cushion area with folded towel.
Indications:
- Sputum retention
Contraindications:
- Directly over rib # or surgical incision/graft, Frank haemoptysis, Severe osteoporosis, Hypoxia (can exacerbate)
Precautions:
- Profound hypoxaemia, Bronchospasm, Pain, Osteoporosis/ long term oral steroids, Bony metastases, Near chest drains
What is Postural Drainage?
When should it be used?
Contraindications and precautions?
Positions which use gravity to drain retained secretions. Position maintained for approx 10 mins. Affected lung uppermost.
Positions= Upper lobe, Lingula, Middle lobe, Lower lobe
Indications:
- Sputum retention (particularly if localised to one segment/lobe)
Contraindications to head-down position:
- Hypertension, Severe dyspnoea, Recent surgery, Severe haemoptysis, Nose bleeds, Advanced pregnancy, Hiatus hernia, Cardiac failure, Cerebral oedema, Aortic aneurysm, Head/neck trauma/surgery, Mechanical ventilation
Precautions:
- Diaphragmatic paralysis/ weakness
How can you use positioning to increase lung volumes?
When should it be used?
Contraindications and precautions?
Positioning of spontaneously breathing pts can facilitate maximal inspiration and improve FRC. Use most upright position pt can tolerate (e.g. standing, high sitting, side lying)
Indications:
- Volume loss (poor expansion because pain/ fear/ immobility)
Contraindications:
- Cardiovascular system instability, Unstable spinal # or had injury
Precautions:
- Proceed slowly if standing pt for 1st time following extended bed rest
What are “Positions of Ease”?
When should they be used?
Positions of Ease= spontaneously breathing pts which encourages relaxation of upper chest and shoulders, and ‘free’ the diaphragm
- Forward lean sitting, Relaxed sitting, Half-lying, Forward lean sitting, Relaxed standing
Indications:
- Increased WOB, Shortness of breath at rest/exercise, Anxiety/panic attacks, Hyperventilation
* No Contraindications/Precautions
How can positioning improve ventilation/perfusion matching?
When should it be used?
Contraindications and precautions?
V/Q matching positioning= used for unilateral lung pathology.
Ventilated= Lung with pathology down
Nonventilated= Lung with pathology up
Indications:
- Hypoxemia
Contraindications:
- CVS instability, Unstable spinal # or head injury
Precautions:
- Proceed slowly if standing pt for folloeing prolonged bed rest
What is Endotracheal/ Tracheostomy Suction?
When should it be used?
Contraindications and precautions?
Removal of secretions from upper airways using a single-use suction catheter. Pre/post oxygenate before and after suction with manual hyperinflation/ increasing baseline FiO2 on ventilator.
Indications:
- Sputum retention in intubated pts (high peak airway pressures with volume-controlled ventilation or decreased TV with pressure controlled ventilation), auscultation, hypoxaemia, reduced SpO2. Visible/audible secretions not effectively removed with cough and causing resp distress. Poor cough (neurologic pathology/pain/intubation/drugs), Aspiration, Reduced TV or Increased peak pressures in ventilated pts.
Contraindications:
- none if indicated
Precautions:
- Low SpO2, Dependency on high O2, High ventilatory requirements (use closed circuit catheters), Severe CVS instability, Anti-coagulated pts/ clotting disorders, Severe bronchospasms, Recent lung oesophageal surgery
What is Nasopharyngeal/ Pharyngeal Suction?
When should it be used?
Contraindications and precautions?
Removal of secretions from upper airways using single-use suction catheter introduced via nose or mouth. Unconcious/semi-concious/neurologically impaired pts.
Indications:
- Retained secretions/ aspiration in the upper airways of pt who are unable to cough/ have reduced cough due to fatigue, neurological pathology, pain inhibition or drugs
Contraindications:
- Stridor, Skull #’s, Craniofacial surgery/injury
Precautions:
- High malignancy- high oesophageal varices, Anticoagulated pts/clotting disorders, Severe CVS instability, Severe bronchospasm, Recent pneumonectomy/oesophagectomy- liaise with surgeons
What is Thoracic Expanison Exercises- give examples?
When should it be used?
Contraindications and precautions?
TEE= maximal breath in followed by relaxed expiration.
Can use in conjunction with manual techniques (percussion, shaking, vibs) or with inspiratory hold and/or sniff to increase depth of breath and improve collateral ventilation
Indications:
- Poor expansion because of lung collapse, Sputum retention, Atelectasis, Pain, Fear of pain/mobility
Contraindications:
- None
Precautions:
- Ensure adequate analgesia prior to treatment, suitable positioning to increase volume
What respiratory management techniques are available for sputum retention?
- ACBT
- AD
- Cough/ Assisted cough
- Humidification/ nebuliser
- IPPB
- Manual insufflation-exsuffation (cough assist)
- Mobilisation
- Ocillating positive expiratory devices
- Manual techniques (percussion, shaking, vibrations)
- Postural drainage (Gravity assisted)
- Suctioning (Unconscious/semi-conscious/neurologically impaired pts only!)
What respiratory management techniques are available for increased work of breathing?
- Breathing Control/ Diaphragmatic breathing
- CPAP
- High flow nasal cannula
- IPPB
- Positions of Ease/ Relaxation Techniques
What respiratory management techniques are available for reduced lung volumes?
- CPAP
- Incentive Spirometry
- Mobilisation
- Positioning
- Oxygen therapy ? (reduced gas exchange)?
What respiratory management techniques are available for respiratory failure?
- IPPB- For initial T1RF due to mm fatigue
- NIV
- Oxygen therapy (T1RF- hyoxemia)
What flow rate and concentration of oxygen can different oxygen therapy devices provide?
- Nasal cannula= 2-6L/min (25-40% FiO2)
- Simple Face Mask= 6-10L/min (35-50% FiO2)
- Non-Rebreather= 10-15L/min (80-90% FiO2)
- High Flow nasal cannula= 30-60L/min (100% FiO2)
Respiratory risk factors post-surgery?
Sputum Retention:
- Decreased mucus transport= sputum retention
-Pain= reduced cough= sputum retention
- Dry mouth= decreased expectoration = Sputum retention
Atelectasis:
- Recumbancy, immobility & pain= Decreased FRC, Airway closure, atelectasis
What does COPD stand for?
Its an umbrella term for what conditions?
Chronic Obstructive Pulmonary Disease
- Emphysema
- Chronic Bronchitis
- Chronic Asthma
What are some common symptoms of COPD?
- Cough
- SOB
- Excessive Mucus Production
- Chest Tightness
- Oedema
- Wheeze
What is Pulmonary Fibrosis?
Signs and symptoms?
How to diagnose?
Treatment?
- Progressive and permanent RESTRICTIVE lung disease characterised by injury to alveoli which leads to patchy lung fibrosis and formation of cystic spaces (honeycombe lung)
S+S: - SOB, persistent dry cough
Diagnosis: - Lung function test- spirometry, imaging (CXR and CT)
Treatment: - Oral medication to reduce scarring, oxygen therapy
What is Obstructive lung disease?
Give examples?
Obstructive= Difficult to fully EXHALE (due to narrowing of airways)
- Means air is left in lungs (with more CO2) at the end of every breath
- E.g. COPD, Bronchiectasis, Asthma, Cystic Fibrosis
What is Restrictive lung disease?
Give examples?
Restrictive= Difficult to fully INHALE (challenging to fully expand lungs)
- Occurs because respiratory muscles weak, or tissue in chest wall becomes stiffened
- E.g. Pulmonary Fibrosis, Interstitial Lung Disease, Asbestos, Neuromuscular Diseases
What are the different types of Stroke?
Brief description?
Causes?
Risk Factors?
1- Ischemic (Infarct)
Most common, occurs due to blockage of blood vessel leads to reduced O2 causing tissue death.
Causes: Thrombosis (clot), Embolus (part of clot broken off from somewhere else in the body), arthrosclerosis (fatty build up)
Risk Factors: CVD, Smoking, Obesisty, Hypercolesterolaemia
2- Haemorrhagic (bleed in brain)
Blood leaking from brain blood vessel causing reduced O2 supply to specific area of brain
Causes: Weakened blood vessels bursting
Risk Factors: Hypertension, Anticoagulant use, Irregular blood vessels, Illegal drugs
3- Transient Ischemic Attack
Temporary blood flow restriction causing temporary lack of O2. Symptoms resolve within 24 hrs
Causes: Infarct or Ischemic mechanism like Ischemic stroke
What red flag questions should you ask if concerned about Cauda Equina?
‘Footballers Really Struggle Scoring Brilliant Goals’
- Faecal Incontinence
- Retention of Urine
- Sexual Dysfunction
- Saddle Anaestesia
- Bilateral leg pain/ parasthesia
- Gait Disturbance
What is Asthma?
What happens in lungs?
Common triggers?
Physio Treatment?
Asthma= common long term condition of the bronchi that when inflamed can cause wheezing, chest tightness and breathlessness
- Causes bronchostriction and excess mucus production
Triggers:
House dust, mites, exercise, animal fur, pollen, cigarette smoke, viral infection
Physio treatment:
- Breathing techniques, Controlled Physical Activity, Respiratory Muscle Training, Education (cough etiquette, lifestyle change), Removal of secretions
What to include in Respiratory SOAP notes?
S:
- Consent to chest ax and tx.
- Seen with?
- Asked to see pt because…? Verbal handover from MDT?
- Nil clinical risk (e.g. COVID, infection control risk, known PTE, rib #, aggression, body fluid risk) and how to manage that risk (e.g. PPE, no hands on..etc)
- Target O2 stas?, CXR results? imaging reports?
- Pt complaining of…?
O:
- Pt location (chair/bed), GCS (alert/sedated/confused)
- Attachments (ventilator/drains/lines)
- Accessory mm’s/breathing pattern/SOBAR/Cough status
-Bedside obs: HR, RR, SPO2 via xxx FiO2, BP, Temp
- ABGs
- Auscultation
- Rx: step by step description
A:
- Change in objective markers? Re-Auscultation?
- Effect of intervention?
- Discussions/Instruction for MDT?
- Escalation planning/ DNACPR?
P:
- Plan for next session? When will session be?
- Goals for that session
What is Bronchiectasis?
How is it diagnosed?
What PT intervention can we provide?
Bronchiectasis= Long term Obstructive condition where airways become abnormally widened leading to build up of excess mucus that can make lungs more vulnerable to infection
S+S:
- Chronic mucus production (purulent), breathlessness, chest pain, insp and/or exp crackles and wheeze, clubbing, reduced exercise tolerance
PT intervention:
- Education
- Antibiotics/Nebulised antibiotics, Airway clearance Techniques (review daily until optomised), Vaccination, smoking cessation, pulmonary rehab
- Modified ACBT, PEP, Postural drainage, Manual techniques, Nebulisers, analgesia, breathlessness management positions
*Avoid techniques which worsen hyperinflation
What is Pneumonia?
How is it diagnosed? S+S?
What PT intervention can we provide?
Pneumonia= Lower resp tract infection, causing inflammation of lung parenchyma causing consolidation of alveolar air spaces.
S+S:
- Fever, productive cough, pleuritic chest pain, dyspnoea, Type 1 resp failure
Management:
- Oxygen, Antibiotics, nebulised saline/broncholdilators, fluid resuscitation, V/Q matching, positioning, PEP?
- Check: CXR, bloods (Hb, CRP), ABG’s, RR, BP, Confusion?
- Differential: Pulmonary oedema (heart failure), COPD exacerbation, pulmonary embolism, pneumothorax
* NIV contraindicated!
What is COPD?
How is it diagnosed? S+S?
What PT intervention can we provide?
COPD= airways become inflammed, narrowed, floppy and produce excess mucus. Causes airflow limitation, air trapping/hyperinflation.
Emphysema= destruction of lung alveoli= poor gas exchange
S+S:
- Breathlessness, Fatigue, Cough, Wheeze, Sputum
- Barrel chest, Accessory mm’s use, Reduced exercise tolerance, Hypoxia
Mx:
- Pulmonary rehab, Smoking cessation, Bronchodilators, Vaccinations, O2 therapy, NIV
- Airway clearance, Positions of ease, O2 therapy but careful hypercapnic response, NIV (T2RF)
*Avoid techniques worsening hyperinflation (e.g. thoracic expansion ex’s)
What is Asthma?
How is it diagnosed? S+S?
What PT intervention can we provide?
Asthma= triggered by allergens (e.g. pollens, smoke, fur, dust, rapid temp change, resp tract infections). Results in widespread airway narrowing (bronchostriction) and inflammation, causing sputum production.
S+S:
- Wheeze (expiratory=common, insp= worsening airway obstruction), Cough (esp night), Breathlessness, Chest tightness, Accessory mm use
Mx:
- Inhaled bronchodilators (short/long acting), Inhaled corticosteroids
-Inhaler technique (use of spacer), Positions of ease, mucolytics/nebulisers, ACBT, Manual techniques, PEP therapy
What are some common S+S of a right sided stroke?
- Poor Spatial judgement
- Constructional Apraxia (inability to copy drawings or 3D structures)
- Topographical Disorientation (Unable to navigate environment in daily life)
- Left sided weakness
- Left sided sensory changes
- Left sided neglect
- Homonymous Hemianopia (Both eyes visual field loss)
- Anosognosia (pt unaware of of their condition)
- Pseudobulbar affect (PBA) (episodes of inappropriate and uncontrolled laughing or crying)
What are the Upper Limb Myotomes?
C1= Upper Cervical Flexion
C2= Upper Cervical Extension
C3= Cervical Lateral Flexion
C4= Shoulder Elevation
C5= Shoulder Abduction
C6= Elbow Flexion/ Wrist Ext
C7= Elbow Extension
C8= Thumb Extension
T1= Finger Adduction
What are the Lower Limb Myotomes?
L2= Hip Flexion
L3= Knee Extension
L4= Ankle Dorsiflexion
L5= Big toe Extension
S1= Ankle Plantarflexion
Names of common Ischemic strokes and their abbrviations?
TACI= Total Anterior Circulation Infarct
PACI=Partial Anterior Circulation Infarct
LACI= Lacunar Circulation Infarct
POCI= Posterior Circulation Infarct
S+S of TACI Stroke
TACI= Total Anterior Circulation Infarct
- Hemiparesis/ Hemisensory loss (decreased strength and sensation)
- Homonymous Hemianopia
- Global Aphasia (ability to understand and recognise words)
- Visuospatial Neglect
- Approx 17% Ischemic strokes
S+S of PACI Stroke
PACI=Partial Anterior Circulation Infarct
- Has 2/3 symptoms same as TACI
- Expressive or Receptive Aphasia (know what what to say but trouble saying it/ see print or hear voice but don’t understand words)
- Typically no drowsiness
- Visuospatial Disturbances
- 34% of Ischemic strokes
S+S of LACI Stroke
LACI= Lacunar Circulation Infarct
- Can have only motor symptoms, only sensory symptoms or mix of both
- Ataxic hemiparesis (Un-Coordinated Mvt on one side of the body?)
- Dysarthria (inability to control speak mm’s-difficulty speaking)
- Clumsiness
- 25% Ischemic Strokes
S+S of POCI Stroke
POCI= Posterior Circulation Infarct
- Vestibular or Ocular signs
- Isolated Cerebellar dysfunction (balance problems, gait disorders, difficulties coordinating mvt)
- Ipsilateral CN (cranial nerve) palsies (same side as stroke) with contralateral sensory/motor loss
- 24% Ischemic Strokes
What are the 5 D’s and 3 N’s?
- Dizziness
- Diplopia (Double vision)
- Dysphasia (Trouble Swallowing)
- Dysarthria (Problems with speech)
- Drop Attacks
- Numbness
- Nausea
- Nystagmus (rapid oscillation of eyes/problems with vision)
What red flag questions should you ask for caudia equina?
- Urinary retention
- Feacal incontinence
- Saddle anesthesia (loss of sensation, pins and needles/ numbness around anus/gentiles)
- Sexual dysfunction
- Widespread LL weakness
- Gait disturbances (progressive motor weakness)
What are common red flags?
- Back pain <20 or >55
- Constant, non-mechanical pain
- Thoracic pain
- Person/ Family hx of cancer
- Systemically unwell (fever)
- Unexplained weight loss
- Widespread neurological symptoms
What are common symptoms of an MCA stroke?
Middle Cerebral Artery
(Frontal lobe, and lateral surface of parietal and temporal lobes)
- Deficits in mvt and sensation (contralateral hemiplegia and hemianesthesia)
- Difficulty swallowing (dysphagia)
- Impaired speech ability (dysarthria, aphasia)
- Impaired vision and partial blindness (hemianopia)
- Headaches
- Hemineglect
What are common symptoms of an ACA stroke?
Anterior Cerebral Artery
(interhemispheric cortical surface of frontal and parietal lobes)
- Deficits in mvt and sensation (contralateral hemiplegia and hemianesthesia) WORSE IN LL
- Gait apraxia
- Disinhibition and speech preservation (cant interpret appropriate behaviour)
- Reduced speech, mvt, and motivation
- Mental state impairments: confusion, amnesia, apathy, short attention span
What are common symptoms of an PCA stroke?
Posterior Cerebral Artery
(Temporal and occipital lobes)
- Hemianopeia (blindness in half their vision field) or inability to perceive colours
- Dyslexia
- Aphasia
- Memory problems
- Pupillary dysfunction
What would you include in the objective assessment for a stroke patient?
*Compare BOTH SIDES
- Observation (alignment, hypertrophy/wasting, spasticity, limb position, associated reactions, hemineglect)
- ROM (active if able and passive)
- Myotomes (UL&LL- strength- oxford scale)
- Dermatomes (UL&LL sensation)
- Reflexes (Triceps, biceps, brachialis, patella, Achilles)
- Tone - “catch”(MAS?)
- Coordination (Finger to nose/ heel to shin)
- UL Subluxation
- Proprioception (finger/toe up or down)
- Bed mobility, STS, Standing, Transfers, mobility/gait/stairs
- Orientation/ Communication/ Vision/ Inattention/ Praxis/ Cognition/ Hearing
-Outcome measures: Berg Balance, Barthel Index, Modified Ranking Scale, grip strength
What are the 4 valves of the heart?
• Mitral Valve – between left atria and ventricle
• Aortic Valve – between left ventricle and aorta
• Tricuspid Valve – between right atria and ventricle
• Pulmonary Valve – between right ventricle and pulmonary artery
What are the coronary arteries?
Heart requires own fuel (Coronary Arteries)
RCA = inferior, SA, AV node
LAD = front
Cx = left side of heart
LCA = LV and ventricular septum
What is LAD? What it supplies?
Left Anterior Descending (LAD)
Supplies:
- Conduction system below the AV node
- Anterolateral myocardium
- Apex
- Interventricular septum
- 45-55% of the left ventricle
• Gives off 2 types of branches:
- Septals- perforate and supply the intraventricular septum.
- Diagonals- run along the surface of the heart and supply the lateral wall of the LV and the anterolateral papillary muscles.
What does the Left Circumflex (LCx) supply?
LCx Supplies:
- Posterior LV
- Anterolateral papillary muscle
- SA nodal artery in 38% of people
- 15-25% of the left ventricle in right dominant systems.
- 40-50% of the left ventricle in left ventricle dominant systems.
Gives off :
- Obtuse Marginal branches
- Posterior Descending Artery in 15% of people
What is the RCA? What it supplies?
Right Coronary Artery
Supplies:
- The AV node and above
- 25-35% of Left Ventricle
- Sinoatrial Nodal Artery in 60% of patients, 40% of the time the SA nodal artery is supplied by the LCX.
Gives off:
- Posterior Descending Artery in 85% of patients
PDA supplies:
- Inferior wall
- Ventricular septum
- Posteromedial papillary muscle
What is distole?
A heartbeat is a two-part pumping action that takes about a second. As blood collects in the upper chambers (the right and left atria), the heart’s natural pacemaker (the SA node) sends out an electrical signal that causes the atria to contract. This contraction pushes blood through the tricuspid and mitral valves into the resting lower chambers (the right and left ventricles). This part of the two-part pumping phase (the longer of the two) is called diastole.
What is systole?
A heartbeat is a two-part pumping action that takes about a second. The second part of the pumping phase begins when the ventricles are full of blood. The electrical signals from the SA node travel along a pathway of cells to the ventricles, causing them to contract. This is called systole. As the tricuspid and mitral valves shut tight to prevent a back flow of blood, the pulmonary and aortic valves are pushed open. While blood is pushed from the right ventricle into the lungs to pick up oxygen, oxygen-rich blood flows from the left ventricle to the heart and other parts of the body.
What is angina?
Angina:
Chest pain caused by spasm or reduced blood flow to heart
Reported as “strangling” sensation in chest
Usually related to increased 02 demand without proportional increase in supply.
Class I – Angina only during strenuous or prolonged physical activity
Class II – Slight limitation, with angina only during vigorous physical activity
Class III – Symptoms with everyday living activities, i.e., moderate limitation
Class IV – Inability to perform any activity without angina or angina at rest, i.e., severe limitation
What is Myocardial Infarction (MI)
- A blockage in the blood flow to the heart/ area’s of the heart.
- The muscle can die due to a lack of oxygen
- Can lead to full cardiac arrest
How does it happen? - Blood clot blocking the coronary artery (from cholesterol plaques)
- Stenosis due to atherlosclerosis
- Severe narrowing of arteries due to drugs
What is STEMI?
STEMI= ST segment elevation myocardial infarction (ST elevation on ECG)
An STEMI is the most serious type of heart attack where there is a long interruption to the blood supply. This is caused by a total blockage of the coronary artery, which can cause extensive damage to a large area of the heart.
ST segment= The ST segment corresponds to the plateau phase of the ventricular transmembrane action potential.
What is NSTEMI?
NSTEMI= A non-ST-elevation myocardial infarction (No ST elevation on ECG)
A SNTEMI is a type of heart attack that usually happens when your heart’s need for oxygen can’t be met. This condition gets its name because it doesn’t have an easily identifiable electrical pattern (ST elevation) like the other main types of heart attacks.
ST segment= The ST segment corresponds to the plateau phase of the ventricular transmembrane action potential.
What is a cardiac arrest?
- A sudden stopping of the heart beating resulting in no blood flow around the body
- It is NOT a heart attack (although a heart attack can progress to cardiac arrest
- Often caused by a reversible cause
4 H’s whic can lead to cardiac arrest?
- Hypoxia –is low levels of oxygen in your body tissues. It causes symptoms like confusion, restlessness, difficulty breathing, rapid heart rate, and bluish skin.
- Hypovolaemia –involves a fall in circulatory volume resulting from a loss of blood, plasma and/or plasma fluid, which is caused by internal or external haemorrhage. Leads to shock.
- Hyper/Hypokalaemia, hypo/hyperglycaemia
A common electrolyte abnormality in hospitalised patients- Potassium level in blood. (Serum potassium of less than 3.5 mmol/l or above 5)
OR Glucose level in blood (less than four millimoles per litre (mmol/l)of blood or above 7mmol/l no food 2hrs) - Hypothermia– A medical emergency that occurs when your body loses heat faster than it can produce heat, causing a dangerously low body temperature. Normal body temperature is around 37 C. Hypothermia occurs as your body temperature falls below 35 C.
What are the 4 T’s related to cardiac arrest?
- Tamponade– Occurs when the space around your heart fills with blood or other fluid, putting pressure on your heart. Because of the pressure, your heart can’t beat correctly, causing a drop in blood pressure
- Tension Pneumothorax– A severe condition that results when air is trapped in the pleural space under positive pressure, displacing mediastinal structures, and compromising cardiopulmonary function
- Toxins– may also include some medicines that are helpful in small doses, but poisonous in large amounts
- Thrombosis- Occurs when blood clots block veins or arteries. Symptoms include pain and swelling in one leg, chest pain, or numbness on one side of the body.
What factors if not treated can result in cardiac arrest?
1- Hypoxia
2- Hypovolaemia
3- Hyper/Hypokalaemia, hypo/hyperglycaemia
4- Hypothermia
5- Tamponade
6- Tension Pneumothorax
7- Toxins
8- Thrombosis
What are the two types of shockable rhythms?
• Ventricular Tachycardia (VT)
- High rate, poor ejection of blood, poor circulating volume
• Ventricular Fibrillation (VF)
- Disorganised depolarisation, poor ejection of blood, loss of output
- Can be caused by faulty electrical impulses, electrocution, choking
• Use defib to ‘shock’ heart into a normal rhythm
• Continue CPR between cycles
What are the two types of non-shockable heart rhythms?
• PEA (Pulseless Electrical Activity)
- Near normal electrical activity but ineffective cardiac output (no pulse)
- Often seen in excessive bleeding, tension pneumothoracies.
• Asystole
- Neither atrial or ventricular activity seen
- Near straight ECG trace (NOT perfectly straight)
• CPR/ adrenaline
What is an angioplasty?
- Angiogram to find area of blockage – or can be done at same time
- A catheter is inserted into an artery.
- The catheter has a small inflatable balloon at its tip. The doctor uses X-ray screening to direct the catheter into a coronary artery until its tip reaches a narrow or blocked section.
- The doctor gently inflates the balloon so that it squashes the fatty deposits in the narrowed artery, allowing the blood to flow more easily.
- The catheter contains a stent - a small tube of stainless steel mesh. While the balloon is inflated, the stent expands so that it holds open the narrowed artery. The doctor lets down the balloon and removes it, leaving the stent in place.
What is ablation?
Catheter ablation procedure, also known as a radiofrequency ablation, is a procedure typically performed for a cardiac arrhythmia.
What is cardioversion?
- Used to restore a fast or irregular heartbeat to a normal rhythm; low-energy shocks are given to your heart to trigger a normal rhythm.
- Defibrillation gives high-energy shocks to the heart to treat very irregular and severe arrhythmias.
What is a CABG?
coronary artery bypass graft
What is PCI?
Percutaneous Coronary Intervention
- Median sternotomy
- Grafts removed (often by second surgeon)
- Heart stopped
- Patient put on CPB (Cardiopulmonary bypass)
- Grafts attached
- Patient taken off CPB and chest closed
What is a TAVI?
Trans Aortic Valve Implantation
• For use with patients requiring AVR (Aortic Valve Replacement)
• Still in research stage
• For use with high risk patients
• Performed on a beating heart – no need for CPB or sternotomy
• Transfemoral, transapical or subclavian approach
• Done by interventional cardiology and CT surgeons
What is a pericardial window?
• Procedure in which an opening is made in the pericardium to drain fluid that has accumulated around the heart.
• A pericardial window can be made via a small incision below the end of the breastbone (sternum) or via a small incision between the ribs on the left side of the chest.
Explain the physiological mechanism of cardiac pacing?
• At rest (not contracting): Positive charge on outside, negative on inside, due to positive ions – polarised.
• Depolarisation = muscle contraction, caused by sodium and calcium ions moving across membrane, making inside more positive
• Causes muscle fibres to contract in synchrony = pumping action.
• SA Node:
- Organised cells that depolarise spontaneously
- Initiates heart beat
- Situated in superior vena cava, above right atrium
• Depolarisation from SA node through right and left atrium to AV node.
• After a short delay, depolarisation continues down the bundle of His (septum) to Purkinje fibres via right and left bundle branch
• Conduction to ventricles = contraction
What is an ICD?
Implantable cardioverter-defibrillator
Whats a PPM?
Permanent Pacemaker (PPM):
• Medical device which uses electrical impulses, delivered by electrodes contacting the heart muscles, to regulate the beating of the heart.
• Primary purpose is to maintain an adequate heart rate
- When native pacemaker is not fast enough or
- When there is a block in the hearts electrical conduction system.
• Modern pacemakers are externally programmable
• Can combine a PPM and a defibrillator in a single implantable device
• Can have multiple electrodes stimulating differing positions within the heart – improves synchronisation
• Batteries last 6 – 10 years – following which need full PPM replacement
• Single or dual chamber
• Usually fitted on left side but can be on right, on side of neck or in abdomen
Advice post Pacemaker Device instillation?
• Skin is glued and incision should heal within 7-10 days
• Some bruising and tenderness maybe experienced in the area
• Patient not allowed to bath or apply talc / deodorant to the area for 24 hours
• Stitches do not have to be removed
• The arm on the side of the pacemaker :-
- Shoulder should be gently rotated in circles daily
- For the first few weeks arm elevation less than 90
- Only lifting only light objects for the first few weeks
- Avoid pushing down through arm on side of PPM
• Driving:
- PPM – not for 1/12 then alert DVLA and insurance company
- ICD – not for 1/12 if inserted prophylactically or 6/12 if inserted following arrhythmia – again insurance company and DVLA must be alerted
- Resume normal activities at one month if pacing check passed
Pacemaker advice for home
• Electrical devices (Microwave/ hairdryers) – ok to use but must be 12cm away from PPM
• Household tools – ok to use
• Induction hob – create electromagnetic field. Must be 60cm away from PPM
• Mobiles/IPAD – ok to use but do NOT place directly over PPM
• No headphones within 3cm – do not dangle or place in breast pocket
• Use phone but on opposite side to PPM. Do NOT place in breast pocket
• Airport/ shop security – should be ok but don’t linger between them
What are the 5 mechanisms that lead to hypoxemia?
- V/Q mismatch- lungs getting enough O2 but not enough blood (increased V/Q ratio) or adequate blood flow and not enough O2 (decreased V/Q mismatch)
- Shunt - blood enters left side of heart without becoming oxygenated in lungs
- Diffusion impairment- enough oxygen entering lungs but not diffusing into blood e.g emphysema/lung scarring or impaired blood flow between heart and lungs
- Hypoventilation- oxygen intake occurs at slower rate, leads to higher levels of CO2 in blood and lower O2 levels
- Low inspired PO2 - usually in higher altitudes, where less O2 available with each breath
What’s the difference between hypoxia and hypoxema
Hypoxemia= decreased partial pressures of oxygen in the blood
Hypoxia= reduced level of tissue oxygenation. If severe can impact ATP production, become anerobic and threaten cellular integrity.
What is an OGD?
OesophagoGastroDuodenoscopy (OGD)
Where gastroscope (flexible tube) used to look at upper gut including oesophagus, stomach and first part of small bowel (duodenum)
