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
2
Q
Who are some transplant candidates for heart issues?
A
Severe CAD
End-stage cardiomyopathy or heart failure
Congenital abnormalities
3
Q
Who are transplant candidates for lung issues?
A
Severe COPD, IPF, CF, pulmonary artery hypertension
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
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
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
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
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
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
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
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
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
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
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..
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
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
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
18
Q
What are some common components of the mechanical circulatory support?
A
Driveline
System controller/console
Power source
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
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
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
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
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
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
25
Different Cardiothoracic incisions lead to what post-op manifestations
Protective psoture- trunk flexed forwards/ to side of incision
DEcreased inspsiratory effort, chest expansion = restrictive lung pathology
Impaired cough
UE limitations
26
What are some post-op complications?
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
27
Pt management for postOP patients
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
28
Post op patients using mobilization exercises as assesment and treatment
Upright positioning progression: supine-> sit-> stand
Bed mobility- rolling, supine, sit
Transfer —> sit to stand, bed —>chair
Gait - distance/duration
29
Mobilization/exercise session considerations to take before planning session
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
30
Sign/symptoms of exercise intolerance
>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
31
Incentive spirometer
- 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
32
Sternal precautions for open heart surgery
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
33
Thoracotomy/VATS precautions
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
34
Abdominal precautions after surgery
Avoid straining abdominals
- log-roll bed mobility
-splint cough
Avoid lifting >5-10lbs
-standing up straight and laying flat hurts
35
Pacemaker/ICD pracautions Post op
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
36
Goal of ICU care
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
37
Hemodynamic monitoring
EKG- HR , rhythm
BP
- cuff
- arterial line
Pulse oximeter - O2 sat
RR
Central venous pressure
Pulmonary artery catheter
38
What are some lines we will se on a patient in ICU?
Peripheral IV
Central line
PICC line
Arterial line
39
What are some tubes you will see on an ICU patient?
Chest tube
Feeding tube- nasla, oral, percutaneous
Foley catheter
Rectal tube
Endotracheal tube
Oxygen tubing
40
What are indication for the use of mechanical ventilation?
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
41
Signs and symptoms of respiratory distress
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
42
Positive pressure ventilators
(+) 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
43
Assist-control (A/C)
Ventilation mode
Pt initiates breaths, ventilator delivers preset tidal volume
- gives respiratory muscle greatest amount of rest
44
Pressure support PS
Ventilation mode
Pt initiates breaths, ventila3tor delivers preset pressure (reduces work of breathing)
45
Constant positive airway pressure CPAP
Pt breathes spontaneously , ventilator maintains positive airway pressure throughout breathing cycle
46
PEEP
Positive end- expiratory pressure
Pressure maintained by ventilator in airways at end of expiration
Normal physiologic PEEP is maintained by surfactant = 5cm H2O
47
Ventilator settings
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
48
What is intubation?
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
49
Tracheostomy tube
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
50
Weaning criteria
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
51
Post-intensive care syndrome
health problems that remain after critical illness
- ICU acquired weakness- may take >1yr to fully recover
- cognitive dysfunction
- sleep disorders
- PTSD, anxiety, depression
52
Intermittent claudication (IC)
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
53
How common is Peripheral artery Disease? PAD
Patients older than 70 or older than 50 years who smoke and have diabetes have a prevalence of nearly 30%
-1/3 have PAD
54
What is the 5yr, 10 yr , 15 yr survival rate for patients with PAD?
5 yr-70%? 30% mortality
10- 50%
15- 20%
55
How to Dx/ Rx PAD/PVD?
Can use angiogram
ABI (ankle brachial index)
Balloon angioplasty, stent, CABG
Exercise
56
Thrombus superficial vs deep
Superficial: saphenous
Deep: femoral or Iliac
Superficial thrombus: non-life threatening
DVT: Important
- can be caused in anterior tibial vein
57
Deep Vein thrombosis DVT
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)
58
Valvular incompetence/insufficiency
Varicose veins- abnormal dilation of superficial veins
Cause: heredity, homonal changes, prolonged standing (no muscle contraction) obesity, pregnancy
Signs: edema, discoloration of distal legs
59
Spider veins
Not serious
| Burst capillaries
60
Varicose vein Rx:
Exercise, stop smoking, antiplatelet drugs, elastic stockings, compression sclerotherapy
Risk for clot formation (main problem of varicose)
61
Venous chronic insufficiency
Deep veins
Edema, pigmented areas
Ulcers- medial malleolus
-skin breaks down
62
Arteriovenous malformations AVM
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
Aneurysm
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
Vaculitis
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
Buerger’s disease
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
Vasomotor Disorder
| Raynaud syndrome
Reaction to cold exposure
Vasoconstriction followed by reactive hyperemia (finger turning purple)
Rx: avoid cold exposure, nicotine, caffeiine, vasodilators
67
Arterial PAD overview
Atheroscelrotic
- stenosis
- aneurysm
- microvasscular- in patients with diabetes
68
Venous PAD Overview
Venous
- stasis, insufficiency
- thrombosis - DVT
69
PAD inspection/observation
Color
Ulcers-venous (painless) vs arterial (painful)
Size, edema
Symmetry
Temp - arteerial (cool) vs venous (warm)
70
Arterial skin changes
```
Cool pale
Shiny
Hairless
Ulceration
- painful
-Ischemic, gangrene
- result of trauma, common in toes and heel
-rapid developing
```
71
Venous skin changes
Warmer than normal
Stasis changes produce increased pigmentation
Dependent edema
Ulceration
- painless
- ankle area or lower leg above medial malleolus
- slowly developing
72
Special tests for PAD
Pulses
Ankle brachial index
Rubor of dependency
Venous filling time
73
Special tests for venous insufficiency
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
Arterial disease
| Ankle Brachial index
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
ABI scale
```
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
Rubor of dependency test
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
Venous filling time test
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
Mild vs Pitting Edema
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
Exercise prescription for PAD —Walking
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
PT managment
| Venous Stasis
Prevent DVT- early mobilization, ankle pumps or heel slides
Compression stockings- promotes venous return
81
Two categories of Lung dysfunction
Restrictive- difficulty getting air INTO lungs
- chest walls vs Lungs
Obstructive- difficulty getting air OUT OF the lungs
- narrowing of airways
82
What are examples of obstructive lung dysfunction
Bronchopulmonary dysplagia
Asthma
COPD
- Emphysema
- chronic bronchitis
Cystic Fibrosis
83
COPD
| Cause and respiration flow rates
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
Decreased Expiratory air flow
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
Decreased alveolar surface Area
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
We define respiratory failure at the point where...
PaO2<60 mm HG
PaCo2 >55 mmHg
Cause of death in COPD patients is respiratory failure plus cor pulmonale
87
Early COPD
| Bronchopumonary dysplasia
- 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
Cystic Fibrosis
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
Asthma
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
Symptoms and treatment of Asthma
Symptoms
- decreased flow rates
- decrease breath sounds, wheezes
- SOB
- Coughing
Treatment
- monitor flow rate
- bronchodilators
- exercise in moist warm air, long warm up
91
Bronchiesctasis
Major infection that leaves a destruction of elastic tissue in airways —> Permanent dilation
- inflammation of medium sized airways
- inflammed and ulcerated
92
Symptoms and treatment of bronchiectasis
Symptoms:
- copious, purulent septum
- hemoptysis
Treatment
- antibiotics
- postural drainage, pulmonary hygiene
93
COPD
| Chronic Bronchitis
```
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
Signs of COPD chronic bronchitis
- 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
RX for COPd Chronic Bronchitis
Stop smoking
Use bronchodilators
Treat respiratory track infections
96
Emphysema overall
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
Emphysema signs and symptoms
Non productive cough
-thin,cachectic
-increased work of breathing, use accessory muscles
—
98
PT treatment for Emphysema
Breathing control
Use diaphragm, not accessory muscles
Energy conservation
99
FEV1 (lung function) levels
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
Normal Breath SOunds
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
Abnormal Breath SOunds
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
Adventitious Lung sounds
CRACKLES
```
Crackles (rales)
- fine , course
-inspiratory (expiratory)
- fluid (edema) or secretions
—
```
103
Adventitious Lung SOunds
Wheezes
(Rhonchi)
- Inspiratory (if severe), expiratory is what we tend to hear
- airway constriction/bronchospasm
104
Extrapulmonary sounds
Pleural rub
- pleura
Stridor
- upper airway- larynx
Crunch- feel
- subcutaneous air (leaked out b/c sking & lung like pushing on rice krispy
105
Optional Voice Sounds to confirm Bronchial Breath Sounds
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
Mediate Percussion
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
Lung sounds in case of pathophysiology Atelectasis - collapse alveoli
Decreased chest wall excursion on affected side
Decreased or absent breath sounds
Decreased vocal or tactile fremitus
Dullness to percussion
108
Pneumothorax
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
Pleural effusion
- fluid between pleura
Over area of effusion:
- absent breath sounds
- decreased fremitus
- decreased chest wall excursion on affected side
- dullness to percussion
110
Pneumonia
- consolidation in one part of the lung
- bronchial breath sounds in area of consolidation
- increased tactile fremitus
- dull to percussion
- late crackles
111
Chest mobility assessment
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
Chest mobility via tape measure
Upper chest- under axilla - 1 in
Middle Chest- xiphoid
- 1.25 in
Lower chest- midway between xiphoid and unbilicus
- 1.5-2 in
113
Diaphragm excursion test
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
Blood gas analysis normal ranges
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
Metabolic acidosis
Metabolic acisosis causes excess production of H+
-evidence by decr HCO3
Diabetic or diet induced ketoacidosis
= decr pH
116
Metabolic alkalosis
Decr production of H+
Evidenced by inc HCO
Emesis
Inc pH
117
Respiratory Acidosis
Inc CO2 drives equation left, inc H+
Hypoventilation (drug induced) or chronic obstructive pulmonary disease
Decr pH
118
Respiratory alkalosis
Decr CO2 , decr H+
Hyperventilation
Inc pH
Breathing Co2 fatser than we can get “o” in to the body
119
Compensation
Primary respiratory cause compensated by kidneys
=
Primary metabolic cause compensated by lungs
120
Compensation for metabolic disorders
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
Compensation for respiratory disorders
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
Patient chart in front saying pH is low what do we expect....
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
Patient chart in front of you pH is high what do we expect....
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
Homocysteine level
Normmal = 5-15 umol/L
| -linked to decr folic acid , B6 , and B12
125
Inflammatory markers
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
Complete blood counts norms
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
Coagulation profiles
Prothrombin/ Partial thromboplastine time in sec
Increased levels mean increased time for clot formation
Increased chance of bleeding or bruising
128
Electrolytes levels
Na 136-143
K+ 3.8-5.0
Kidney function
- blood urea nitrogen
- creatinine
Fasting glucose
- 70-110 mgDl
129
Non- invasive tests
Holter monitoring- 24 hr monitoring
Doppler ultrasound- blood flow
130
Echocardiogram
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
MRI
Evaluate mass,chest wall or aneurysm
Limiation: cant use with metal
132
CT scan
For arteries calcium plug
Limitation: radiation in children
Fat distorts
133
PET/ CT scan
Structure and function
Limitation: expensive
134
Thallium perfusion imaging during exercise
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
Angiogram - catherterization
Catheter iinserted through artery in leg
Dye highliights cardiac arteries
Risks: can tear walls
- lying still fro 4-6 hours afterwards
136
Pharmacologically induced stress
Coronary artery spasm evaluated with ergonovine
Arbutamine to raise HR
137
Arterial line
| Indwelling arterial catheter
Measurement of arterial BP
138
Mean arterial pressure
MAP= (SBP + (2x DBP))/ 3
= 70- 110 mmHg
139
Central Venous Line
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
Pulmonary artery pressures capillary wedge pressure
Through central line
Normal 8-12 mmHg (4-15)
Elevation : pulmonary edema
No exercise with UEs
141
Cardiac Output
(HRx SV)
5 L/min
- meausres by thermodilution
- cardiac index: 3 L/min/m^2
-cardiogenic shock
142
Intra-aortic balloon catheter
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
Bronchoscopy
Examine bronchial tree
| Combine with wash or biopsy
144
Directional coronary atherectomy
Uses specialized catheter to shave off and remove hardened plaque from artery
145
Coronary artery bypass graft
Saphenous vein, internal mammary artery or radial artery 3-7 days in hospital 4-6 weeks recovery time
146
Trasmyocardial revascularization
Laser creates pathways or channels directly through the heart
Used for patients with chrinic angina nott responsive to CABG or angioplasty
Stimulates angiogenesis
147
Partial left ventriculectomy
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
Left ventricular assidt device
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
ACORN Device
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
Abdominal aortic aneurysmectomy
Incision xiphoid to pubis
High risk for pulmonary complications
Bronchial hygiene is essential
151
Carotid edaryerectomy
PT intervention:
Watch SCM function and neck mobility
