CardioPulm Flashcards
Draw Lung Volumes
Phases of Cardiac Rehabilitation
Phases of Cardiac Rehabilitation
- Phase I: Inpatient
- Phase II: Outpatient (Exercise-Training)
- Phase III: Maintenance
QUESTION
A 52-year-old female avid exerciser recently had a myocardial infarction and underwent stent placement. The patient is now preparing to start cardiac rehabilitation. The patient is eager to begin strength training when cleared. Which of the following is the MOST consistent with ACSM’s guidelines for starting strength training during cardiac rehabilitation?
A.Phase I : 3 weeks
B.Phase II : 5 weeks
C.Phase II : 8 weeks
D.Phase III : 12 weeks
A: Too early
D: Too late. PHASE 3 = YMCA
People will enter phase 2 around 3-4 weeks
B: CORRECT answer. Can we begin streagth training during scar formation of 4-6 weeks? YES
C: Pt with CABG or Sternotomy must wait to 8 weeks because bone damage has to heal.
Explain
Phase I
–Process (3-5 days)
Patients enter intensive care unit (ICU) under medical surveillance until considered medically stable (typically post 24 hours)
Patients who were considered stable are transferred to step down unit
– Physical Therapy Goals
• Activate, Educate, and Initiate
–Activate
»Get the patient moving in order to combat effects of bed rest. (BSChair)
–Educate
»Promote lifestyle modifications and educate about recovery process
–Initiate
»Begin process of returning patient back to independent functioning (ADLS)
What are the ADLs to get the patient to get back to.
- ABCDTT
- Ambulation
- Bathing
- Continence
- Dressing
- Toileting
- Transfers
Phase I
Physical Therapy Exercise Guidelines
•ADL’s, Ambulation, some UE/LE exercises (UE avoid for CABG – 6-8wks)
–Low Intensity exercise (2-3 METS) -> 5 METS by DC
–
–Duration: 5-10 minutes progressing duration over days (maintain intensity within protocol)
–Frequency: 2-4x per day (ACSM)
Phase I Contraindications
– Exercise Discontinuation Criteria
- Diastolic blood pressure (DBP) >/= 110
- Decrease in systolic blood pressure >/=10 mmHg during exercise with increasing workload (other symptoms don’t matter)
- Significant ventricular or atrial arrhythmias with or without associated signs or symptoms
- Second or third degree heart block*
- Signs and Symptoms of exercise intolerance (angina, marked SOB, ECG changes related to ischemia, >1mm dep)
–
A patient is being treated in physical therapy for deconditioning following a long history of stable angina. During vigorous exercise on the treadmill, the patient begins to report significant left-sided chest pain radiating into his anterior neck. The patient is instructed to take one sublingual nitroglycerin tablet, however the patient’s symptoms seem to worsen slightly. Which of the following is the best course of action?
A.Terminate the treatment and contact the physician immediately
B.Hold treatment for 10 minutes monitoring vitals, and have the patient take a second dose of the nitroglycerin if chest pain is still present
C.Call EMS
D.Instruct the patient to take another nitroglycerin tablet after five minutes, monitor chest pain, and vitals
Stable Angina is situation angina, or exertional angina
Why do they have it when they start exercising
- Myocardial ischemia (Lack of blood flow)
Left sided chest pain radiating to the neck.
Nitroglycerin Vasodialates and increases blood flow to tissues that are not getting enough.
A: Seems like a medical emergency, terminating is good
B: No, there is a nitroglycerin protocol, and this is not consistent
C: YES, they shouldn’t be worsen, if they do, should immediately contact EMS
D: NO, doesn’t go with protocol
NITROGLYCERIN PROTOCOL
Step 1: Stop treadmill, have pt sit down
2: assess pain level (ex. 10), pt takes tablet, must wait 5 minutes. After 5 minutes, ask pain level again and pt is not better (same or worse), CALL EMS
If getting better (8), another nitro tablet, wait 5 minutes, ask pain level (3). Take a third tablet (MAXIMUM amount) and presents with 1.
If still pain and does not COMPLETELY go away, call EMS
If NO PAIN = restart activity at lower level.
Must have 12 hours period between doing tablets
MAX Heartrate = 220-age
What is Phase II
– Process (weeks to months)
- Patients enter a specialized cardiac rehabilitation outpatient program with qualified staff with ability to monitor vitals, EKG, and understand the patient’s medication regimen.
- Prior to entering Phase II it is recommended that the patient have a symptom-limited ETT at the 4-6 weeks mark.
- Phase II can begin immediately after phase I but will begin at a exercise prescription determined by the low level GXT
–
Phase II goals
– Physical Therapy Exercise Guidelines
–Intensity: Based on exercise test
»When The Test is Negative
•Common exercise prescription is 70-85% of Max HR
»When The Test is Positive
- You must keep RPP below ischemic threshold
- RPP = SBP x HR
- Stay >/=10 beats below ischemic threshold
•
WHAT IS RPP
RPP – rate pressure product
RPP = SPB X HR
systolic blood pressure X Heart Rate
A patient with a recent uncomplicated MI is being evaluated before participating in outpatient cardiac rehab. The patient had a positive exercise tolerance test however has had no symptoms while ambulating at home. Which of the following is the MOST recommended during exercise
A.Exercise only up to the point of chest discomfort
B.Keep Systolic BP 10 mmHg below any symptoms
C.Exercise the lower extremities only
D.Exercise the patient below 70% MaxHR
OUTPATIENT = Phase 2
No symptoms while ambulating at home.
A: NO, we don’t want to bring them UP to discomfort
B: Should be HEART RATE, not Systolic BP
C: Would be a CABG thing
D: YES, This is correct.
A patient being seen in fully monitored cardiac rehabilitation outpatient clinic has fair to good cardiovascular and musculoskeletal endurance. Which of the following would BEST allow for incremental assessment of the patient’s endurance?
A.FEV1/FVC
B.Respiratory rate at 70% MHR
C.6 Minute Walk Test
D.VO2max
A: FEV1/FVC – measures severity of obstructive or restrictive condition – pulmonary function test
B: Not going to determine a persons endurance
C: One of the most used for endurance
D: BEST – incremental assessment test.
Would pick C if they poor, or poor to fair test. A debilitated or deconditioned patient.
– Physical Therapy Exercise Guidelines
Phase III
–Intensity
»50-85% of functional capacity
–Type
»Aerobic
»Strengthening
–Duration:
»45-60 minutes (5-10 minute warm up/cool down)
–Frequency:
»3-5x week (begin following CDC’s exercise guidelines)
–
A patient with lymphedema is being treated in a therapeutic pool up to the waist level. Which of the following hemodynamic responses is the MOST likely to occur?
A.Decreased in respiratory rate
B.Increased cardiac output
C.Decreased central venous pressure
D.Increased peripheral resistance
A: No, if water was up the chest level, but it shouldn’t change. Plus this is not a hemodynamic response
B: Cardiac Output = Stroke Volume X Heart Rate
Stroke volume how much is pumped/contraction. So it should increase with increase volume pushed to heart
More blood flow = increased heart rate.
C: More fluid should be forced to heart, so increased venous pressure
D: Therapeutic pool is a WARM pool, so blood vessels should increase and therefore decrease peripheral resistance
What increases and decreases the heart
What slows down the heart – The vagus nerve – rest and digest. CN X
What increases – Catecholamines – They are made in the adrenal glands – out of the medulla.
IMPORTANT TO KNOW.
What is CARDIAC OUTPUT
Cardiac Output (CO) = amount of blood pumped throughout the body per minute (mL/min)
CO = HR x SV
SV = amount of blood pumped out per ventricular contraction
Blood pressure
What is
Systolic?
Diastolic?
3 ways to change blood pressure?
- Systolic BP: Pressure on the artery walls when ventricles contract
- Diastolic BP: Pressure on artery walls when ventricles are relaxed
- Changes in BP
–Peripheral artery diameter
–Blood volume
–Force of contraction
Blood Pressure Categories
What does Calcium channel blockers do?
Decrease contractility of the heart
ex. Digitalis Digoxin
What is VO2 Max
- VO2 Max = maximum oxygen consumption during incremental exercise
- Measuring efficiency of your muscles
–The more O2 you can consume the more ATP you can create AND the longer you can continue
–How quickly do your muscles go from using the aerobic system to the anaerobic system
•Gold standard for endurance testing
–This is an outcome measure!
–Determines improvement in endurance over time
PHYSIOLOGICAL RESPONSE RELATED TO BARORECEPTOR REFLEX & VALSALVA
1.Stimulation of baroreceptors
•Increasing intra-abdominal/intrathoracic pressure = increased pressure on arteries (including aorta)
- Signal the medulla (which has an inhibitory effect on Vagus nerve)
- Medulla stops inhibiting Vagus nerve (CN X)
- Vagus nerve signal = parasympathetic effect
- Implications for HR = decreased
- Implications for BP = decreased
Describe the path of blood through the cardiopulmonary system
As blood moves from feet and legs to abdomen
To superior and inferior vena cava
Into the R atrium
Through the tricuspid valve
To the R ventricle
Through semilunar valve
Through pulmonary arteries
To LUNGS
Back from the lungs TO the heart
Through pulmonary veins
To L atrium
Through Mitral valve
Into Left ventricle
Into aorta and to extremities
Afterload
•The weight (pressure) the heart must work against in order to eject blood
–Think bench press
•Afterload is determined by the size of the arteries.
–Vasoconstriction = increased (weight) afterload
–Vasodilation = decreased (weight) afterload
What does that mean? We want them to vasodilate
- Nitro (immediate)
- Ace inhibitors (Longer term basis)
PRE-LOAD
- Amount of blood that returns back the heart from the extremities and enters the heart chambers
- Pre-load is also known as End-diastolic volume (EDV)
Remember, CO = SV X HR
What does Heart Failure lead to?
- Tissue ischemia
- Diminished energy production
- Hypoxemia
Not able to supply enough oxygen to muscles
Ischemia – decreased oxygen in the bloodstream leads to necrosis (infarction) when prolonged
Diminished energy production because O2 is not getting around = no ATP which leads to anaerobic system and builds lactic acid (VO2 Max)
Why does the Left or Right side of the heart hypertrophy?
Increased Peripheral resistance increases afterload
For example: vasoconstriction
Leads to LEFT ventricular hypertrophy because it works harder.
Space is very small and doesn’t hold enough blood
What failure leads to R sided hypertrophy – Pulmonary hypertension.
What happens when the heart cannot pump blood out or fill up with blood?
–Angina (Chest Pain)
–Back up of blood (Edema)
–Cyanosis (decreased oxygenation)
–Decreased Exercise tolerance (Fatigue)
–Dyspnea (SOB)
A patient is being treated for hypertension and an acute myocardial infarction. The patient’s medical record shows that the patient is currently taking enalapril. Which of the following is the physiological rationale for this medication?
A.Decrease afterload
B.Increase afterload
C.Decrease preload
D.Decrease heart rate
A patient with cor pulmonale is being seen for functional decline and deconditioning. After 5 minutes, the patient requests a rest break secondary to muscle fatigue and complaints of heaviness in the lower extremities. Upon examination, which of the following is MOST likely present?
A.Hemosiderin staining
B.Pitting edema
C.Non-pitting edema
D.Positive Buerger’s test
Cor pulmonale (Right sided heart failure)
Heaviness in lower extremities (edema)
=congestive heart failure
A: Venous Insufficiency
B: seen with R sided edema (also called dependent edema)
C: Seen with lymphedema (scleroderma, psoriasis, late stage 2,3 lymphedema with HARDENED SKIN)
D: Would be seen Arterial Insufficiency. (Supine with hip flexion) Testing with arterial insufficiency.
Buergers and Rubor dependency test.
Buergers test: supine with hip flexion and look at color
Dependency: foot down and see how long blood gets back
Left sided Heart Failure signs and symptoms
If your in the left ventricle, backs up through mitral valve to atrium, to pulmonary veins, then to the lungs.
Right side backs up into the body and extremities.
Moderate to Severe Dyspnea
Significant fatigue (muscular weakness)
NOT ENOUGH O2
Reduced activity tolerance
NOT ENOUGH O2
Paroxysmal Nocturnal Dyspnea
When pt lays down to sleep at night and wake up bc they feel like they’re drowning
BC fluid is backing into the lungs
Productive Spasmodic Cough (Pink Frothy)
Starts to get crackles, and cough up the fluid
L Sided heart failure = pulmonary edema.
Right sided heart failure signs and symptoms
Cyanosis (back up of deoxygenation blood)
Ascites (Water retention into the abdominal region)
Mild Dyspnea (Not circulating the flood properly, shortness of breath – mod to severe with Left)
Dependent Edema (Pitting) – typically immediate
Decreased activity tolerance – bad O2 flow
Jugular vein distention – All your veins have more fluid
Weight gain – Water retention
Can Left sided heart failure result in dependent edema – CAN if it has progressed so much that it affects the Right as well.
Won’t be severe
When would you contact the physician?
- Monitor for decreases in the patient’s blood pressure and changes in cognitive status to physician immediately
- Decreasing BP with increasing workload should be reported immediately (Left ventricular pump dysfunction)
- New EKG findings should be reported directly to the physician
CONTACT PHYSICIAN - Significant changes in pt medical status
When should you contact the nurse:
Pain that affects moving forward with therapy
IMPLICATIONS FOR THE PT
- RPE should range between 11 – 14 (Add 0 for heart rate)
- Exercise intensity (40-60% HRmax) w/ longer warm-up & cool down
- Exercise __ bpm below ischemic threshold
- High Fowler’s position is recommended for Left sided CHF (20 inches above supine or more)
- Legs kept in a dependent position is recommended for Right sided CHF
Medications
Betablockers – decrease heartrate
ACE inhibitors - Dec hypertension, increase vasodilation
Calcium Ch blockers – dec contractility
Digitalis or Digoxin – NOT CA Ch Blocker – INCREASES contractility in the heart
•Left Sided Heart Failure
–Decrease Peripheral Resistance
•Ace inhibitors
–Lisinopril
–Enalapril
–Decrease Contractility
•Calcium Channel Blockers
–Amlodipine (Norvasc)
–Diltiazem (Cardizem)
•
A patient is undergoing pulmonary function testing to reveal likely reasons for his progressive shortness of breath. Which of the following forms of data is the LEAST likely obtained by the use of spirometry?
A. Forced vital capacity
B. Forced expiratory volume in one second
C. Total lung capacity
D. Vital capacity
LUNG VOLUMES and Vital Capacity Testing
•Total Lung Capacity (5 – 6 L)
•Residual Volume (1.1 L) - ONE LITER
•Vital (Voluntary) Capacity (3.5 – 4.5 L)
- Tidal Volume (~0.5 L)
- Expiratory Reserve Volume (~0.7)
•Functional Residual Capacity (AKA Expiratory & Residual Capacity) (1.8 L)
- Inspiratory Reserve Volume (1.9 L)
- Inspiratory Reserve Volume (1.9 L)
FRV = ERV + RV
Vital Capacity Testing -
- BREATHE ALL THE WAY OUT
- BREATHE IN RIGHT NOW!
BREATHE ALL THE WAY OUT
A patient’s lab values are reviewed by a physical therapist prior to treatment. The following values are identified, HgB 10 mg/dl, LDL 110 mg/dl, WBC’s 4.5x109/liters, PaO2 55mmHg, PaCO2 55 mmHg, Troponin 0.01 ng/ml. Which of the following conclusions is the MOST accurate regarding the patient’s condition?
A. Metabolic Acidosis
B. Respiratory Failure
C. Recent Acute Myocardial Infarction
D. Respiratory Alkalosis
Hemoglobin – Does it matter right now? NO – 13-14; 12-16 FEMALE; 14-17 MALE
LDL – Not important – A little high, normal is below 100
WBC – 4-10 or 5-11 is normal
PaO2 – LOW – under 60 = hypoxemia
PaCO2 – 25-45 HIGH
Troponin – marker for myocardo infarction
don’t want over .02 anywhere .01 is very significant
A: Don’t have pH so can’t determine
B: YES, when O2 is below 60, and CO2 is above 50
C: Not likely, it is in normal ranges.
D: Don’t have a pH
What are PFTs
•Pulmonary tests that measure lung volumes and capacities and gas flow rates
–Forced vital capacity (FVC)
•Maximum amount of air that you can actually move in and out of the lungs (3.5 – 4.5 L)
–Step one: Exhale deeply
–Step two: Take a maximum inhalation
–Step three: Maximally exhale as quickly as possible
•Forced Expiratory Volume
–Can be expressed as a fraction or percentage (FEV1/FVC or FEV1%)
–Interpretation
–FEV1/FVC < .70 = Obstructive Condition
–FEV1/FVC > .80 = Restrictive Condition
–FEV1% of greater than 80% indicates restrictive disease as long as FEV1/FVC is > .70
COPD GOLD STAGES
Have to be obstructive.
FEV1 Percentage = Severity on scale
Most tested COPD GOLD Stages
EMPHYSEMA RADIOGRAPHIC FINDINGS
- Increased air space on radiograph
- Increased subcostal angle
- What happens to the diaphragm position?
If more decreased angle – restrictive.
Diaphragm is bottomed out.
Can’t take a deep breath.
BRONCHO
PULMONARY HYGIENE / POSTURAL DRAINAGE
Clearance requires something else as well.
CROSSED SYNDROMES
What muscles and which are inhibited or faciliated
Lower Cross Syndrome:
What muscles and which are inhibited or faciliated
