Lecture 1: Cardiovascular and Pulmonary Anatomy and Physiology

Question 1

What is rate pressure product and how is it calculated?

Answer 1

A measure of O2 demand; HR x SBP

Question 2

Humidifying inspired air is done by what portion of the upper respirartory system?

Answer 2

Nasal cavity

Question 3

What is the function of the myocardium layer of the heart

Answer 3

Facilitates the pumping action of the heart

Question 4

Normal breathing during inspiration is done by what two muscles

Answer 4

Diaphragm / external intercostals

Question 5

The ribs are the weakest point for fx in the thorax, especially at which point in the ribs?

Answer 5

The angle

Lower rib fx more likely to break off because they’re only connected at 1 point
* more likely to cause diaphgram issues when they’re disrupted

Question 6

True ribs
Vertebrochondral Ribs
Floating ribs

Answer 6

1-7
8-10
11,12

Question 7

What happens in a sternotomy and its used for what kind of surgery
* what muscle is most infolved

Answer 7

Sternum is cut down the middle.

Typically utilized in heart surgery

Peck Major is most impaired by this surgery

Question 8

Know: Chest tube plcacements is when theres fluid, water, blood, inflamation, or air where it shouldnt be in the chest
* can be placed in multiple different places
* Stitched in an probs stays there a while.
* Placement area will impact PT - think transfers to that side if they have a chest tube placement
* Will need to know what lvl its at to know if you can utilize a gait belt of if its going a tube

Question 9

What muscle is most involved in a sternatomy?
* sternal percautions? (4)

Answer 9

Peck major

Abduction passed 90
No pushing
No pulling
No reaching

“Move in the tube”

Question 10

W/ inspiration how do the ribs move?

Answer 10

Move like a bucket handle around the sternum/vertebraae

Question 11

w/ inspriation is there increased or decreased intrathoracic pressure
* What are the priamry muscles of inspiration

Answer 11

Less pressure on the inside, so air travels down its concentration gradient and into the lungs
* theres more pressure outside in the environment than inside our lungs –> so air moves to the area of least resistance
* air is forced into the lungs

Primary muscles of inspirationa are the external intercostals and the diaphgram (flattens to contract)
* its active in inspiration and passive in expiration

Question 12

What is diaphragm excursion?

Answer 12

How much the diaphragm moves

Question 13

What is normal diaphragmatic excurison?

Answer 13

2-3 inches of movement w/ breathing

Question 14

What is maximal ventilatory effect diaphragmatic excursion #’s?

Answer 14

2.5-4 inches
* so this like breathing as hard as you can
* so its forced massive breaths

Question 15

What happens to diaphragmatic excursion of person has COPD?
* why would someone w/ this disorder rely more on accessory muscles

Answer 15

Can’t get air out but can get it in just find (you’re retaining air)

So lungs are chronically hyper inflated.
* meaning that with maximal breaths you’ll have a lower diaphragmatic excursion because its already pretty expanded and can’t expand that much more w/ ventilation
* so you won’t have much excursion (it doesnt move as much)

So remember our muscles of inspiration are our diaphragm and external intercostals. Well now we’ve taken the diaphragm out of the picture (because it doesnt have any more room to contract because its already chronically stretched/contracted) because it can’t move that much, meaning were now going to rely more on accessory muscles

Note: We use accessory muscles during forced inspiration or EX:
* SCM, scalenes, SA, rhomboids, pectoralis major and minor, trapezius, lats, and erector spinae are some examples

You’re likely to see someone w/ COPD who reports neck / back problems due to overuse of those accessory muscles. Its a good idea to test the MMT of that SCM, rhomboids, etc…

Question 16

What are the muscles of expiration (2)
* active or passive?

Answer 16

Abdominals
Internal intercostal muscles

this is a passive process because it happens when the diaphragm relaxes
* forced expiration incorporates thsoe abdominals

Question 17

Question 18

Lesion at or above C4 = issues w/ breathing because the phreneic nerve that imapcts the diaphragm is disrupted

NOTE: a lesion to this area means the diaphragm cant push air out meaning they’re going to have to do forced expiration with abdominals instead of the passive expiration they would get with the diaphragm
* they are very at risk for fluid buildup/infection that leads to pnemonia in the lungs
* People who are bed ridden for a long time are also at risk for pneomina because they arent contracting their abdominals often (at least not as much as someone walking around) meaning shit can buildup in the lungs

Question 19

Inspiration = external
Expiration = internal

Question 20

this is showing pleural effusion. the pleural space has a fluid buildup

chest tubes would be dropped into this area

Your lungs can collapse due to this excess fluild (pneumothorax)

Question 21

upper respiratory tract includes the larynx but its kind of in the middle

what is the bifurcation in the trachia called

Answer 21

Cernia

Question 22

What is the main job of the upper respiratory tract

Answer 22

Humidification
* primarly done in the nasal cavity

Question 23

Lower respiratory tract includes
* Tracheal bronchile tree
* goblet cells and cilia
* Acini

Question 24

what do goblet cells do

Answer 24

Produce mucus

Question 25

Cilia are what

Answer 25

Little hairs

Question 26

What is the point of the mucociliary pathway?

Answer 26

So its mucus produced by the goblet cells and moved by the cilia to entrap pathogens and move them outwards to the stomach where they will die

Question 27

Where does gas exchange happen

Answer 27

Acini * the alveoli, alveolar sacs and ducts, and respiratory bronchioles

Question 28

4 main jobs of the nasal cavity?

Answer 28

Air conduction Filtration humidification Temp control - don't want to breath in cold air

Question 29

Knowledge check: What nerve is responsible for the contraction of the diaphragm

Answer 29

Phrenic nerve

Question 30

Knwoledge check: Which of the following upper respiratory structures provide humidification?

Answer 30

Nasal cavity

Question 31

R lung = 3 lobes * Upper * Middle * Lower L Lung = 2 lobes * Upper * Lower

Question 32

**When listening to lungs you need to compare side to side** * one at a time * this will be on lab * Want to focus on these primary areas of lung

Question 33

For the R lower lobe its primarily going to be to the side and posterior * if you have a question asking where to listen the the lower R lobe the best answer would be towards the back because theres not that much room on the lateral portion

Question 34

**When listening to the lungs what body position is the pt in?**

Answer 34

Sitting

Question 35

For the Lungs what does Apical mean?

Answer 35

Towards the top. Its like the apex of the lung essentially

Question 36

For the heart what does Apical mean?

Answer 36

Towards the bottom, its the apex

Question 37

What does basal mean in the lungs?

Answer 37

Toward the bottom

Question 38

What does basal mean in the heart?

Answer 38

Towards the top (remember, the heart is flip flopped)

Question 39

Knowledge check: you're instructed to ausculate the anterior basal region of the right lung. Where would you place the bell of your stethoscope?

Answer 39

R lower lobe Basal = toward bottom NOTE: We would never listen over the scapula If it was above the R clavicle you would be listening to the apical portion of the R lung

Question 40

Bronchial trees/projections grow to specific lobes * know what you're draining so you can position the pt appropriately also notice the carina

Question 41

What plexus is the main NS control for respiration and ventilation?

Answer 41

Pulmonary plexus

Question 42

Where is the respiratory contorl center? (2) * What does it respond to a change in?

Answer 42

Medulla/Pons Responds to change in CO2 * theory of yawning

Question 43

A sympathetic stimulus is sent to the lungs * What happens to the bronchus? * What happens to the vessels?

Answer 43

bronchodilation SLIGHT vaso**constriction**

Question 44

What happens to the bronchioles w/ a parasymapthetic stimulus?

Answer 44

Bronchoconstriction

Question 45

What do chemoreceptors respond to a change in? * Where are they located?

Answer 45

Responds to a change in O2 (hypoxemia) Carotid/Aorta * They're here because the carotid leads to the brain * Aorta leads to systemically

Question 46

What do baroreceptors respond to? * Some things that can trigger them

Answer 46

Stretch in arteries This can triggered by a deviation in BP / Blood fluid

Question 47

What does sarfactant production help w/

Answer 47

reduces tension in alveoli * However, you need the perfect amount, not too much or too little.

Question 48

What do type II pneumocytes produce?

Answer 48

Sarfactant * can be impaired genetically * can be impared by lifestyle things such as smoking

Question 49

What do mast cells do? * What two things causes an increase in mast cells?

Answer 49

Signal inflammation (think putting out the cones) Smoking/Asthma = cause an increase in these * this is because you have inflammation there

Question 50

Diffusion coefficent is a # that tells u if enough O2 is going into the blood

Question 51

does glottis close during inspiration or expiration?

Answer 51

Expiration

Question 52

Where is the diaphragmatic portion of the heart

Answer 52

inferior, posterior surface f the heart (most R/L ventricle)

Question 53

3 layers of heart tissue * Outer most layer is anchored to what?

Answer 53

1) Endocardium * Innermmost mesothelial lining of the heart, connective tissue 2) Myocardium: Middle layer consisting of muscle tissue; contractile elements 3) Pericardium: thick outer layer of the fibrous sac around the heart * ouble walled - outer parietal and inner pericardium (epicardium) * This layer is anchored to the diaphram she said there really is 4 layers

Question 54

Last the 3 major cornary arteries

Answer 54

1) Right coronary artery - right 2) Left anterior descending - anterior right 3) Circumflex - back * Supplies LV Left main bifurcates into LAD/Circumflex If arterial pressure drops BF is decreased to these cardiac arteries --> less blood to myocardium

Question 55

Which side of the heart is a high pressure system

Answer 55

L side --> has to pump systemically

Question 56

Valve betweeen the R atrium and R ventricle

Answer 56

Tricuspid (most first)

Question 57

What valve is between the R ventricle and the pulmonary artery?

Answer 57

Pulmonic valve

Question 58

What is the only artery in the body w/ deoxygenated blood?

Answer 58

Pulmonary artery

Question 59

What does the pulmonary connect?

Answer 59

RV to lungs

Question 60

What valve is between the L atrium and L ventricle?

Answer 60

Mitral/Bicuspid valve (less last)

Question 61

Answer 61

Question 62

Is diastole or systole the filling portion?

Answer 62

Diastole during filling systole during pump

Question 63

Ausculate means to

Answer 63

listen

Question 64

Areas to listen to on the heart: * Aortic area * Pulmonary area * The third left itnercostal space * The tricuspid area * The mitral area

Question 65

Which part of the heart is best auscualted in the second intercostal space close to the sternum on the right of the sternum?

Answer 65

Aortic area (this is where the aortic valve is)

Question 66

Which part of the heart is best auscualted at the second intercostal sapce to the left of the sternum?

Answer 66

Pulmonary area

Question 67

What is best heard at the third left intercostal space?

Answer 67

Murmurs of both aortic and pulmonary origins are best heard here

Question 68

Which part of the heart is best auscualted at the lower left sternal border, approximately the fourth to fifth intercostal space

Answer 68

The tricuspid area

Question 69

Which part of the heart is best auscualted at the fifth left intercostal space, medial to the midclavicular line. This is also known as the point of maximal impulse (will indicate strength of heart and also how large it is - won't be tested specifically on this)

Answer 69

The mitral area (apex of heart)

Question 70

O2 transport

Question 71

How should a pt be positioned when listening to heart

Answer 71

Supine

Question 72

How should the pt be positioned when listening to the lungs

Answer 72

Sitting

Question 73

Amount of O2 the heart uses * Product of what two things?

Answer 73

Myocardial O2 consumption * Product of HR and stress on the ventricle

Question 74

**Indirect index of O2 demand** * Product of what two things? * What kind of person reaches higher levels?

Answer 74

Rate Pressure Product HRxSBP Healthy individuals can reach higher lvls I think its essentially the amount of O2 the heart uses for energy which is why it can get higher in healthier individuals

Question 75

What is afterload * High afterload does what to SV

Answer 75

What the heart has to work against as its pushing blood out * Hypertension/increased resistance will increase that afterload which will decrease that SV

Question 76

knowledge check: during auscultation, where is the tricupid area located?

Answer 76

Fourth to fifth intercostal space on the lower-left sternal border "You know that the pt has a valve insufficiency and hear the murmer in the 4th-5th intercostal space what valve is the issue" * tricuspid valve * this is how questions are going to be presented on the exam

Question 77

Conduction system in heart

Answer 77

SA node --> AV node --> bundle of HIS (AC bundle) --> Purkinje Fibers (excite the RV and LV)

Question 78

Cardiac cycle 1/3 = systole 2/3 = diastole Diastole = filling Systole = beat

Question 79

EDV measured in daistole

Question 80

Diastole = relaxation * Blood flows into the RA and LA --> atrioventricular valves --> LV/RV * SA node = deporization * This is the P wave on an ECG * Depoarization --> atrial contraction (last event in diastole) * EDV and pressures record here

Question 81

Systole = contraction * Depolarization travels to AV node --> bundle of HIS --> bundle branches --> Purkinje Fibers (makes sense these cause ventricule contraction) * Mitral valve and Tricuspid valve close (because blood is pumping systemically) * Ventricular control - end SV

Question 82

Notice how pressire drops significantly as it reaches venous circulation. * higher pressure in the arterial side because it has to get into every cell

Question 83

Question 84

What regulates pressure into the capillaries?

Answer 84

Arterioles

Question 85

Do arterioles respond to symapthetic / parasympatheic stimulation? If so which 4 hormones are used to signal

Answer 85

1) Epinephrine 2) Vasopressin 3) Atrial natriuretic Peptide 4) Angiotensin II Im guessing theres others so don't memorize this silly list

Question 86

How is pulse pressure calculated? * what is this indicative of?

Answer 86

SBP - DBP ~40 Indicative of mortality

Question 87

how is map calcualted? * what does it tell us about? * What settings are these best utilized in? * **How much is needed for tissue perfusion?** * **What is normal?** * What two disaeses is it utilized w/

Answer 87

Map = 1/3systolic + 2/3diastolic BP tells us about the averge of blood flow and perfusion to the tissues (how much blood is actually getting there) * tells us if theres enough blood reaching our vital organs * we need to know this before we work with a pt, because when they start exercising those blood demands are going to be even greater 120/80 = MAP of 93 Utilized best in acute care settings Greater than 60mmHg is needed for tissue perfusion Normal = 70-100mmHg Utilized incodnittions like sepsis (follows shock and your vital organs begin to shut down) and TBI * thats because w/ these conditions they cannot regulate their BP

Question 88

Knowledge check: You are treating a 16 year old who sustained head trauma and R humeral fracture from being hit while riding their bike. You would like them to use the recumbent bike. * Why would MAP be helpful in this situation? * How would you go about calculating MAP? * What MAP would be appropriate for this patient to continue EX?

Answer 88

1) Helpful to see if organs are getting the BF they need 2) 1/3Systolic + 2/3Diastolic 3) 60 is the bare miniumum but we want 70-100 This is done before to intiate EX * however, you would calculate this at every stage of submax testing

Question 89

Blood has a certain pH, we do get arterial blod gasses from it, that give us an idea of lung function (PA student lecture on this)

Question 90

Volume of blood ejected by the heart per beat * equation? * What 3 things affect it

Answer 90

Stroke volume EDV-ESV 1) Preload - resting tension * increases w/ EX / poor function of heart (because everything gets backed up) 2) Contractility - how hard it beats 3) Afterload - what the heart has to work against * increase in afterload = decrease in SV (cant push it out as well)

Question 91

Ejection fx is

Answer 91

Percentage that tells you the current function of heart * certain surgeries need this to be at least a % to do surgery ~35-40% * can heart tolerate ansthesia EF = SV/EDV * so essneitally its the percentage of the blood ejected per beat (I guess higher = better)

Question 92

How easily the hearts ventricles expand

Answer 92

ventricular compliance * increased compliance means they expand easily

Question 93

NOTICE: preload is that resting tension in the heart before it beats

Question 94

normal cardiac output * equation * does EX cause an increase in CO or does it stay stable?

Answer 94

5.5 (4-6) CO = HRxSV * remember, body wants homeostasis so as one increases the other decreases CO increases w/ EX

Question 95

Where is the autonomic NS controlled in the brain?

Answer 95

Medulla / Lower Pons

Question 96

Chronoctropic effects are

Answer 96

timing of heart beat (heart rate)

Question 97

Iontropic effects are

Answer 97

Contractility

Question 98

What kind of chronoctorpic / inotrophic affects does the vagus n have on the heart?

Answer 98

Vagus nerve = parasympathetic stimulation * Negative inotrophic (decreased contractility) * Negative chronotropic (decreased HR)

Question 99

During a sympathetic response what are the chronoctrophic / ionotrophic affects to the heart?

Answer 99

Sympathetic = fight or flight * Positive inotrophic (increased contractility) * Positive chronotrophic effects (increased HR) Vasoconstriction systemically and vasodilation in the heart and bronchioles

Question 100

These make sense NOTE: positive and negative do not mean good or bad here, sometimes we need both General anesthesia: this decreases the general contarctility of the heart. So if heart is already not working well and you decrease it even more, well you're just not likely to survive this.

Question 101

To show us that there are a lot more factors affecting stroke volume than HR HR variability is influenced by less things which is why HR can shoot up quickly or drop down quickly. SV takes longer to turn on/adjust vs HR * when we get anxious that HR just shoots straight up

Question 102

CO = HR * SV If you have significant bradycardia you're going to have a decreased/poor cardiac output * You're decreasing 1 factor in the equation and the SV can't balance it back out Excessive tachy --> increased HR --> impaired diastolic filling because it beats to fast to fill efficeintly --> poor SV --> decreased CO Mild tachycardia and increase cardiac output * Increased HR * SV = +CO

Question 103

If you notice the pt has bad endurance after several weeks of therapy and their HR is increased increased. Most likely that lack of endurance is cardio releated. * follow the excessive tachycardia pathway below

Question 104

Question 105

Line of questioning is different in acute care ask more yes or no questions to avoid long converstations "are you in any pain" Be as objective as possible * EX: Write "patient was teary eyed" not "pt was sad" Are these acute or chronic symptoms

Question 106

Why should you take BP fast following activity

Answer 106

because it can drop within 15 seconds of stopping ex

Question 107

Have pt in supine **Do not do this through clothing, needs to be on the skin** murmers can be normal

Question 108

same slide as before. Will need to know how to palpate these ares

Answer 108

Question 109

Normal sounds of heart S1 and S2 (lub and dub) Abnormal * S4 = **heard with bell before S1** (this is when you switch it to the smaller side of the stethascope) - also called an atrial gallop - denotes hyperteions / micardial hypertrophy * S3 = **Heard with bell after S2** - also called ventricular gallop - children and under 40 often have this We do not have to diliniate between S3/S4 we just have to know when something is abnormal. * "Does pt have a S4 sounds, yeah thats abnormal" abnormal heart sounds / murmers may be a sign of heart failure in nonathlete Heard with flat part of stethoscope

Question 110

if you can't find a pulse check above and below where you think it is * there would most likely be other things indiciating a problem if there was a missing pulse

Answer 110

Question 111

Bed --> Chair = transfer

Question 112

reget levels of assistance

Question 113

Asses posture w/o patient knowing you're doing it In the acute setting your goals are going to be more functional than something like "pt will get 160 degrees of shoulder flexion" Scoliosis can potentially impact respiration