Cardio Flashcards
(86 cards)
1
Q
Peri-post complications
A
- Changes to planned procedure
- Large blood loss low Hb post-op
- Cardiac complications
- Labile BP, intra-operative CVA
- Contamination of the field
- Other tissue damage
2
Q
Mobilisation limited by
A
- Pain, incision
- Anxiety
- Drowsiness
- Medications
- Attachments
- Blood pressure, syncope
3
Q
Thoracic post-op complications
A
Pulmonary Oedema
Post-pneumonecotmy syndrome
Pleural space problems
4
Q
Pathogenesis of post-op pulmonary complications
A
- Anaesthesia decreased ventilatory drive, monotonous breathing, decreased gas exchange
- Restrictive reduction in lung volume drowsiness, pain, altered chest wall dynamics
- Decreased FRC
- Atelectasis
- Slowing of mucociliary clearance
- Secretion retention/painful cough
- Abnormalities in gaseous exchange
- Impaired surfactant production and sign mechanism
- Diaphragmatic dysfunction
5
Q
Common medical complication post- thoracic surgery
A
Post-operative bleeding – if severe re-open Respiratory failure Bronchopleural fistula Emphysema Pulmonary embolus Pneumonia Myocardial infarction Cardiac arrhythmias (especially atrial fibrillation)
6
Q
Thoracic: Pulmonary complications Amendable by physio
A
Sputum retention Attachments Respiratory failure Respiratory infection Exacerbation of underlying chronic lung condition
7
Q
Thoracic: Pulmonary complication not amendable by physiotherapy
A
Pulmonary embolus
Pulmonary oedema
Pleural effusion
Pneumothorax
8
Q
Objective assessment
A
- Vital signs
- Attachments
- Surgical incision
- Access breathing pattern
- Auscultations
- Huffing/cough ability
- Bed mobility & positioning
- transfers and mobility
9
Q
Discharge planning
A
- Safe on stairs
- Home exercise program
- Discuss return to activity
- Referral to community services
- require referral to pulmonary rehab
10
Q
Post of challenges of lung transplant
A
- Deinnervation
- Impaired mucociliary clearance
- Location-exposure to inhaled material
- Chronic lung allograft dysfunction
- Higher immunosuppression
- Impaired lympathic drainage
- Poor cough reflex
11
Q
Precaution of sternal wires
A
- Avoid reaching behind back
- minimise pressure through UL
- Bilateral rather than uni UL activities
- no weight for 1 month
- no heavy lifting 3 months, no driving 6 wks
- sternal support when coughing
12
Q
Thoracic: Respiratory complications
A
- Atelectasis: CPB causes surfactant washout and alveolar collapse, resorption type from bronchial secretions, compressive from pleural effusion
- Fluid: Consolidation, pleural effusion
- Pneumonia
- Pulmonary oedema
13
Q
Thoracic: circulatory complications
+ predisposing factors
A
-Venous thromboembolism
- Major surgery
- Increasing age
- Venous stasis from immobility
- Cardiac failure
- Obesity
- Blood disorders
- Prolonged hospital stay
14
Q
Thoracic: cardiovascular complications
A
- Rhythm disturbance
- hyper/hypotension
- Fluid overload
- Cardiac failure
- AF: 90-120 care with mob, >120 breathing and bed exercises only
15
Q
Thoracic: neurological complication
A
3% strokes
-delirium, anxiety, PTSD, memory loss, depression
16
Q
Thoracic: Sternal complications
A
- Superficial sternal wound infection
- Sternal dehiscence
- Deep sternal wound infection
17
Q
Thoracic: Sternal risk factors
A
- Obesity
- Diabetes
- COPD
- IMA
- Re-sternotomy
- severe coughing. PVD, delirium, prolong duration of surgery
18
Q
Thoracic Post-op mobility Contraindications
A
- PVC>5 at rest
- Rapid AF >100
- iniotropic support to maintain resting BP usually if Dopamine is >5mics/kg
- IABP: 4-6 hrs after removal
- Low Hb requiring transfusion
19
Q
thoracic Post-op mobility precautions
A
- Rest HR> 100bpm
- AF > 100bpm for >24hrs
- Systolic >160 or <80, Diastolic > 90
- PVC < 5 at rest
- Low Hb not requiring transfusion
20
Q
Aims of NIV
A
- enhance airway clearance, atelectasis management and exercise with physiotherapy
- offlaod resp muscles, reduce WOB, relieve dyspnoea
- Maximise QoL and function
- improve sleep duration and quality
- improve gas exchange
21
Q
How bilevel works
A
- Increase PS for increased tidal volume
- EPAP=PEEP=CPAP
- CPAP= sustained pressure needed to keep airways open
- PEEP= positive end expiratory pressure
22
Q
Explain IPAP
A
Inspiratory positive airway pressure
- augmenting pressure by supporting inspiratory efforts
- Increase TV, MV and reduces CO2
- Rest respiratory muscles and decrease work of breathing
- IPAP> EPAP (at least 4cm)
23
Q
Explain EPAP
A
Expiratory positive airway pressure
- acts as a splint pressure to prevent airways closure at end-expiration
- positive pressure also assists secretion removal
- recuit atelectatic regions of lung via collateral ventilation therefore improving ventilation/perfusion matching
- increases FRC: improves oxygenation, reduce diaphragmatic effort
24
Q
BIPAP modes
A
Spontaneous: I & E level set independently
- Triggering EPAP and IPAP reliant on patient effort and flow
- RR and cycle determined by patient
Spontaneous/Timed
-Augments breaths indicated by patient + delivers additional breaths if spontaneous efforts fall below the ‘back up’ rate set
Timed: Clinician set cycle, all breaths machine generated
25
CPAP
- Single level of continuous positive pressure throughout respiratory cycle
- CPAP=EPAP (alone)
- Patietn controls all aspects of the respiratory cycle including RR and inspiratory time
- effective in pulmonary oedema and post-op atelectasis
- Useful for Obstrution sleep apnoea
- ARF T1
- Cardiopulmonary oedema
- post-op atelectasis
26
Contraindications for NIV
- Undrained pneumothorax
- Severe haemoptysis
- Cardiovascular instability
- Airway obstruction
- Respiratory or facial trauma
- Severely depressed level of consciousness
27
Precautions of NIV
- Bullae/cystic disease
- GCS< 9, unprotected airways
- Inability to clear secretions
- Facial pressure areas
- GOR
- Persistant air leaks
28
NIV complications
```
Pressure:
-SInus pain
-Gastric insufflaation
-pneumothorax
Airflow:
-dryness
-nasal congestion
-eye irritation
```
- Severe hypoxaemia
- Aspiration
- Hypotension
- Mucous plugging
- Pressure sores at nasal bridge
29
Indication for full face mask
- Acute respiratory failure
- Mouth breather
- Extremely breathless
- Naive patient
- Facial weakness
- High Bilevel pressure
30
Indication for nasal mask
- Claustrophobia
- Able to maintain closed system with mouth closure
- Airway clearance and regular expectoration
31
Indication for humidification
thick secretions
Supplemental O2
Mouth dryness
32
NIV help CF
- reduced respiratory muscle fatigue, increased tolerance to treatment
- Prevent airway closure during techniques (EPAP)
- Additional humidification assists MCC, oxygen aids hypoxaemia
- Noctural use: improve gas exchange
33
NIV positives
- Airways clearance easier
- may help exercise tolerance
- fatigue lower with NIV compared to CPT
- RR lower with NIV
34
NIV negatives
- no long-term effects
| - no diff pre/post lung function
35
Physio app NIV
- Sputum clearance
- decrease WOB
- Increase patient tolerance to airway clearance techniques
- Enhanced collateral ventilation
- Ventilatory support exercise
- Overcome pain limitation post #
36
Signs of inadequate airway
- voice alteration, Hoarse
- tachycardia, tachypnoea, sweating
- Anxiety, confusion, lethargy
- gurgling
- drooling
- choking, gagging
- inspiratory stridor
- Hypercarbia and hypoxaemia
37
Methods of maintaining clear airways
- Positioning
- jaw position
- Nebulised adrenaline
- Suctioning
- Intubation
- Tracheostomy
38
Indications or intubations
- Airway obstruction
- Inadequate oxygenation
- Inadequate ventilation
- elevated work of breathing
- Airway protection
- Facilition of tracheobronchial suctioning
- Facilitation of mech ventilation
39
Endotracheal considerations
- larger tube
- less tolerated by patient
- tube occlusion by biting
- damage to patient teeth
40
Nasotracheal considerations
- Oral hygiene
- easier to insert
- Smaller tube, easier to block with secretion
- Sinus infections, nose bleeds
41
Indication for tracheostomy
- Long term intubation >7 days
- reduced anatomical dead space
- prevent laryngeal damage from ETT
- ETT not well tolerated
- Head and neck injuries
- Facilitation of suctioning
- Bypass obstruction or tumour
42
Tracheostomy Complications
- Risks of operation procedure
- Placement in pre-tracheal tissues
- Haemorrhage of innominate artery
- Trachealstenosis
- Surgical emphysema
- Blockage of secretions
43
Cuffed tube
Indication
Adv
- Unconscious
- Unable to swallow
- Required full mech ventilation
- Can potentially cause trauma to vocal cord
- Prevents aspiration GTI
- Provides good seal
- Prevents movement
- Low pressure, high volume
44
Uncuffed tube indications
- Awake or able to swallow
- Paediatric use
- patients able to speak
May cause increased secretions
45
Complications due to intubation
-Trauma: teeth, insertion, movement
-Malposition
-Obstruction: biting, kinking, increased secretion
Physiology disorders:
-increased secretion
-Decrease ciliary activity
-inability to cough
-tendency towards infection
-Inability to talk or swallow
-Lack of humidification
-Sinus infections from nasal intubation
46
Indications for suctioning
- Artificial airways
- Unconscious
- Inability to cough & expectorate effectively with retained secretions
47
Precautions for suctioning
- Hypotension
- High PEEP level
- head injuries
- Pulmonary oedema
- Severe infection
- respiratory burns: soft catheter
- Haemoptysis
48
Side effects of Suctioning
- Hypoxaemia: drop O2 turn up prior to suctioning
- Cardiac arrhythmia: quick
- Haemodynamic alterations: may increase ICP
- Gastric aspiration: turn on side
- Trauma: damage to larynx
- Distress: reassurance
- Atelectasis: hyperinflation
- Infection: sterile technique
49
Indications for mechanical ventilation
- Respiratory failure
- Patient at risk of respiratory failure: unsustainable level of cardiac work or WOB
- Major insult to body
- Airway protection or large secretion load
- Condition must be reversible
50
Indications or ventilation
- Spontaneous ventilation inadequate to maintain gas exchange: PaO2< 60 and PaCO2 >49
- Increased WOB, accessory muscle use, Sweating, increase HR, increase RR, increase BP, confusion, aggression
51
Effects of mech ventilation
Hypoxaemia= increase gas exchange, decreased WOB
Improve cardiac function= decrease preload and afterload
Allows oxygen to be used by other organs= multi organ failure, sepsis, burns
Hypercarbia= Improves thoracic stability, improves alveolar ventilation
52
Methods of ventilatory support
CMV
SIMV
A-C
PS + PEEP
53
Explain CMV
Controlled mandatory ventilation
- machine takes all breaths
- requires heavy sedation and causes weakened respiratory muscles
54
Explain SIMV
Indications
Advantages
Synchronised intermittent mandatory ventilation
1. Controlled breathes
2. Assisted breathes- triggered by Pt, assisted by ventilator looks same as controlled breath
3. Spontaneous breaths - assisted by ventilator (PS) but volume not controlled
Indications
- weaning from mechanical ventilation
- used for most patients
Advantages
- Improves comfort
- No breath stacking
- Reduced respiratory muscle atrophy
55
Explain A-C
Assisted controlled
- May receive assisted or controlled breaths
- When patient triggers ventilator, breath of identical duration and magnitude as mandatory breath
56
Explain PS + PEEP
Adv and Dis
Total spontaneous supported by ventilator
Advantages
- Reduced bronchiolar and alveolar collapse as PEEP holds open
- Increases FRC
- Allows lower FiO2
- Reduces shunting
Dis
- Reduced CO
- Increases airways pressure
57
Why spontaneous breathing better
- Less disuse atrophy
- less sedation required= exercise and mob more
- reduced weaning time
- Less infection
58
Explain pressure support
Augments pressure during spontaneous breath to decrease WOB and increase TV
-Patietn regulates own TV and RR
59
Explain Flow-by
Continuous baseline flow
- Reduces dead space
- reduces WOB to trigger a breath
60
Explain Peak flow
- how quickly air enters the lungs
| - COPD high flow
61
Explain volume vs pressure controlled (SIMV)
Volume (CMV, SIMV)
- TV and RR pre set
- Airway pressure variable
Pressure controlled
- Inspiratory pressure and RR pre set
- TV variable
- Improves recruitment : long time constant so beneficial for lung with uneven atelectasis
- Better high flow reqd or where lungs can be easily damaged by high pressure
- asthma or COPD
62
Side effects of ventilation
Pulmonary
- Maldistribution of ventilation
- Progressive atelectasis
- Hyperinflation
- V/Q mismatch
- decreased surfactant
Ventilator induced lung injury
-Barotrauma, atelectrauma, volumtraums, biotrauma
- Ventilator associated pneumonia
- Haemodynamic effect: Decreased CO
- DVT
- Gastric ulcerations
- Disuse atrophy of diaphragm,
63
Ventilator: Prevent Ventilator acquired Pneumonia
```
Humidification
Position
Percussion/vibs + MHI
Hand washing
NIV
Aspiration of subglottic secretions
Early tracheostomy
```
64
Prevent DVT
Leg exercises
Passive movements
TED's
SCD's
65
Prevent ventilator induced disuse weakness
Provide exercises
Mobilise while still ventilated
Prevent ICU psychosis
66
Cause and prevention Hypoxaemia in ventilation
Causes
- Incorrect setting
- Secretions
- Malposition
- Pneumothorax
- Medications
Prevention
- check settings
- suction tube
- auscultations
- increase FiO2
67
Process of weaning
- Decrease rate of SIMV
- Change to PS/PEEP ASAP
- If tracheostomy: T-Piece
- Extubate: high flow nasal prongs or NIV
68
Parameters for weaning
• Original cause of admission resolved or improved
• Adequate gas exchange SaO2 >90%, FiO2 ≤ 0.4, PaO2/FiO2 >200, PEEP ≤ 8 cmH20
o MIP5ml/kg,VC>10ml/kg
o RR/TV < 105 breaths/L
• Absence of fever
• Normal Hb (for ICU)
• Stable cardiovascular function
• Appropriate neurological and muscular status
• Correction of metabolic and/or electrolytes disorders
• Adequacy of sleep, no sedation, adequate mentation
69
Physio role in weaning
- Early exercise, mobilise to prevent weakness
- monitor while weaning for signs of not coping
- avoid exercise when just placed on lower level ventilation
70
Sign of not coping weaning
- Patient anxiety, discomfort or progressive obtunbation
- High RR, shallow breaths, high HR, low SpO2
- Laboured breathing
- Accessory muscle recruitment
- Rapid shallow breathing
71
Purpose MHI
- Secretion removal and cilliary function decreased because of intubation, immobility and mech ventilation & PEEP
- Prevent or reverse atelectasis
- Improve compliance'
72
Complications of MHI and VHI
- pneumothorax
- barotrauma, volutrauma
- desaturation
Decreased venous return
Decreased CO
73
Contraindication for MHI
- Pulmonary oedema
- Severe haemoptysis
- Undrained pneumothorax
- Nitric oxide
- Severe broncho spasms
- Acute septic shock
- Low BP
74
Precautions with MHI
- Bullae
- PEEP >10
- FiO2 >0.7
- low lung compliance
75
ARDS and cause
Syndrome of inflammation and increased lung permeability
```
Mild= PaO2/FiO2 <300
Moderate= <200
Severe= < 100
```
- Multitrauma
- Blood loss >3L
- Head injury
- Burns
- Pneumonia
- Pancreatitis
- Near drowning
76
Management of ARDS
-concept of baby lung
-limit volume and pressure
-Open lung tech
TV <8ml/kg
Low IP <32 mmHg
PEEP- 5-15cm H2O
- prone positioning
- High levels of PEEP
77
Physio ARDS
- disconnecting from vent, may reduce FRC
- MHI may cause trauma
- need to prevent secretion retention: Positions, perks and vibe, closed scution
78
Intrapulmonary ARDS
Consolidation
| Stiff lung
79
Extrapulmonary
Atelectasis
| Compliant lung
80
benefits of prone positioning for ARDS
- Recruit dorsal lung
- V/Q improves
- Imporves compliance on return to supine
- Improves in oxygenation maintained when returned to supine
- Improves even distribution of ventilation and perfusion
81
Explain SIRS
Systemic inflammatory response syndrome
-Response to release of exotoxins
- Increase RR>20
- Increase WCC >12
- Increase HR> 90 bpm
- Temp >38 after Day 1
82
Explain Sepsis
Life threatening organ dysfunction due to dysregulated host response to infection
- RR >22
- GCS >13
- Systolic <100
-NO HI
83
Septic shock
Persistant hypotension requiring vasopressors to maintain MAP >65
84
Cranial perfusion pressure
CPP=MAP-ICP
if <40 tissue perfusion fails
85
Medical management of head injury
- Paralysis and sedation
- Optimal ABG (Co2 30-35)
- Ensuring CPP>70
86
Implication for physio head injury
- Intubated, ventilated, sedated, paralysis to rest brain and ensure optimal ABG's (CO2 30-35, CPP>70)
- Rx short and frequent
- SAP and MAP stable
- head midline, 30 deg head up
