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Cardiopulm > Test 2 > Flashcards

Test 2 Flashcards

1
Q

What are the organ transplant Criteria?

A

NYHA class III, unresponsive to medical management
Normal function or reversible dysfunction of organ system.
No malignancy >5 yrs
Life expectancy <1 yr
No contraindications to immunosuppression
Medication and follow up compliance
Financial requirements
Psychologically sound, good social support
Ambulatory with rehab potential

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2
Q

Who are some transplant candidates for heart issues?

A

Severe CAD
End-stage cardiomyopathy or heart failure
Congenital abnormalities

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3
Q

Who are transplant candidates for lung issues?

A

Severe COPD, IPF, CF, pulmonary artery hypertension

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4
Q

What are some alternatives for lung transplantation?

A

LVRS- reducing size of lungs in patients with emphysema, improve symptoms an dpulmonary function, decrease CO2 retention

BiPAP- decrease WOB,HA, daytime fatigue, increase quality of lseep, activity level

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5
Q

What are some alternatives to heart transplants?

A

Pharmacologic- diuretics, ACE inhibitor, ionotropes

Mechanical circulatory support
- 6 weeks of exercise training recommended for bridge to transplant candidates

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6
Q

Pre-Op aerobic training program for Pre Lung Transplant

A

3-5x/week
At 70-80% age predicted max HR, or dyspnea scales
30-40 minutes (target)

Watch O2 stats

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7
Q

Pre-Op aerobic training Program Pre heart Transplant

A

Exercise as tolerated without. Increasing symptoms

Interval training, slow build up

Watch cardiac symptoms, BORG 11-13/20 or 3-5/10

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8
Q

What can limit Phase I of post op treatment in cardiac rehab?

A
  • Resting HR>120
  • HR and systolic BP increase of 30 mmHG
  • RPE= 15/20 or 5/10
  • dizziness, SOB
  • EKG abnormalities
  • excessive fatigue
  • mental confusion
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9
Q

What are some lung transplant specifics to look for Post-Op?

A

Airway clearance techniques

  • postural drainage
  • percussion/vibration
  • flutter valve
  • active cycle of breathing

Thoracic mobility
Breath control re-training

Activity tolerance- aerobic capacity

  • HR limits backed by RPE and dypnea scale
  • O2 sat
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10
Q

Heart transplant HR response

A

Higher resting HR (90-110 bpm)
Donor heart is denervated
Slow rise to exercise stimulus >5min
- Hr rise due to incr leves of circulating catecholamines

HR rise only to 80% of age predicted max

Slower recovery

Use long warm up and long cool down, RPE and O2 sats to gauge exercise response

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11
Q

Heart transplant BP response

A

Normal initially but may develop HTN over time (due to meds)

Normal resting systolic, higher than pretransplant

Elevated diastolic at rest - due to LV stiffness

Incr response to isometric exercises

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12
Q

What is the max VO2 consumption for heart and lung transplant?

A

Heart transplant- 60-70% of normal

Lung transplant- 40-60% of normal

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13
Q

What are some transplant meds?

A

Immune suppression/ anti-rejection

  • calcineurin inhibitor, blockes cell division , reduce replication of helper and killer Tcells- cyclosporine, tacrolimus
  • inhibit WBC production- mycophenolate
  • inhibit WBC function- sirolimus

Corticosteroid, decrease killer T cells - prednisone

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14
Q

What are some side effect of transplant med?

A 
Acne
Anxiety
Hair loss
HA
*High blood pressure
*Osteoporosis
*tremors
Weight gain
Kidney damage
Etc..
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15
Q

What are some signs and symptoms of acute rejection?

A 
Low-grade fever
Inc resting blood pressure
Hypotension with activity
Myalgias (soreness/pain in muscle)
Fatigue
Decreased exercise tolerance
Ventricular dysrhythmias
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16
Q

What are some indications that suggest need for mechanical circulatory support?

A

Severe heart failure- NYHA class IV

Severe cardiomyopathy, cardiogenic shock
Bridge to trnasplant
Destination therapy
Bridge to recovery
Bridge to decision
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17
Q

Contraindications to mechanical circulatory support

A

Body Surface Area BSA- pump may be only able to handle certain body size

Pregnancy

Can’t tolerate anticoagulation therapy

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18
Q

What are some common components of the mechanical circulatory support?

A

Driveline
System controller/console
Power source

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19
Q

Total artificial heart

A

70cc or 50 cc sizes
Replaces both ventricles all 4 valves

Pneumatic—> pulsatile

Physiological response- partial fill (3/4) full eject

SV up to 70 mL

CO up to 9.5 L/min
Fixed rate 100-140bpm

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20
Q

HeartWare HVAD

A

Impeller spins blood —> continuous flow
Carddiac output up to 10L/min

N palpable pulse can’t use manual cuff pressure instead use doppler ultrasound

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21
Q

Thoratec Heart Mate II

A

Assist the failing heart
Implkanted beneath diaphragm, in preperitoneal or intraabdominal space

Rotor(magnet), located inside a thin-walled titanium duct, spins on bearings —> cont flow

CO up to 10L/min

Designed for several years of circulatory support- BBT, DT

Only device approved by the FDA for people waiting for transplant traveling

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22
Q

Heart Mate 3

A

MagLev tech allows rotor to be “suspended” by magnetic forces- less friction, wear and tear, reduces blood trauma

Artificial pulse tech designed to promote “washing” of the pump to prevent stasis

CO up to 10 L/min

Indicated for DT, BTT and bridge to recovery

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23
Q

ECMO

A

Short term- days to weeks , waiting for organ recovery

For management of lfethreatening cardiac failure when no other form of treatment has been or is likely to be successful
- veno-arterial: venous blood diverted from RA, pumped across a membrane oxygenator and heat exchanger, then back to aortic arch

For ventilatory support
- veno-venous: venous blood withdrawnn from RA, circulates through CO2 scrubber and membrane ooxygenator, blood returned via cannula and directed through tricuspid valve

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24
Q

Physical therapy intervention for MCS

A

May begin as early as POD 1
Before initiating mobility- check position of stabilization belt, system controller, driveline

Monitor cardiovascular response to upright positioning, functional mobility, exercise tolerance (phase I cardiac rehab)

  • vitals , EKG change, Borg/RPe
  • doppler US
  • pump rate, speed, flow, SV
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25
Q

Different Cardiothoracic incisions lead to what post-op manifestations

A

Protective psoture- trunk flexed forwards/ to side of incision

DEcreased inspsiratory effort, chest expansion = restrictive lung pathology

Impaired cough

UE limitations

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26
Q

What are some post-op complications?

A

Prone to aspiration, atelectasis —>collapsed lung/alveoli
- Related to decreased arousal, surgical pain, restricted lung capacity

Phrenic nerve irritation or compression trauma
- common in thoracic and upper abdominal surgery

PE, DVT
- due to restricted mobility, bed rest, recumbency

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27
Q

Pt management for postOP patients

A

Optimize O2 transport - lung volumes, chest wall mobility, gas exhange, mucociliary transport, circulation, tissue perfusion

Minimize work of breathing, aspiration risk, undue work of the heart

Max arousal,maintain/restore mental status and sleep/wake cycle

Maintain/restore normal muslce length, ligament integrity

Max cardiopulm enndurance, aerobic capacity, functional capacity

PT education- post op complication prevention, early mobilization, activity progression, porecautions

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28
Q

Post op patients using mobilization exercises as assesment and treatment

A

Upright positioning progression: supine-> sit-> stand

Bed mobility- rolling, supine, sit

Transfer —> sit to stand, bed —>chair

Gait - distance/duration

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29
Q

Mobilization/exercise session considerations to take before planning session

A

Warm-up, steady state, coold-down, recovery phases whenever possible

Timing- coordinate with meds, other tests/procedures, not after heavy meal

Prepare necessary equipment, assistance workspace

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30
Q

Sign/symptoms of exercise intolerance

A

> 20 mm drop in systolic, >10 mm rise or drop in diastolic
10 bpm drop in HR with increased workload

HR too fast, too slow
- acute- limit response to 120bpm or 20-30bpm above resting

Monitor EKG- PVCs, ST elevation/depression, heart blocks, Twave inversion, change from baseline

Monitor O2 saturation
- cardiac <95%
-Pulmonary<90%
- stop if >5% drop from baseline
Dyspnea index 3/4 or Borg>5/10 or RPE >15/20

Angina,duspnea, dizziness, pallor, confusion

Pt request to stop

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31
Q

Incentive spirometer

A
  • encourages deep breath
  • post surgery, immobile patients
  • to re-open airways, improve oxygenation
  • increase surfactant production
  • 10 breaths/hour

Also used to maintain and increase inspiratory muscle strength and endurance

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32
Q

Sternal precautions for open heart surgery

A

Varies with surgeon/facility

In general 6-8 weeks- limit shoulder flex/abd <90 deg

No lifting >5-10lbs

-Avoid UE WB, unilateral reaching posteriorly (trunk rotation + shoulder ext/ horizontal ABd), horizontal shoulder ABd

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33
Q

Thoracotomy/VATS precautions

A

Encourage shoulder and scapular ROM- flex,ext,abd ,add, horizontal abd, horizontal add, butterfly, shrugs, finger wall crawl, scapular protraction/retraction
- lack of movement could lead to frozen shoulder

  • avoid heavy lifting (>10Lbs)
  • vats 1-2 weeks
  • thoracotome - 6-8 wks
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34
Q

Abdominal precautions after surgery

A

Avoid straining abdominals
- log-roll bed mobility
-splint cough
Avoid lifting >5-10lbs

-standing up straight and laying flat hurts

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35
Q

Pacemaker/ICD pracautions Post op

A

Check for contras for arm lifting

  • keep shoulder flex/abd <90deg
  • 1-6 weeks

Avoid heavy lifting <10lbs for 1-6 weeks

Avoid contact sports,

Avoid electromagnetic interference, hih voltage
- carry cell phone >6 in away from device on contralateral side

Carry ID indicating implant
Notify airport security screeners

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36
Q

Goal of ICU care

A

Provide intense, life-preserving, specialized care with teh view of eventual return to maximal functional participation in life and activity

Monitoring:

  • hemodynamic stability
  • optimal oxygen transport
  • fluid and electrolyte balance
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37
Q

Hemodynamic monitoring

A

EKG- HR , rhythm

BP

  • cuff
  • arterial line

Pulse oximeter - O2 sat

RR

Central venous pressure
Pulmonary artery catheter

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38
Q

What are some lines we will se on a patient in ICU?

A

Peripheral IV
Central line
PICC line
Arterial line

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39
Q

What are some tubes you will see on an ICU patient?

A

Chest tube
Feeding tube- nasla, oral, percutaneous

Foley catheter

Rectal tube

Endotracheal tube

Oxygen tubing

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40
Q

What are indication for the use of mechanical ventilation?

A

PaO2< 50 mmHg with supplemental O2

RR>30

Vital capacity <10L/min

Negative inspiratory force <25 cm H2O

Acute repiratory failure

Airway protection from aspiration
Reversal of respiratory muscle fatigue
Respiratory distress

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41
Q

Signs and symptoms of respiratory distress

A

RR>35
Paradoxical breathing pattern (reverse normal breathing insp abs out), use of accessory muscle or dyspnea

Desaturation- O2 sat<90% or decrease of PaO2

Decrease in pH <7.25-7.30 associated with increasing PaCO2

change in HR >20 bpm
Change in BP >20 mmHG
angina, cyanosis, cardiac arrythmias, aagitation, panic, diaphoresis

Change in level of consciousness

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42
Q

Positive pressure ventilators

A

(+) pressure ventiltion the machine forces air into lungs
Classified based on method used to stop inspiratory phase and allow expiration
- cycling method: pressure cycled, volume cycled, time cycled

Circuit- wide-bore tubing that connects patient to ventilator via ETT, tracheal tube, or face mask

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43
Q

Assist-control (A/C)

A

Ventilation mode
Pt initiates breaths, ventilator delivers preset tidal volume
- gives respiratory muscle greatest amount of rest

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44
Q

Pressure support PS

A

Ventilation mode

Pt initiates breaths, ventila3tor delivers preset pressure (reduces work of breathing)

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45
Q

Constant positive airway pressure CPAP

A

Pt breathes spontaneously , ventilator maintains positive airway pressure throughout breathing cycle

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46
Q

PEEP

A

Positive end- expiratory pressure
Pressure maintained by ventilator in airways at end of expiration

Normal physiologic PEEP is maintained by surfactant = 5cm H2O

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47
Q

Ventilator settings

A

Parameters established to provide the necessary support to meet patient’s ventilatory & oxygenation needs- FiO2, RR, Vt

Dependent on: ABGs, vital signs, airway pressures, lung volumes, pathophysiologic condition, including ability to spontaneously breathe

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48
Q

What is intubation?

A

Artificial airway into trachea
Oral or nsal endotracheal tube

Indication: upper airway obstruction, inability to protect lower airway from aspiration, inability to clear secretions from lower airways, need for positive pressure mechanical ventilation

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49
Q

Tracheostomy tube

A

Inserted into trachea below level of teh vocal cords
Usually follow prolonged endotracheal intubation
Benefits: reduce laryngeal injury, improved oral comfort, decreaed airflow resistance, increased effectiveness of airway care, feasibility of oral feeding and vocalization

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50
Q

Weaning criteria

A

Resolution event/disease

Maximized nutrition, stability, fluid and electrolyte balance

RR<35
FiO2<50%
O2 sat>90%
PEEP<5cmH2O

Negative inspiratory force of 20-30 cmH2O

Preferably alert & cooperative

Psychologically ready

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51
Q

Post-intensive care syndrome

A

health problems that remain after critical illness

  • ICU acquired weakness- may take >1yr to fully recover
  • cognitive dysfunction
  • sleep disorders
  • PTSD, anxiety, depression
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52
Q

Intermittent claudication (IC)

A

Main symptom of peripheral arterial disease

Characterized by pain, aching, or fatigue in exercising leg muscles

Pain goes away with rest

It is ANGINA of the legs

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53
Q

How common is Peripheral artery Disease? PAD

A

Patients older than 70 or older than 50 years who smoke and have diabetes have a prevalence of nearly 30%
-1/3 have PAD

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54
Q

What is the 5yr, 10 yr , 15 yr survival rate for patients with PAD?

A

5 yr-70%? 30% mortality
10- 50%
15- 20%

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55
Q

How to Dx/ Rx PAD/PVD?

A

Can use angiogram
ABI (ankle brachial index)
Balloon angioplasty, stent, CABG

Exercise

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56
Q

Thrombus superficial vs deep

A

Superficial: saphenous
Deep: femoral or Iliac

Superficial thrombus: non-life threatening

DVT: Important
- can be caused in anterior tibial vein

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57
Q

Deep Vein thrombosis DVT

A

Risk factors: LE surgery, immobility, trauma to endothelium

Signs: pain, redness, edema

Life threatening if move to pulmonary or brain

No PT Rx because we don’t want it to move

Anticoagulation

Prevention: early mobilization (ankle pumps)

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58
Q

Valvular incompetence/insufficiency

A

Varicose veins- abnormal dilation of superficial veins

Cause: heredity, homonal changes, prolonged standing (no muscle contraction) obesity, pregnancy

Signs: edema, discoloration of distal legs

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59
Q

Spider veins

A

Not serious

Burst capillaries

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60
Q

Varicose vein Rx:

A

Exercise, stop smoking, antiplatelet drugs, elastic stockings, compression sclerotherapy

Risk for clot formation (main problem of varicose)

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61
Q

Venous chronic insufficiency

A

Deep veins
Edema, pigmented areas

Ulcers- medial malleolus

-skin breaks down

62
Q

Arteriovenous malformations AVM

A

Congenital
Blood flow direct between arterial and venous without capillaries, tangle of vessels
- high pressure, rupture

Brain common site- progressive neurologi deficits

DX: angiography MRI

RX: radiation

If known avoid weight training, strenuous aerobic ex

63
Q

Aneurysm

A

Artery or vein, abnormal dilation

Weakened wall, genetic risk, may be aysmptomatic

true: all 3 layers (congenital)
False: spares 1-2 layers (infection, trauma)

Dissecting- medical emergency, severe HA or thoracic abdominal pain, PTs palpate for throbbing mass prior to abdominal tissue massage

64
Q

Vaculitis

A

Poluarteritis nodosa

  • small and medium sized vessels
  • inflammation and formation of nodules throughout organ system

Arteritis: temporal and cranial arteries

Kawasaki Disease- childhood- fever and flulike symptoms - aneurysm

65
Q

Buerger’s disease

A

Inflammation of the peripheral arteries and veins- ectremities
Thrombosis and vasospasm

Intermittent claudication in arch of foot

-cyanosis, chiny skin, numbness, skin ulcers, gangrene, amputation

Young men, smokers, asian <40yrs

RX: stop smoking , medical management

66
Q

Vasomotor Disorder

Raynaud syndrome

A

Reaction to cold exposure

Vasoconstriction followed by reactive hyperemia (finger turning purple)

Rx: avoid cold exposure, nicotine, caffeiine, vasodilators

67
Q

Arterial PAD overview

A

Atheroscelrotic

  • stenosis
  • aneurysm
  • microvasscular- in patients with diabetes
68
Q

Venous PAD Overview

A

Venous

  • stasis, insufficiency
  • thrombosis - DVT
69
Q

PAD inspection/observation

A

Color
Ulcers-venous (painless) vs arterial (painful)

Size, edema

Symmetry

Temp - arteerial (cool) vs venous (warm)

70
Q

Arterial skin changes

A 
Cool pale
Shiny
Hairless
Ulceration
- painful
-Ischemic, gangrene
- result of trauma, common in toes and heel
-rapid developing
71
Q

Venous skin changes

A

Warmer than normal
Stasis changes produce increased pigmentation

Dependent edema

Ulceration

  • painless
  • ankle area or lower leg above medial malleolus
  • slowly developing
72
Q

Special tests for PAD

A

Pulses
Ankle brachial index
Rubor of dependency
Venous filling time

73
Q

Special tests for venous insufficiency

A

Peripheral edema measurement

Venous insufficiency- swelling of calf
-tredelenburg test for saphenous system
—venous filling with tourniquet in place = incompetence

Homan’s sign for DVT
- squeezing gastroc during dorsiflexion

74
Q

Arterial disease

Ankle Brachial index

A

To distinguish neurologic vs vascular (claudication) LE pain

Compares ratio of systolic BP or arms and legs
- use doppler US for legs on posterior tibial artery or dorsalis pedis

Ex: L leg systolic/ highest brachial BP= ABI for L LE

75
Q

ABI scale

A 
0-0.4 severe
0.4-0.7 moderate
0.7- 0.9 mild
0.9- 1.3 normal
>1.3 noncompressible (calcified, diabetes, chornic renal insufficiency, old age)
76
Q

Rubor of dependency test

A

Changes in color with position

  • pallor with elevation
  • deep red color in <30 sec in dependent position

Veins must be competent

We want to do ~1 min

77
Q

Venous filling time test

A

Arterial flow through capillaries into veins

Watch positional change in one peripheral LE vein (elevation—> dependent position)

Insufficient if >10-15 sec to fill

78
Q

Mild vs Pitting Edema

A

Leaves visible depression following pressure
We test how deep and for how long

Grades
1+= barely detectable impression
2+= slight indentation, rebound <15 sec
3+= deeper indentation, rebound 15-30 sec
4+= rebounds >30 sec
79
Q

Exercise prescription for PAD —Walking

A

Weight bearing aerobic- walking is best
3-5x/wk
5-10 minute warm up and cool down
- exercise at 3/4 claudication pain as long as tolerated(5/10) moderate-severe , but tolerable

Time: Interval trianing: 8-10 minutes bouts of exercise: rest until symptoms subside
- increase length of interval as tolerated
- goal 30-60 minutes/day of actual exercise
Resistance 2x/wk

80
Q

PT managment

Venous Stasis

A

Prevent DVT- early mobilization, ankle pumps or heel slides

Compression stockings- promotes venous return

81
Q

Two categories of Lung dysfunction

A

Restrictive- difficulty getting air INTO lungs
- chest walls vs Lungs

Obstructive- difficulty getting air OUT OF the lungs
- narrowing of airways

82
Q

What are examples of obstructive lung dysfunction

A

Bronchopulmonary dysplagia

Asthma

COPD

  • Emphysema
  • chronic bronchitis

Cystic Fibrosis

83
Q

COPD

Cause and respiration flow rates

A

Cause: environmental irritants- smoking

Obstruction to air flow- narrowing of bronchi and bronchioles from inflammation- spasm
- mucous collection

Functional residual capacity, residual volume and total lung capacity increased

Decreased expiratory flow rates

84
Q

Decreased Expiratory air flow

A

Decreased elastic recoil (pressure to push air out)

Increased resistance through spasm, inflammation

Over-inflated lungs, barrel chest

Increased respiratory work

Overtime as we try to push air out but more and more of our residual volume inc we end up with over inflated lungs & what we refer to a barrel chest

85
Q

Decreased alveolar surface Area

A

Destroyed alveolar walls-> opening of alveolar become enlarged which results in less cross-sectional area for exhange to occur—> results in low “O” in blood hyxemia

-vasocontriction of pulmonary arteries

Increased work for R ventricle

-cor pulmonale

86
Q

We define respiratory failure at the point where…

A

PaO2<60 mm HG
PaCo2 >55 mmHg

Cause of death in COPD patients is respiratory failure plus cor pulmonale

87
Q

Early COPD

Bronchopumonary dysplasia

A
  • 10-20% of ventilated infants
    (Due to no enough surfactant airways collapse)
  • oxygen toxicity increases capillary permeability
  • interstitial edema plus WBCs with enxymes to digest elastic network

When infants survice they can have chronic with restrictive airway disease

RX: bronchodilators, dieuretics, surfctant

88
Q

Cystic Fibrosis

A

Recessive genetic chromosome 7

-multi-system
Life expectancy near 40yrs

  • block in chloride permeability
  • viscous secretions- plugs many ducts in body
  • diagnosed through sweat test- increase sodium chloride
89
Q

Asthma

A

Chronic inflammatory disease with acute episodes

Stimuli
-dust,pollen, presevatives, exercise, cold, infection

Bronchoconstriction with increased mucous

Airways are enlarged white spots in airway

90
Q

Symptoms and treatment of Asthma

A

Symptoms

  • decreased flow rates
  • decrease breath sounds, wheezes
  • SOB
  • Coughing

Treatment

  • monitor flow rate
  • bronchodilators
  • exercise in moist warm air, long warm up
91
Q

Bronchiesctasis

A

Major infection that leaves a destruction of elastic tissue in airways —> Permanent dilation

  • inflammation of medium sized airways
  • inflammed and ulcerated
92
Q

Symptoms and treatment of bronchiectasis

A

Symptoms:

  • copious, purulent septum
  • hemoptysis

Treatment

  • antibiotics
  • postural drainage, pulmonary hygiene
93
Q

COPD

Chronic Bronchitis

A 
Airway disease
Blue Boater
- from pulmonary hypertension - lack of oxygenation
- R heart failure
- Peripheral edema
Inflammation of airways with secretion
Starts in large airways, progresses to small
Destruction of cilia
From irritant - smokers
Edema in airways, bronchospasm, coughing
94
Q

Signs of COPD chronic bronchitis

A
  • large production of clear sputum
  • productive cough every day for 3 months of every 2 years
  • crackles and wheezes on expiration
  • R heart failure
  • Peripheral edema
  • FEV less than 65% predicted (face expiratory volume)
95
Q

RX for COPd Chronic Bronchitis

A

Stop smoking
Use bronchodilators
Treat respiratory track infections

96
Q

Emphysema overall

A

Pink Puffer
- incr work of breathing burns all their fat and adipose tissue

Alveolar disease- (NOT AIRWAY)- destruction of walls, creating one large space rather than several small alveoli

  • loss of elastic recoil, collapse of airways on expiration
  • cause : cigarette smoking, alpha1-antitrypsin disease
97
Q

Emphysema signs and symptoms

A

Non productive cough
-thin,cachectic
-increased work of breathing, use accessory muscles
—

98
Q

PT treatment for Emphysema

A

Breathing control

Use diaphragm, not accessory muscles

Energy conservation

99
Q

FEV1 (lung function) levels

A

Forced expiratory volume in 1 sec

FEV1 decreases in everyone as we age but smokoer the slop of decline is drastic

FAV1 high in restrictive 80-90%
FAV1 normal obstructive <75%

Asthmatics/obstructive disease- peak flow rate
- normal is 9-10 L/sec

100
Q

Normal Breath SOunds

A

Vesicular: normal- Peripheral lung. Full inspiration and lil exp

Bronchial: Normal If over manubrium/ trachea ( full expiration)

Bronchovesicular - if over main-stem bronchi (full inspiration full expiration)

101
Q

Abnormal Breath SOunds

A

Decreased- barrel chest so when we listen, sound is diminished b/c we are further away

Or Absent- not heard at all ex: pneumothorax -collpased lung

Bronchial or bronchovesicular
- if heard over peripheral lung fields

102
Q

Adventitious Lung sounds

CRACKLES

A 
Crackles (rales)
- fine , course
-inspiratory (expiratory)
- fluid (edema) or secretions
—
103
Q

Adventitious Lung SOunds

Wheezes

A

(Rhonchi)
- Inspiratory (if severe), expiratory is what we tend to hear

  • airway constriction/bronchospasm
104
Q

Extrapulmonary sounds

A

Pleural rub
- pleura

Stridor
- upper airway- larynx

Crunch- feel
- subcutaneous air (leaked out b/c sking & lung like pushing on rice krispy

105
Q

Optional Voice Sounds to confirm Bronchial Breath Sounds

A

Broncophony “99” “1,2,3”
- if it is louder then consolidation

Whispered perctoriloquy “99”

Egophony- “e” becomes “a” with consollidation

Heard louder over consolidation

106
Q

Mediate Percussion

A

To confirm auscultation findings

-normal,resonant

Hyper-resonant- hyperinflation

Flat, dull
- consolidation, effusion, atelectasis

Techinique

  • dominant middle finger on non-dominant finger
  • intercostal space, tap 2-3 times
107
Q

Lung sounds in case of pathophysiology Atelectasis - collapse alveoli

A

Decreased chest wall excursion on affected side

Decreased or absent breath sounds

Decreased vocal or tactile fremitus

Dullness to percussion

108
Q

Pneumothorax

A

Absent breath sounds
Hyperresonant percussion

Decreased chest wall excursion on affected side

Absent fremitus

If closed (one way air) tracheal deviation to contralateral side

109
Q

Pleural effusion

A
  • fluid between pleura

Over area of effusion:

  • absent breath sounds
  • decreased fremitus
  • decreased chest wall excursion on affected side
  • dullness to percussion
110
Q

Pneumonia

A
  • consolidation in one part of the lung
  • bronchial breath sounds in area of consolidation
  • increased tactile fremitus
  • dull to percussion
  • late crackles
111
Q

Chest mobility assessment

A

Evaluate symmetry Right vs left

Upper chest: thumbs should separate 0.5-1 in

Middle chest : thumbs should separate 1 in

Lower chest: thumbs should separate 1-1.5 in

112
Q

Chest mobility via tape measure

A

Upper chest- under axilla - 1 in

Middle Chest- xiphoid
- 1.25 in

Lower chest- midway between xiphoid and unbilicus
- 1.5-2 in

113
Q

Diaphragm excursion test

A

Percuss down “alley”
Mark where sound changes from resonant to dull = represents level of diaphragm
- max inhale- diaphragm descends, at lowest level
-max exhale- lungs contract, diaphragm rises, at highest level

Diaphragm excursion= difference between inspiration and expiration levels
Normal = 3-5cm
-COPD <3cm

114
Q

Blood gas analysis normal ranges

A

PH: 7.35-7.45- normal: 7.4

PCO2: 35-45 normla :40

PO2: >80. Normal 97

HCO3: 22-28. Normal24

BE: +/- 2 normal 0

%Sat: >95%. Normal 97%

Lungs regulate CO2, kidneys regulate bicarbonate

115
Q

Metabolic acidosis

A

Metabolic acisosis causes excess production of H+

-evidence by decr HCO3

Diabetic or diet induced ketoacidosis

= decr pH

116
Q

Metabolic alkalosis

A

Decr production of H+

Evidenced by inc HCO

Emesis

Inc pH

117
Q

Respiratory Acidosis

A

Inc CO2 drives equation left, inc H+

Hypoventilation (drug induced) or chronic obstructive pulmonary disease

Decr pH

118
Q

Respiratory alkalosis

A

Decr CO2 , decr H+

Hyperventilation

Inc pH

Breathing Co2 fatser than we can get “o” in to the body

119
Q

Compensation

A

Primary respiratory cause compensated by kidneys

Primary metabolic cause compensated by lungs

120
Q

Compensation for metabolic disorders

A

Metabolic acidosis = decr pH
- lungs hyperventilate to remove CO2
Less CO2= less H+ = inc pH

Metabolic alkalosis = inc pH
- lungs hypopventilate to allow CO2 to build up
More CO2 = more H+ = less pH

Respiratory compensation takes hours

121
Q

Compensation for respiratory disorders

A

Respiratory acidosis (dec breath) = decr pH

  • metabolic compenstaion = buildup of HCO3
  • less CO2= excrete H+= inc pH

Respiratory alkalosis= inc pH
Metabolic compensation = decr HCO3
In pH= more CO2= more h+in blood = decr pH

Metabolic compensation takes days

122
Q

Patient chart in front saying pH is low what do we expect….

A

If low look at CO2

  • if high = respiratory cause
  • then BE for compensation : acute oor chronic, fully or partially compensated

-if not caused by high CO2, it it metabolic acidosis
-if low lungs are trying to compensate
Less CO2= less H+= inc pH

123
Q

Patient chart in front of you pH is high what do we expect….

A

If high, look at CO2

  • if low CO2, respiratory cause
  • BE- probably not time to compensate

-if not caused by lo CO2, it is a metabolic alkalosis
-if CO2 is high, lungs are trying to compensate
-fully or partially compensated
—

124
Q

Homocysteine level

A

Normmal = 5-15 umol/L

-linked to decr folic acid , B6 , and B12

125
Q

Inflammatory markers

A

C Reactive Protein should be <5mg/L

  • good predictor of CHD related events
  • aspirin, physical activity, weight loss - decr CRP

-hsCRP- high sensitivity CRP

Increased WBCs

126
Q

Complete blood counts norms

A

RBC x 10^6 uL

  • male 4.6-6.2
  • female 4.2- 5.4

WBS of whole blood
- 4500- 11000

Platelets
- 300000/ uL

Hemoglobin

  • male 13.5- 18 g/dL
  • female 12-16

Hematocrit %RBC

  • males 40-54%
  • female 38-47%
127
Q

Coagulation profiles

A

Prothrombin/ Partial thromboplastine time in sec

Increased levels mean increased time for clot formation

Increased chance of bleeding or bruising

128
Q

Electrolytes levels

A

Na 136-143

K+ 3.8-5.0

Kidney function

  • blood urea nitrogen
  • creatinine

Fasting glucose
- 70-110 mgDl

129
Q

Non- invasive tests

A

Holter monitoring- 24 hr monitoring

Doppler ultrasound- blood flow

130
Q

Echocardiogram

A

Limitation: not high enough resolution to see arteries

Shows big changes in structure

Detects a valve that doesn’t properly isolate the chambers of the heart

131
Q

MRI

A

Evaluate mass,chest wall or aneurysm

Limiation: cant use with metal

132
Q

CT scan

A

For arteries calcium plug

Limitation: radiation in children

Fat distorts

133
Q

PET/ CT scan

A

Structure and function

Limitation: expensive

134
Q

Thallium perfusion imaging during exercise

A

Light up if perfused

Doctors inject a radioactive substance and use gamma-rays to see how blood moves through hear. Shows how well herat is doing at keeping itself saturated with oxygen-rich blood

Limitation: carrying out two scan can take as long as 5 hrs, radiation exposure

135
Q

Angiogram - catherterization

A

Catheter iinserted through artery in leg

Dye highliights cardiac arteries

Risks: can tear walls
- lying still fro 4-6 hours afterwards

136
Q

Pharmacologically induced stress

A

Coronary artery spasm evaluated with ergonovine

Arbutamine to raise HR

137
Q

Arterial line

Indwelling arterial catheter

A

Measurement of arterial BP

138
Q

Mean arterial pressure

A

MAP= (SBP + (2x DBP))/ 3

= 70- 110 mmHg

139
Q

Central Venous Line

A

Right atrial pressure

  • 0-8 mmHg
  • inserted in R subclavian or jugular

Elevation: fluid overload

  • R vent failure
  • tricuspid insufficiency

Low pressure:

  • dehydration
  • hypovolumic
  • exercise id OK
140
Q

Pulmonary artery pressures capillary wedge pressure

A

Through central line
Normal 8-12 mmHg (4-15)

Elevation : pulmonary edema

No exercise with UEs

141
Q

Cardiac Output

A

(HRx SV)

5 L/min

  • meausres by thermodilution
  • cardiac index: 3 L/min/m^2

-cardiogenic shock

142
Q

Intra-aortic balloon catheter

A

Pump assist
-inflated during diastole, deflated during systole

  • pt must remain in bed
  • participation in bed mobility an ROM ok as long as No hip flexion >70 degrees
143
Q

Bronchoscopy

A

Examine bronchial tree

Combine with wash or biopsy

144
Q

Directional coronary atherectomy

A

Uses specialized catheter to shave off and remove hardened plaque from artery

145
Q

Coronary artery bypass graft

A

Saphenous vein, internal mammary artery or radial artery 3-7 days in hospital 4-6 weeks recovery time

146
Q

Trasmyocardial revascularization

A

Laser creates pathways or channels directly through the heart

Used for patients with chrinic angina nott responsive to CABG or angioplasty

Stimulates angiogenesis

147
Q

Partial left ventriculectomy

A

Used with CHF patients with an underlying end-stage dialated cardipmyopathy

Volume redcution procedure for improving Left ventricular function and decr wwall tension and improving cardiac efficiency

Low level activity and cardiac rehab initiated as soon as hemodynamically stable
Discharge within 7-10 days

148
Q

Left ventricular assidt device

A

Bridge to heart transplantation for CHF patients

LVAD pulls blood from left ventricle into pump and sends blood to aorta “bypassing” the weakened ventricle

LVSD rate increases in proportion to venous return

Provides cardiac output sufficient fo rADL’s and modertae exercise

No palpable pulse por pulse OX

149
Q

ACORN Device

A

A fabric device, surgically positioned around the ventricles to halt progression of CHF

Provides diastolic support and reduces wall stress/ myocardial stretch
- improves cardiac function

150
Q

Abdominal aortic aneurysmectomy

A

Incision xiphoid to pubis

High risk for pulmonary complications

Bronchial hygiene is essential

151
Q

Carotid edaryerectomy

A

PT intervention:

Watch SCM function and neck mobility

Cardiopulm (4 decks)

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