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Cardio pulm exam 2 > Surgical Management of Cardio & Pulmonary Disorders > Flashcards

Surgical Management of Cardio & Pulmonary Disorders Flashcards

1
Q

What is a Thoracotomy?

A

Surgical procedure = incision made between the ribs to access the lungs or other structures of the thorax

Examples: Pneumonectomy, lobectomy, lung reduction surgery, single-lung transplant, some double-lung transplants

Approach = anterior, lateral, posterior

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2
Q

Possible Complications of thoracotomy include:

A

phrenic nerve laceration

complete motor innervation to the diaphragm and sensation to the central tendon aspect of the diaphragm

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3
Q

PT implications of thoracotomy include:

A

Chest tubes, Chest PT, Thoracotomy side shoulder ROM, Breathing Re-training, Incentive spirometry, Bed mobility, Transfers, Early progressive ambulation

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4
Q

Pneumonectomy =

A

Surgical removal of one lung

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5
Q

Most common reasons for Pneumonectomy:

A

Lung Cancer
Congenital abnormalities
Traumatic lung injury
Chronic lung infection = tuberculosis, fungal infections, abscesses

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6
Q

Thoracocentesis =

A

A technique used to remove fluid or air from the pleural space

It can be used as both a diagnostic tool and a therapeutic intervention

Typically used with ultrasonography to pinpoint location, and effectiveness of treatment

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7
Q

Most common reasons for Thoracocentesis:

A

Large pleural effusions
Heart failure
Liver cirrhosis
Nephrotic syndrome

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8
Q

Pleural effusion =

A

excess amount of fluid around the lung in the pleural cavity

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9
Q

Medical Surgical Management: Thoracic Surgical Procedures

A

Posterolateral Thoracotomy Muscles Impacted

Lung Volume Reduction Surgery (LVRS)

Video-assisted thoracoscopic surgery (VATS)

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10
Q

Posterolateral Thoracotomy Muscles Impacted:

A

Latissimus Dorsi, Serratus, Rhomboid Major

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11
Q

Lung Volume Reduction Surgery (LVRS):

A

used for the treatment of pulmonary malignancy, infection, and trauma

used to diagnose pulmonary disease

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12
Q

Video-assisted thoracoscopic surgery (VATS):

A

a minimally invasive surgical technique used to diagnose and treat pulmonary conditions, thoracoscope used for image, small surgical instruments used via a small incision in the chest wall

VATS -> aortic procedures, aortic valve replacement (AVR)

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13
Q

VATS Surgical Approach

A
  • Less surgical time/less anesthesia time
  • Less painful
  • Smaller wound = decreased chance of wound infection
  • Faster recovery/shorter hospitalization
  • Less invasive internally
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14
Q

Anterolateral Thoracotomy Muscles Impacted:

A

Pectoralis Major/Minor, Serratus Anterior

Commonly used for cardiac procedures, pulmonary resections, esophageal procedures

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15
Q

Lateral Thoracotomy Muscles Impacted:

A

Latissimus Dorsi, Serratus Anterior, Obliques, Pec Major

Commonly used for pneumonectomy, lobectomy, wedge resection

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16
Q

Chest Tubes =

A

Fluid or Air Removal:

Placed between ribs = Pleural space between parietal & visceral layers

Used post-surgical for air and fluid removal

Pneumothorax = creates a negative pressure for air removal

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17
Q

Chest tube placement =

A

through the chest wall to drain intra-pleural fluid or blood in the chest post thoracic surgery or chest trauma

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18
Q

Jackson-Pratt Drain (JD)

A

placed in wounds during surgery to prevent the collection of fluid underneath the incision site or used for persistent fluid leaks after surgery

closed, air-tight drainage system which operates by self-suction

drain(s) promote healing by keeping excess pressure off the incision and decreasing the risk of infection.

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19
Q

Lung Bullectomy =

A

Bullectomy: surgical removal of a bullae, which is a dilated air space in the lung parenchyma measuring more than 1 cm

Most common cause of a lung bulla is chronic obstructive pulmonary disease

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20
Q

Lung Volume Reduction Surgeries (LVRS) =

A

Surgical treatment for the symptoms of emphysema in which approximately 30% of the damaged lung tissue is removed in an attempt to improve the mechanics of respiration

Surgery is generally performed by either a median sternotomy or video-scope assisted thoracoscopy (VATS)

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21
Q

Optimization of Diaphragm after LVRS =

A

Reduces lung volume, improves elastic recoil

Results in a less expanded thoracic cage, improved mechanical function of the muscles of respiration, particularly the diaphragm and the mobility of the rib cage

With removal of localized emphysematous areas, lung expansion & recoil of more normal lung tissue may occur = improving ventilation/ perfusion

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22
Q

Lung Transplant Candidates =

A

FEV1 < 30%

Have a condition for which lung transplant is considered an effective treatment

Have severe/progressive lung disease that no longer responds to medical tx

Be physically capable of undergoing surgery and subsequent treatments

Stopped smoking or abusing alcohol, drugs—including pain meds

Have adequate financial resources

Have an acceptable support system

Motivated/compliant with therapy

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23
Q

Lung Transplant =

A

‘Clamshell’ incision = Bilateral thoracotomies

24
Q

Lung transplant PT Implications:

A

Splinted cough, bilateral shoulder ROM, Chest PT, Breathing exercises  diaphragm & rib cage mobility, Incentive spirometry, Bed mobility, Transfers, Posture, day 1 ambulation

25
Q

The primary indication for heart or lung transplantation is =

A

terminal cardiopulmonary disease

26
Q

Heart and Lung Transplantation indication =

A

Combined heart-lung transplantation remains the only definitive therapy for patients who have both end-stage heart failure and end-stage lung failure

Most common indication is congenital heart disease (CHD) followed by idiopathic pulmonary arterial hypertension (IPAH)

27
Q

Donor Organs =

A

The availability of donor organs dictates the pace of the transplant

The list of candidates awaiting transplantation is maintained by the

United Network for Organ Sharing (UNOS)

Pharmacological agents are used to medically manage organ transplant candidates until a donor organ is available

Donor organs are matched to the recipient using a specific organ allocation system

28
Q

Candidates for transplantation are evaluated by a transplantation team member and must meet certain eligibility criteria =

A

Cardiopulmonary Exercise Test is primary indicator used to guide transplant listing

Patients eligible are classified as: Class I, IIa, IIb, III based primarily on CPET along with other factors such as ventilation status, obesity, age

A Physical Therapist evaluates the patients cardiac and/or pulmonary system limitations as well as musculoskeletal condition, exercise capacity, ventilator function, and mucociliary clearance

29
Q

Preoperative rehabilitation program:
(heart and lung transplantation)

A

Patient and family education
Cardiovascular endurance training
Musculoskeletal strength
Flexibility training
Breathing retraining

30
Q

The goal of the pre-operative rehabilitation, is to:

A

improve or prevent deterioration of the candidate’s physical condition and to assure the ability to increase post-operative physical function

31
Q

Factors considered when an organ becomes available:

A

Blood type

Body size: within 10%

Medical urgency
Survival
Location of donor and recipient

UNOS

32
Q

UNOS computer system generates a “match run” =

A

a rank-order list of candidates to be offered each organ

33
Q

Organ preservation time:

A

kidney = 24-36 hours

pancreas = 12-18 hours

liver = 8-12 hours

heart/lung = 4-6 hours

34
Q

Heart-Lung Transplant Procedure - donor

A

No significant valvar stenosis or insufficiency

Chest X ray free of significant infiltrate

Free of systemic infection

No evidence of malignancy

35
Q

Heart-Lung Transplant Procedure - recipient

A

Sternotomy

Cardiopulmonary bypass

Heart excised followed by each lung leaving the main stem bronchus intact

Donor heart-lung bloc placed

Aortic, inferior vena cavam superior vena cava anastomosis

Considerable time taken to weak patient form bypass and initiate ventilation to allow for homeostasis

36
Q

Heart-Lung Bypass Machine =

A

pump returns oxygenated blood to the aorta and delivers it to the rest of the body

Functions as the heart and lungs during surgery

Maintains circulation of blood and oxygen

Maintains appropriate temperature

Bloodless field for thoracic surgery

37
Q

Reasons for Lung Transplant =

A

COPD
Pulmonary fibrosis
Pulmonary hypertension
Cystic fibrosis

38
Q

Lung transplant post-op care =

A

ventillatory support
hemodynamic monitoring
immunosuppressive therapy
monitor for s/s of infection and rejection
emotional support

39
Q

First 3 months post lung transplant =

A

ICU -> P Rehab -> Home Health -> OP Rehab

Close daily to weekly monitoring by lung transplant team

40
Q

Domino effect Heart and Lung Transplantation =

A

donor = deceased

patient 1 = has malformed but viable heart and bad lungs

patient 2 = has a bad heart

donor heart and lungs given to patient 1

old heart from patient 1 given to patient 2

41
Q

Common Immunosuppressants =

A

Azathioprine
Basiliximab
Belatacept
Prednisone

42
Q

Immunosuppressive medications are used to:

A

prevent rejection and infection

43
Q

Acute rejection =

A

both cellular and/or antibody mediated occur when the immune system is not adequately suppressed, thus causing inflammation that can damage the new tissue over time

44
Q

For all thoracic transplant patients, vital signs should be monitored:

A

Hemodynamic Response = heart rate, BP, RR, RPE, SpO2 and/or SaO2

Heart rate of a heart transplant recipient will not increase linearly with activity progression secondary to denervation

45
Q

Cardiac Denervation =

A

Disappearance of neural input to the sinoatrial node

Loss of efferent and afferent nerve signaling into and out of the heart = Heart Transplant recipients unable to experience the sensation of angina due to ischemia

Loss of ventricular sensory input = hypotension and bradycardia

Potential impact on inotropic responses = decreased strength of heartbeat

46
Q

Exercise capacity in denervated HTx recipients seems to be diminished =

A

denervated hearts must rely on circulating catecholamine to adjust to increased needs of exercise

HR increases more slowly than normal to reach a lower maximal HR

HR decrease during recovery from exercise at a slower than normal rate

Abnormal cardiac output (CO) response to exercise

47
Q

Exercise prescription for a patient after heart transplantation =

A

critical to have a sufficient warm-up and cool-down period to allow the denervated heart to accommodate to the change in activity level and maintain cardiac output

This accommodation occurs during the warm-up phase by an increase in stroke volume provided by the contracting muscles of the new heart and by increases in circulating catecholamines (a type of inotrope)

Breathing and pacing exercises to allow for increased gas exchange in lung transplant pts

48
Q

Inpatient treatment and goals =

A

focus on improving impaired gas exchange, ineffective airway clearance, patient positioning, pain reduction, and reducing mobility restrictions

49
Q

Outpatient treatment and goals =

A

focus on strengthening large skeletal musculature, weight-bearing exercise, continues aerobic conditioning, resolution of any musculoskeletal problems, home exercise program, education and independence with self-monitoring

50
Q

The Physical Therapist should be alert for transplant complications, which can often manifest themselves initially in the exercise response:

A

decrease in SaO2/SpO2

reduced exercise tolerance = SOB, dizziness, fatigue

abnormal increase/decrease in HR or RR

51
Q

Frequent complications of the transplant patient include:

A

rejection, infection, steroid myopathy, osteoporosis, and malignancy

52
Q

Surgical Management of CHF =

A

Cardiac Transplantation
Left Ventricular Assist Device (LVAD)
Cardiomyoplasty

53
Q

Left Ventricular Assist Device (LVAD) =

A

Successfully used as an alternative to cardiac transplantation

Used for patients with end-stage heart failure who are not candidates for cardiac transplantation

Mechanical pump that typically assists the LV, can be used to assist the RV

Used to bridge a patient waiting for a heart transplant = not available, patient not strong enough

54
Q

Research to date has shown that exercise testing and training for patients with an LVAD =

A

are safe and effective in improving physiologic and functional status

55
Q

Cardiomyoplasty: Left or Right Ventricular Muscle Flaps

A

Latissimus dorsi or trapezius muscle
> wrap around LV/RV
> attached to a pacemaker
> pacemaker stimulates flap to contract
> contracts the LV/RV

major problem = muscle fatigue

56
Q

General Post-Operative Issues =

A

General Anesthesia: anaphylaxis, aspiration, peripheral nerve damage, nausea and vomiting, respiratory distress, hypoxic tissue damage

Blood & Fluid Loss
Blood Transfusion
Pain
Infection
Chest tubes
Mobility

57
Q

Post-Surgical Observation

A

Incisional care = Watch for redness, drainage, edema, heat

Cardio pulm exam 2 (8 decks)

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