pulmonary or cardiac

analyze the gas transport system

mechanical factors, receptors

maximal inspiratory effort needed to produce normal negative pleural pressure

more work than normal to move air into lungs

increased resistance to flow

end-inspiratory volume approximates TLC

1. destruction of diffusing membrane

2. fluid or inflammatory material at A-C membrane

bronchospasm

pulmonary embolism

pneumothorax

pulmonary infection

upper airway obstruction

1. COPD

2. restrictive lung disease

cardiac pump dysfunciton

1. actue myocardial ischemia

2. CHF

3. cardiac tamponade

anemia

1. mild: noticeable to pt, not observer

2. some difficult: noticable to observer

3. moderate difficulty: but can contiue

4. severe difficulty: pt. can't continue

1. exercise training

2. pharmacologic therapy

3. fans

4. breathing exercises/patterns

5. positioning

6. positive airway pressure (CPAP)

1. mild, barely noticable

2. moderate, bothersome

3. moderately severe, very uncomfotable

4. most severe or intense pain ever experienced

(rating of 3 or pain that would cause pt. to stop normal activities) are reason to stop ecercise)

LE pain caused by ischemia of LE due to peripheral arterial occlusive disease

2. when 02 bloody supply is no adquate to meet demand of peripheral tissue

3. intermittent claduication: brought on by walking

1. definite discomfort or pain, but only of intial or modest levels (established, but minimal)

2. moderate discomfort or pain from which the patient's attnetion can be diverted

3. intense pain (attention can't be diverted)

4. excuciating and unbearable pain

1. pulmonary disease (asthma, chronic bronchitis, bronchiectasis, respiratory infections)

2. cardiac disease (CHF, cardiac structures placing pressure on trachea/bronchi)

3. GERD

4. side effect of angiotension converting enzyme (ACE) inhibitors

• alternating between apnea and hyperpnea
• seen in strokes, brain injury or tumors, CHF, near death

• irregularly alternating periods of apnea
• seen in brainstem dysfunction

• deep and labored breathing with increased or normal rate
• seen in acidosis

• sustained respiratory pauses
• seen in lesions of respiratory centers

• RA & RV
• AV node (90%)
• posterior L ventricle (80-90%)

• posterior IV septum
• inferior LV

• results from totally occluded artery
• associated with full thickness (transmural) necrosis
• marked increases in specific serum cardiac markers
• Q wave formation

• diagnosed in pts with ST depression or other ST or T wave change accompanied by: rise in serum cardiac markers, subendocardial necrosis, non-Q wave MI

• severe crushing chest pain
• dyspnea
• ecg changes
• elevation of cardiac serum enzymes
• diaphoresis
• nausea, vomiting
• lightheadedness, dizziness, syncope
• apprehension or sense of impending doom
• weakness
• denial

at least 2 of the followoing:

• history of symptoms
• ECG changes
• rise and fall in serum cardiac enzymes
• creatine kinase (CK) and CK-MB
• troponin

• ischemia: ST segment depression or T wave inversion
• injuty: ST segment elevation
• infarction: Q waves

• disease
• severity
• guidlines for management: meds, surgery, lifestyle modifications, exercise

• LV dysfunction (systolic, diastolic or combined) leads to LV pump failure -as a result of MI, HTN, aortic valve dz; fluid accumlates back into lungs
• reduction in renal BF and may lead to renal disease
• reduced peripheral blood flow elads to skeletal muscle abnormalities

• impaired contractility of ventricle
• decrease in SV
• decrease in EF
• rising pulmonary pressures leads to transudation of intravascular fluid from capillaries into interstital space
• dilated heart
• INCREASED VENTRICULAR VOLUMES AND PRESSURES ARE REFLECTED BACKWARDS, RESULTING IN CONGESTION AND EDEMA

• increased ventricular stiffness (dec. compliance)
• impaired ventricular relaxation
• abnormal ventricular filling-can reduce CO, inc. ventricular and pulmonary vascular pressures)
• at any volume, ventricular pressures are elevated and reflected backwards resulting in congestion and edema

• dyspnea, dry cough
• orthopnea, paroxysmal nocturnal dyspnea
• pulmonary rales
• tachpnea

• hypotension
• tachycardia
• lightheadedness, dizziness
• fatigue, weakness, decreased exercise tolerance
• peripheral edema
• S3 (third sound or ventricular gallop)

• LV failure
• mitral valve disease
• pulmonary HTN
• pulmonary embolus
• RV infarction
• chronic lung disease

• increased pressure load on RV due to higher vascular pressure
• leads to RV dilation with or without RVH
• exentually RVEDP increases: reflected back to RA and venous system

• jugular vein distension (JVD)
• peripheral edema
• weight gain
• hepatomegaly
• ascites
• anorexia, nausea, bloating
• cold, pale, and cyanotic extremities
• accentuated P2 (pulmonary component of 2nd heart sound)

dependent on:

• coronary BF
• DBP
• vasomotor tone
• resistance to flow
• LVEDP
• 02 carrying capacity of blood
• coronary artery antomy
• diastolic filling time
• net driving pressure

describe myocardial 02 demand

• closely related to myocardial 02 consumption (MV02)
• determinants of myocardial 02 demand
• HR
• SBP
• myocardial wall tension
• contractility
• LV characteristics (volume, wall thickness, diameter)

relative changes in MV02 can be estimated by using an indirect index such as the rate pressure product

RPP=HR X SBP

Post. IV sptum

portionof inferior LV

IRRestrictive Lung Disease

pathogenesis

• decreased compliance
• if pleural abnormalities compress the lung, normal lung expansion is inhibited
• reduced lung volumes
  • IRV
  • ERV
  • VC,IC, TLC
  • TV decreases over time
  • RV may  be normal, increased or decreased
• increase work of breathing
• greater transpoulmonary pressure required to achieve normal TV
• uneven/decreased alveolar ventilation

• pulmonary arteries constrict in response to hypoxia
• direction blood flow away from hypoxic or poorly ventilated regions of lung and to better aerated parts of lung
• contributes to pulmonary HTN

• signs:
• tachypnea
• hypoxemia
• decreased breath sounds
• PFT: decreased lung volumes and capacities
• possible decreased diffusing capacity
• cor pulmonale if severe dysfunction
• decreased exercise tolerance

symptoms:

• dysnpnea
• cough: dry, non-productive

physiological monitoring during PT sessions

continue monitoring

familiar with side effects of medications and how affect exercise

recognize signs and symptoms of hypoxemia and ventilatory muscle fatigue

PT interventions may benefit pts with RLD

describe the signs and symptoms of hypoxemia for Pa02

• 80-100
• 60-80
• 50-60
• <50

• 80-100:normal
• 60-80: tachycardia, dyspnea
• 50-60: malaise,  nausea, central cyanosis, vertigo, lightheadedness, restlessness,, poor judgement
• <50: marked confusion, agitation, peripheral vasoconstriction, respiratory distress

what are some signs and symptoms of respiratory muscle fatigue (RLD)

• rapid, shallow breathing, retaining c02, hypoventilating
• uncoordinated chest wall movements with breathing
• increased accessory activity
• dysnpnea
• signs and symptoms of hypoxemia
• signs and symptoms of c02 narcosis

• hypercarbia, hypercapnea
• headache
• decrease mental status, confusion, drowsiness, coma
• tachycardia
• flushed/red skin
• abnormal BP
• diaphoresis
• muscular twitching, myoclonic jerking

describe the example of RLD atelectasis

definition

clinical features

medical

pt interventions

• def: collapse of part or all of lung
• caused by blockage of air passages (bronchioles) or pressure on the lung
• clinical features: symptoms: dyspnea, chest pain cough
• signs: CXR, fever, low 02 saturation
• medical treatment: goal is to remove secretions and reexpand affected lung, aerosolized respiratory meds to open airway, remove obstruciton by bronchoscopy
• PT treatments: deep breathing exericses (inceptive spirometry) and coughing, CPT to loosen and drain mucus, mobilize pt

describe the RLD, IDIOPATHIC PULMONARY FIBROSIS, basic

chronic, primary restrictive lung disease

iflammatory process involving alevolar wall

can progress to gross distortion of lung architecture

• signs
• decreased TLC, VC< FRC, RV
• dec. DLCO
• as disease progresses-decrease TV, inc RR
• decrease in Pa02
• intially hypoxemic with exercise, eventually hypoxemic at rest
• dry rales and decrease breath sounds
• pulmonary HTN if cap beds destroyed

• DOE, evenutall dyspnea at rest
• repetitive non productive cough, some will have mucuous hypersecretion
• weight loss
• decrease appetitie
• fatigue
• sleep distrubrances

• medical: coricosteroids, cytoxic drugs, supportive: smoking cessation, maintaining 02/ventilation, nutrition, lung transplant
• PT: assessment of 02 with functional activities, exercise and pulm rehab to improve functional limitations

• obstruction to airflow
• lung compliance increased
• mechanical function affected
• gas exchanging capability is affected

• hyperinflation
• barrel chest
• hypoxemia
• +/- hypercarbia
• decrease expiratory flow rates
• increased lung volume (TLC, RV)
• V/Q mismatch
• decreased diffusing capacity
• breathing pattern: prolonged expiration
• breathing sounds: decreased, wheezes, rales

health ed

medications

PT interventions

pulmonary rehab

supportive measures: 02 therapy, nutrtional support

management of acute exacerbations

surgical interventions

non-septic: asthma, emphysema, chronic bronchitis

septic: CF, bronchiectasis

barrel chest

chest radiograph: hyperinflation, flatten diaphragms

accessory muscle use/hypertrophy

pursed lip breathing

decreased breath sounds

assumes posture with arms/upper body supported

abnormal pulmonary function test (PFT)

FRC, TLC, RV increased, FEV1 and FVC are decreased

low diffusing capacity

treatment for emphysema: medial and PT

medical: stop smoking, prevent respiratory infections, meds, 02

PT: exercise, pulm rehab, education: breathing retraining, energy conservation, inspiratory muscle training, smoking cessation

OLD:

obstruction to airflow

increased airway resistance

increased lung volume

RLD:

problems with breathing mechanics

decreased compliance

reduced lung volumes

FEV/FVC: <70% OBSTRUCTION

Look @ FEV1 (% predicted for degree of obstruction)

assess FVC for restrictive component (FVC<80%)

if FEV1/FVC normal, look at FVC

if FVC normal (FEV1/FVC normal): no obstruction or restriction

if FVC is reduced: restriction

look at FVC (%predicted) for degree of restriction