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Describe the blood flow of the heart
- blood flows from superior vena cava and inferior vena cava to the right atrium
- then to the tricuspid valve into the right ventricle
- right ventricle ejects blood through pulmonic valve into pulmonary artery during ventricular systole
- blood enters pulmonary capillary system
- exchanges CO2 for O2
- oxygenated blood leave lungs via pulmonary veins and returns to left atrium
- from left atrium, blood flows through mitral valve into the left ventricle
- left ventricle pumps blood into systemic circulation through aorta
- supplies tissues of body with O2
- blood then returns to heart through superior vena cava and inferior vena cava to begin cycle again
What is the total body volume, intracellular fluid, extracellular, and blood?
- Total - 40-50L
- intracellular fluid - 25-35L
- extracellular fluid - 10-14L
- --blood plasma
- Blood - 4-5L
Signs and Symptoms of CVD
- chest pain
- cardiac syncope
- vasovasal syncope
- peripheral edema
What is Angina?
- symptom of coronary artery disease
- described as pressure, squeezing and tightness in chest
- cardiac syncope
What is Coronary Artery Disease?
- most common and seious effect of aging
- fatty deposits build up in vessel walls and narrow passageways for movement of blood (artheriosclerosis)
Risk factors for Coronary Heart Disease
- cigarette smoking (#1 cause of preventable death)
- family history
Medical Management for Coronary Heart Disease
- early diagnosis: check cholesterol ~5 years, angiograms
- modifications of risk factors: quit smoking, manage diabetes and fat
- exercise: moderate ~30 minutes > 4x/week
- medication: reduce clotting, treat HTN, decrease cholesterol levels
- medical surgical intervention: CABG, vessel acclusion
What are the different types of Hypertension?
- Primary: idiopathic, most common (90-95%)
- Secondary: 5-10% of all cases
- Labile: HTN boarderline goes up and down
- Malignant: elevated BP with diastolic >125, hemmorages
What are the different BP values
- Normal: s < 120, d <80
- Prehypertensive: s ~ 120-139, d ~ 80-89
- Stage 1 Hypertension: s ~ 140-159, d ~ 90-99
- Stage 2 Hypertension: s >160, d >100
What are the consequences of malignant HTN
- transient ischemic attack, stroke
- peripheral artery disease
- chronic kidney disease
- LVH, CHP, CHF
Symptoms of HTN
- frequently assymptomatic
- flushed face
- blurred vision
- nocturnal urinary frequency
- spontaneous epistaxis (nose bleeds)
Cardiovascular sypmtons of progressive HTN
- chest pain
- leg edema
Cerebral symptoms of progressive HTN
- fleeting numbness/tingling in limbs
Medical Management of HTN
- early monitoring
- aggressive early treatment (esp w/ DM)
- physical activity and exercise
- lifestyle modifications
- --weight control, smoking cessastion
What degree of change in BP can reduce risk of CVD and by how much?
- 2 mmHg change can reduce CVD by 10%
- 7% decrease of ischemic heart disease mortality
- 10% decrease of stroke mortatlity
What is the most common site of an MI?
left coronary artery
What is an Myocardial Infarction?
- occlusion of coronary arter, L or R
- majority involves L ventricle
- 80-90% due to coronary artery thrombosis
- smokers 2x MI, 2-4x more sudden death
- area of injury becomes necrotic
- size and location determine damage
What are the symptoms of an MI?
- sudden sensation of pressure
- prolonged "crushing chest pain"
- occassionally radiates to arms, throat, neck and back
- constant pain 30min - hours
- observable pallor, SOB, diaphoresis
- atypical signs from women
What are the Post-MI symptoms?
- cardiac shock
What are the diagnostic test for an MI?
- ECG - infarcted tissue is electrically silent
- cardiac troponin - markers of myocardial injury
- TEE - ultrasound image of heart
- pulmonary artery pressure measure
What is the treatment for an MI
- O2 therapy
- drugs (pain relief, anticoagulation to prevent thrombosis formation, limit infarction size, reduce vasoconstriction
- cardiac rehab
- prognosis depends on size/site of infarct
How could cardio disease affect PT treatment?
- during evaluation, assess cardiac signs and symptoms
- check degree of impairment
- level of disabilitylevel of functional limitations
- pt needs to communicate symptoms to MD
- PTs need to help pt characterize symptoms
- when beyond scope of practice > REFER
What are the implications for PT for CAD?
- cardiac rehab: education and exercise, promotes development and maintenance
- post-op considerations: sternal precautions
- sutured? closed?
- no pulling up in bed
- no push, pull, lift >10lbs for 6 weeks
- no driving
- shoulder, neck, torso ROM may/not be limited
- avoid shoulder horizontal abduction
What are the implications for PT for HTN
- know patients medications
- avoiding heaving lifting and isometrics
- close monitoring of vitals
What are the implications for PT for an MI?
- progressive physical activity begins w/in 24 hours
- gentle exercises as prophylactic (prevent immobility)
- avoid intra-abdominal pressure (no valsalva)
- avoid excessive hot water submersion
- close monitoring of vitals
- return to sex requires MD guidance
What is Congestive Heart Failure?
- heart unable to pump sufficient blood to meet metabolic needs
- pulmonary congestion and HTN due to:
- --back up of blood in pulmonary veins
- --increased pressure in pulmonary capillaries
- acute or chronic
What are the four types of CHF?
- systolic heart failure
- diastolic heart failure
- left sided heart failure = CHF
- right sided heart failure = Cor Pulmonale
What is the incidence of CHF
- older adults
- existing CVD - especially in pre-existing HTN
What are the risk factors for CHF?
- emotional stress
- physical inactivity
- nutritional deficiency
- throid disorder
- pulmonary disease
What are the etiologic factors of CHF?
- valvular heart disease
- congenital heart disease
- chronic alcoholism
- chronic anemia
What is the pathophysiology of CHF?
- 1st Compensation Phase:
- chambers enlarge to hold increase of blood
- right ventricles pump increased blood to the lungs
- accumulation of blood leads to pulmonary edema
- fluid seeps from distended blood vessels
- leads to SOB and flooding of air spaces
- 2nd Compensation Phase:
- as myocardial cells lose contractibility
- --HR increases
- --muscle mass increases
- --strengthens contraction
- results in ventricular hypertrophy and need more O2
- angina due to ischemia when coronary arteries unable to meet O2 demands
- 3rd Compensation Phase:decrease blood coming from the heart, decreased blood through kidneys
- kidneys respond by retaining water and sodium to increase blood flow
- exacerbates tissue edema
- expanded blood volume increases load on the system
What is compensated CHF?
if system is still able to maintain normal levels
What is decompensated CHF?
- after compensation fails and unable to maintain levels, disease progresses to final stage
- massive heart overload
Results of Left-Sided Heart Failure
- decrease level ventricle output deosn't meets body's metabolic needs
- causes pulmonary edema/disturbance in respiratory control
- fatigue and muscular weakness
- renal changes
- --decrease urine formation, decrease blood flow, decrease cardiac output
- --renine secretions, stim angiotension, vasoconstriction
- (increased preipheral vascular resistance, increased BP, increased cardiac work, worse heart failure)
What are symptoms of Left sided heart failure?
- pulmonary edema
- cerebral hypoxia
Results of Right-Sided Heart Failure
- failure of R ventricle to pump blood to lungs
- dependent edema - fluid retained because body senses decrease blood volume in kidneys
- jugular vein distension
- cyanosis - lack of O2 (turns blue)
Medical Management for CHF
- diet and exercise!!!
- medications to decrease workload, increase strength and contraction
- surgeries - CABG
What is pulmonary edema/congestion?
- excessive fluid in alveoli and/or interstitial spaces
- barrier to gas exchange
- primarily associated with left sided CHF
- --acute HTN
- --mitral valve disease
- --kidney and liver disorders
- --IV narcotics
- --inhalation of smoke
- --shock, ect
- normally lung is "dry" through lymphatic drainage and a balance of capillary hydrostatic pressure, pulm oncotic, and capillary permeability
Pulmonary Edema is cause by?
- fluid overload:
- fluid pushed from capillaries into interstitial tissue
- peripheral pressure "backs up" system causing limited "forward flow"
- decreased serum and albumin:
- decreased production of plasma protein -> decrease capillary oncotic pressure -> decreased reabsorption at venous end -> edema
- lymphatic ovstruction:lymph obst decreases absorption of interstitial fluid -> decreased transport of capillary filtered protein -> increased tissue oncotic pressure which pulls fluid in -> edema
- disruption of capillary permeability:increased capillary permeability
- movement of protein plasma into tissues
- icreased tissue oncotic pressure
What are the symptoms of Pulmonary Edema?
- initially assymptomatic
- occur in stages
- restlessness, anxiety, feeling of cathing a cold
- persistant cough, slight dyspnea, diaphoresis
What is the medical management for Pulmonary Edema?
- prevention - lower salt intake or meds if at risk
- diagnosis ASAP
- treatment - supplemental O2, diuretics, diet
What is an Aneurysm?
- abnormal stretching in wall of an artery, vein, or the heart with diameter increases more that 50% of normal
- >5cm is likely to rupture
What are the symptoms of an Aneurysm?
- may be assymptomatic
- depends on size, position, and rate of growth
- AAA (untreated) - intermittent/constant pain in mid-ab or low back
- AA disection - sharp pain in base of neck/scapular area, MI reversible ischemia, stroke, paraplegia, renal failure, ichemia of arms/legs due to pressure
What is the medical management of an Aneurysm?
- diagnosis - detection of mass by x-ray
- prevention - smoking cessation, BP control and cholesterol
- treatment - surgery is >5cm
- surgery - replaces diseased aorta or stent graft
What are the diagnostic tests for Cardiovascular function?
- ausculation (heart sounds)
- exercise stress tests
- chest x-ray
- cardiac catheterization
- doppler studies (assess blood flow)
- blood tests
- arterial blood gas determination
What are the general treatments for Cardiac disorders?
- diatary modifications
- regular exercise program
- quit smoking
- drug therapy
- surgical intervention
What type of drug therapy is used for cardiac disorders?
- cholesterol/lipid reducing drugs
- calcium ion channel blockers
- digitalis compounds (digoxins)
- antihypertenstive drugs
What are the surgical interventions for cardiac disorders?
- angioplasty: squishes clot against wall to try and keep open
- stenting: like angioplasty, balloon is permanent
- rotational atherectom: drills out clot
- CABG: healthy blood vessels removed from leg, creates new blood flow around occulsion
- coarctation of aorta
What are the PT implications for CHF?
- montior vitals!!
- exercise - low to moderate exercise with tests, gradual increase intesity and duration, maintain functional levels
What are the PT implications for Pulmonary Edema?
- monitor vitals
- watch for jugular distension
- pitting edema
What are the PT implications for an Aneurysm?
- activites restricted post surgery - only bedside mobility
- monitor vitals
- no valsalva maneuvers
What structures are in the upper respiratory system?
- nasal cavity
- oral cavity
What structures are in the lower respiratory system?
Structures of the lower airway
- 1st 16 generations are for condution
- transitional airways lead into final respiratory zones
- --consists of alveoli where gas exchange happens
What are the funtions of the lungs?
- ventilation: ability to move air in and out of lungs via pressure gradient
- respiration: gas exchange that supplies O2 to blood and body tissues. removes CO2
What are the symptoms of pulmonary dysfunction?
- abnormal sputum
- chest pain
- hypoventilation (most common)
- digital clubbing
- altered breathing patterns
How does aging affect pulmonary function?
- physiological function of lungs
- ability of respiratory system to defend
- structural changes lead to decrease gas exchange
- --decrease chest wall compliance
- --decrease elastic recoil
- --decrease gas exchange 2o flattened alveolar walls decreased surface area
- --decreased cilliary action to clean out mucus leads to increased infection
- --decreased respiratory musculoskeletal strength and endurance leads to dyspnea
- --pulmonary complications during anesthesia post-op
- --decreased effective cough leads to increased risk of pneumonia and atelectasis
- inflammation of parenchyma of lungs
- may be secondary to disease
- often follows influenza
- may involve B lungs at lobe or bronchioles and alveoli
- bacterial, viral, fungal, or myoplasmal infection
- inhalation of toxins, chemicals, smoke, dust, gases
- apiration of food, fluid, vomitus
What are the different types of pneumonia?
- aspiration: suck and swollow difficulties, anatomic defense mechanisms are impaired
- fungal: limited geographic region or compromised immune system
- viral: usually mild and self-limiting
- bacterial: may follow influenza virus
What is the source of pneumonia?
- usually airborn pathogens
- circulation, sinus or contagious infection
What are the risk factors of pneumonia?
- cigarette smoking
- complications of influenza and sinusitis
- chronic bronchitis, uremia, dehydration, malnutrition
- DM- poorly controlled
- hospitalization, surgery intubatin, incontinance, inactivity
- impaired cough and/or swallowing
- pooling of secretions in aireways after being supine too long
- impaires gas exchange which leads to dyspnea
What are the symptoms of pneumonia?
- sudden and sharp pleuritic chest pain aggravated by chest movement
- hacking, productive cough with green/rust colored sputum
- dyspnea, tachypnea, decreased chest wall excursion on effective side
- cyanosis, HA, fever, aches, chills, synalgias
What is the medical management for pneumonia?
- diagnosis: suptum cultures, blood culture, urine test, chest X-ray, physical exam, percussion and aussiltation
- bacterial and mycoplasmal - to antibiotics and rest, fluids
- fungal - antifungal meds
- viral - symptomatic relief
- vaccination - for elder, good for 3-5 years
- airway clearnence PRN
What is chronic obstructive pulmonary disorder (COPD)?
- chronic airflow that is NOT fully reversible
- caused by - emphysema and chronic bronchitis
- 4th leading cause of death - 2nd behind heart disease as cause of disability
What is the medical management of COPD?
- smoking history, physical exam, chest xray
- use pirometer - max force of exhalation
- labs for blood gas and blood pH, sputum culture, precsence of immunoglobulin
- can be managed, but not cured
- different for everyone depending on severityearly diagnosis
- --slow progression
- --relieve symptoms
- --icrease ability to stay active
- --prevent and treat complications
- --improve quality of life
- smoking cessation
- airway clearance
- pharmacological management
- goal = improve oxygenation and decrease CO2 retention
- medications -
- --O2 therapy
- --annual flu vaccine
- --lung volume reduction surgery
- --pneumonia vaccine
- --lung transplant
- support to stop smoking
- conservation of energy
- breathing exerciases
- chest physiotherapy
- self-manage medications
What is Emphysema?
- pathological accumulation of air in tissues (lungs)
- abnormal distension of air spaces
- destruction of elastin proteins which normally maintain strength of alveoli walls
- leads to collapse of bronchioles and air is trapped
- destruction of walls between alveoli leads to pockets of air
What are the three types of Emphysema?
- distruction of bronchioles
- most common
- mostly in smokers
- destroys air spaces of entire acinus
- involves lower lung
- mostly in smokers
- destroys alveoli in lower lobes
Clinical Manifestations of Emphysema
- early stages:
- dyspnea on exertion (DOE)
- nonproductive cough
- diaphragm flattens
- barrel chest
- prolonged expiratory phase
- late stages:
- dyspnea at rest
- hypercapnia (increase CO2 in blood)
- pursed-lip breathing
- use of accessory muscles to breathe
- lung sounds diminished
Who are known as the "pink-puffers"?
- people with emphysema
- breathing is difficult and working hard
- causes face to turn pink
What is Chronic Bronchitis?
- a productive cough at least 3mo/year > 2 years
- inflammation and scarring of bronchial lining
- increased mucous production
- irritants increase mucous secretion and hypertrophy
Who are known as the "Blue Bloaters"?
- people with chronic bronchitis
- cyanotic color fo skin and liops
- hypoxia and fluid retention
What is the medical management for chronic bronchitis?
- persistant cough and sputum production - worse in the am and evening
- SOB, prolonged expiration, persistant coughing
- decreased chest expansion, wheezing, cyanosis
- hypoxia, sever disability or death
What is Asthma?
- a reversible obstructive lung disease
- inflammation and increased smooth muscle reation of airway
- chronic condition with exacerbations
- mucosal edema
- increased mucus gland secretions
- mucus plugs airways (edema)
- hypoxemia, increased WOB
- extrinsic (allergic) - 50% of all cases
- intrisic - no known cause
- most common chronic diseases in adults and children
- incidences of asthma/deaths are increasing
What are the risk factors for Asthma?
- environmental factors
- low birth weight
- childhood - more likely < 5 years
- antibiotic use in infancy
- before puberty - boys 3x>girls. after boys = girls
- industrialized regions
- colder climates
- low SES
- overcrowding living with environmental factors
What are the symptoms of Asthma?
- respiratory-related signs
What are the different types of Asthma?
- emotional stress
What are the 3 stages of Asthma?
- symptoms reverse with stop of activity
- Sx <2x/wk
- inhaler PRN
- audible wheezing
- leans forward to catch breath
- daily symptoms
- daytime Sx >2x/wk night >4x/wk
- blue lips and fingernails
- cyanosis induced seizures
- skin and rib retraction
- activity limited
- frequent day and night symptoms
What is Cystic Fibrosis?
- congenital disorder in the exocrine system
- affects hepatic, male reproductive syst and respiratory system
- predisposed to chronic bacterial airway infections
- develop obstructive lung disease
- progressive loss of pulmonary functions
What does Cystic Fibrosis result in?
- dehydrated and increase viscosity of mucous glands secretions
- elevation of sweat electrolytes
- abnormal increase of sodium and choloride concentrations in sweat
What are they symptoms of Cystic Fibrosis?
- chronic bronchitis
- respiratory failure
- barrel chest
- pigeon chest
- intestinal obstruction
- cor pulmonale
- 98% infertility in males
- muscle atrophy
- marked tissue wasting
What is the medical management for cystic fibrosis?
- prenatal genetic testing
- newborn screening
- genotype analysis
- sweat test
- chloride levels > 60mmols/L
- alleviate symptoms
- thin secretions
- airway clearance
- nutritional management
- supplemental O2
Implications for PT for Cystic Fibrosis
- breathing/posture exercises
- CF centers for life long care
What is Lung Cancer?
- malignancy of epithelium of respiratory tract
- leading cuase of cancer deaths in US
- more people die of lung cancer than breast, colon, and prostate together
What are the risk factors of Lung Cancer?
- environmental exposure
- 2nd hand smoke (increased risk 1.5x)
What are the symptoms of Lung Cancer?
- depend on location in lung
- productive coughdyspnea
- recurrant infections
- chest pain
What are the two types of Lung Cancer?
- small cell:
- a result of obstructive air flow
- non-small cell:
- few symtoms until localized
- sharp and sever pleural pain increase with inspiration
- digital clubbing
What is the medical management for Lung Cancer?
- chest xray
- sputum cytology
- staging tests:
- CT chest/abdomen
- bone scan
- prognosis is poor
- caught early ->70% cure rate
- death within one year without treatment
- in one year of smoking cessation decreases risk by 1/2
What are the implications for PT for Lung Cancer?
- teaching gradual exercises, postitioning, prevent loss of funtion
- energy conservation is key!
What is Cor Pulmonale?
- enlargement of R ventricle due to pulmonary HTN
- occurs mostly in females and smokers
- pulmonary vascular disease
- repiratory disease (COPD)
What are they symptoms of Cor Pulmonale?
- attributable to pulmonary HTN
- typical exertional angina
- less common Sx- productive cough, hoarseness, hemotysis
- severe R ventricular failure
- exercise induced cyanosis, clubbing
What is the medical management for Cor Pulmonale?
- reduce workload of R ventricle
- supplemental O2, salt and fluid retention
- surgical removal of PE if accessable
What are the PT implications for Cor Pulmonale?
- monitor vitals
- purse-lip breathing
What are the PT implications for Pneumonia?
- standard precautions
- ventilory support/ supplemental O2 early ambulation
- proper positioning to preent aspiration
What are the PT implications for COPD?
- montior vitals
- gentle progression program
What are the PT implications for Asthma
- watch vitals
- watch for cyanosis