Cardiopulmonary Rehabilitation Exam II PDF

Cardiovascular Conditions Part Hypertension (HTN) This is considered as the constant elevation of arterial pressure of 130/80 mmHg or higher Epidemiology - Men>F...

Cardiovascular Conditions Part Hypertension (HTN) This is considered as the constant elevation of arterial pressure of 130/80 mmHg or higher Epidemiology - Men>Female - More common in blacks (non-hispanic) - 1 in 4 adults with HTN have it under control Risk factors - Conditions: DM, Gout, and kidney disease - Race: african american - Gender - Male>Female (early to middle adult years) - Female>Male (middle to later adult years) - Family hx - Overweight - High salt diet - Heavy alcohol drinkers - Lack of exercise and physical activity Pathophysiology - Determinants - Cardiac output (CO) - Total peripheral resistance (TPR) Primary/Essential HTN: - Unknown cause - Risks: age, ethnicity, obesity, lifestyle, diet, and level of activity Labile HTN: - BP is sometimes elevated and other times normal White coat HTN: - Elevated BP that happens in the clinic but not during daily life Masked HTN: - Pt has normal BP in the clinic but high in ambulatory - Associated with increased rate of organ damage Malignant HTN: - Marked elevated BP (>160/110 mmHg) causing retinal hemorrhages, exudates, and papilledema Isolated systolic HTN (ISH): - SBP that is 130 mmHg or higher with a normal DBP Hypertensive heart - Is a long-term effect of unmanaged high blood pressure disease - Cause: chronic HTN (>120/80 mmHg) - Mechanism: pressure overload on the L ventricle - Decreased O2 supply and demand on myocardium - Reduce ventricle compliance - Clinical manifestations: exertional dyspnea, fatigue, impaired exercise tolerance, tachycardia, palpitations, exertional chest discomfort, dizziness, fainting, and signs and symptoms of CHF Diagnostic tests and - Regular appointment with your PCP measures - Hypertensive heart disease - Blood test - Urine test - Electrocardiogram (EKG) Treatment Pharmacology - Diuretics (thiazide), B-blockers, A-blockers, Ca channel blockers (CCBs), Angiotensin-converting enzyme (ACE) inhibitors, Angiotensin II receptor blockers (ARBs), Vasopeptidase inhibitors (VPIs) Lifestyle modification - Weight reduction, Diet modification, Physical activity, Stress management, Smoking cessation, Alternative medicine Implications to PT -Include BP monitoring during PT examinations interventions -Take notes of patients prescribed medications, compliance, and reinforce the importance of adherence - Monitor BP at rest, during activity, and post activity - For uncontrolled and severe BP (SBP >180 mmHg and DBP * >110 mmHg): needs medical clearance and prescribed medications prior to exercise prescription * - If resting BP is excessively high (SBP >200 mmHg or DBP >110 mmHg) postpone exercise - If resting BP is excessively high (SBP >250 mmHg or DBP * >115 mmHg) terminate exercise - If there is an underlying organ damage due to HTN: blood pressure should be controlled both at rest and during exercise before PT interventions - Watch out for hypotension especially orthostatic hypotension Ischemic Cardiovascular Conditions Arteriosclerosis The accumulation of fatty deposits (plaque) inside the artery wall that causes blockage of blood flow Factors 1. Endothelial dysfunction 2. Dyslipidemia 3. Inflammation 4. Plaque rupture Coronary artery Accumulation of plaque in the arteries of the heart → coronary heart disease (CAD) disease Symptoms of heart attack - Angina - Cold sweats - Dizziness - Lightheadedness - Nausea - Neck pain - SOB with activity - Sleep disturbances - Weakness Women with CAD - Dizziness - Extreme tiredness - Nausea - pressure/tightness in the chest - Stomach pain Risk factors - Sex: M>F - Age - Family hx - Race or ethnicity - Lifestyle habits - Medical conditions Diagnostic tests and procedures - Regular appointment with PCP - Specific diagnostic test and measures - EKG - Stress test - Nuclear stress test - Cardiac MRI - Cardiac PET scan - Coronary catheterization and angiogram Treatment: Lifestyle modification - Weight reduction, diet modification, physical activity, stress management, smoking cessation, high-quality sleep, alternative medicine Pharmacology - Aspirin, b-blockers, a-blockers, Ca channel blockers (CCBs), angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), cholesterol drugs, nitroglycerin, ranolazine, blood sugar control medications, metformin  Procedures - Percutaneous coronary intervention (PCI) - Coronary artery bypass graft (CABG) - Transmyocardial laser revascularization or coronary endarterectomy - for severe angina linked to CAD Angina Substernal pressure or discomfort that occurs anywhere from epigastric area to up the jaw. Described as: squeezing, tightness, or crushing Pain: gradual, diffuse, and is accompanied by SOB, nausea, and diaphoresis Symptom of CAD or CHD and coronary microvascular disease (MVD) - Basically when there is not enough O2 to the heart musculature. Stable angina - Occurs when the heart needed to work harder (physical exertion) - “Classic exertional angina” - Relieved by rest/nitroglycerin - Triggers: emotional stress, hot/cold temp exposure, heavy meals, and smoking Unstable angina - Unexpected chest pain and usually occurs at rest - Cause: reduced blood flow - Comes at a surprise and lasts longer than stable angina - Usually not relieved by rest or medication A- May lead to a heart attack Vasospastic or variant angina - Aka: prinzmetal; angina inversa - Cause: spasm in coronary arteries in response (typically) to temp, stress, medications - Treatment: Ca channel blockers and nitrates Microvascular angina - Symptom of coronary microvascular disease (MVD) - Cause: spasm of the very small arterial blood vessels - Symptoms: dull chest pain lasting for about 15-20 minutes - More common in women Diagnostic test and procedures - Regular appointment with PCP - Specific diagnostic test and measures: - EKG - Stress test - Blood test  - Chest x-ray - Coronary catheterization and angiogram Treatment Lifestyle modification: - Weight reduction, diet modification, physical activity, stress management, smoking cessation, treatment of medical conditions (DM, HTM and high cholesterol) Pharmacology - Aspirin, nitrates, b-blockers, CCBs, statins, ranolazine Procedures - Percutaneous coronary intervention (PCI) - Enhanced external counterpulsation (EECP) therapy - Usually 5 1 hour sessions per week - Inflate and deflate with heart beat Implications for PT interventions - Patients with stable angina should stay active - Build up the patient's activity level gradually and pace activity - Rest time = activity time - Remind patients to keep GTN spray or tablets with them (nitrate) - Have them take medications, if needed prior to exercise - Unstable angina is an absolute contraindication for exercise testing - Unstable angina should be treated as an emergency Myocardial Infarction It is a result of insufficient blood supply to the heart muscles resulting (heart attack) in: ischemia, injury, and death of the area of the myocardium Other causes: - Coronary vasospasm - Atherosclerosis - Trauma - Embolism - Electrolyte imbalance - Eating disorder - Takotsubo or stress cardiomyopathy - Anomalous coronary arteries Zones of infarction 1. Zone of ischemia a. Outer area; cells undergoing metabolic changes b. ECG: T wave inversion 2. Zone of injury a. Adjacent to the central zone; tissue noncontractile; cells undergoing metabolic changes b. ECG: ST segment elevation  3. Zone of infarction a. Necrotic tissue; tissue noncontractile b. ECG: abnormal Q wave (deep or wide) Etiology - Smoking, abnormal lipid profile, HTN, DM, obesity, psychosocial factors, nutrition, lack of physical activity, alcohol consumption Risk factors - Advanced age - Sex: M>F - Genetics Types of MI Type 1: - STEMI - Total blockage  - ST segment elevation - Elevated cardiac biomarkers - Cardiac muscle starts to die in 30 minutes - NSTEMI - Partial blockage - ST segment depression or T wave inversion - Elevated cardiac biomarkers - Higher risk for reinfarction - Accounts for 40% of MI Diagnostic tests and measures - ECG/EKG - Lab: cardiac biomarkers (CK-MB; troponin I&T) - Imaging: cardiac CT, or MRI - Chest x-ray - Coronary catheterization (angiogram) Treatment Lifestyle modification - Weight reduction, diet modification, physical activity, stress management, smoking cessation, treatment of medical conditions (DM, HTN, and high cholesterol) Pharmacology - Aspirin, clot busters (thrombolytics or fibrinolytics), other blood thinners, nitroglycerin, morphines, b-blockers, ACE inhibitors, statins - O2 supplement Procedures - Coronary angioplasty and stenting - Coronary artery bypass graft (CABG) Implications for PT interventions - Early mobilizations, therapeutic exercise, and ambulation are important - Close monitoring is necessary for cardiac patients due to a possibility of having cardiac event during exercise - Patients with CAD should have their short-acting nitroglycerin (NTG) accessible - Physiological responses to activity should be monitored during  PT in order to detect any signs and symptoms of myocardial ischemia - Reduce the activity intensity if the patient start showing signs or symptoms of angina/myocardial ischemia (pt can sit and take NTG and rest for a few min) - If activity is resumed, it should be at a lower intensity - If there is an occurrence of angina after an acute MI, report to physician immediately - Exercise training should be coupled with lifestyle modification to decrease CV risk factors - Take note of medication side effects and exercise interactions - Modify exercise as needed Peripheral Vascular disease Peripheral arterial The narrowing of peripheral arteries resulting in a decreased blood disease (PAD) supply Risk factors: - CAD, smoking, diabetes, HTN, high blood cholesterol, CVD, metabolic syndrome Clinical manifestations - Intermittent claudication - Atrophic skin changes - 6 Ps: pain, pulselessness, pallor, poikilothermia, paresthesia, paralysis Claudication pain scale Diagnostic tests and measures - ABI, pulse examination, doppler US, segmental pressure measurement, capillary refill, rubor of dependency, venous filling time Treatment - Lifestyle modifications and secondary prevention (aggressive risk factor reduction - smoking cessation and hyperglycemia control, exercise training) - Pharmacological: antihypertensive drugs, statins, antithrombotic therapy, prostaglandins - Revascularization: catheter based (percutaneous transluminal angioplasty), surgical (endarterectomy, bypass grafting) - Cardiac rehab  Venous disorders Chronic venous Condition where the veins are unable to allow blood to flow back to insufficiency (CVI) the heart. Risk factors: - Advanced age, genetics, obesity, prolonged standing, sedentary lifestyle, smoking, female hormones Clinical manifestations - Dull ache, heaviness, swelling, itching, tingling, cramping  A Diagnostic tests and measures - Pulse examination, doppler US, ABI, trendelenburg test, clinical assessment for DVT, venous filling time Pt interventions - Exercise - Extremity elevation - Avoid prolonged standing or sitting - Compression - Aggressive wound management Deep vein thrombosis Development of clot in the deep veins of the LE (DVT) Commonly found: - Popliteal vein, femoral vein, iliac vein Pulmonary edema: an emergency condition that happens when a clot is dislodged and reaches the lungs Risk factors - Hypercoagulability - Venous stasis - Endothelial injury Clinical manifestations DVT - Pain, ipsilateral swelling, a palpable cord, warmth, redness PE - SOB, anxiety, pleuritic chest pain, cough, tachycardia Wells decision tool  * Diagnostic tests and measures - D-dimer, duplex US, venography, MRI, CT pulmonary angiogram Treatment - Primary prevention - Early ambulation, intermittent pneumatic compression, graduated compression stockings, anticoagulant drugs - Treatment of DVT: - Anticoagulation, thrombolytic therapy, thrombectomy, vena cava filter placement PT implications Pulmonary Examination and Assessment Procedures Chest wall motion Tracheal position Fremitus Diaphragmatic excursion using percussion Lung sounds Normal  Adventitious breath sounds Pulmonary diagnostic tests and measures Chest imaging Advantages and disadvantages Pulmonary Emboli read as complete obstruction, intraluminal filling defects, or arteriography decrease in flow rate  Advantages - Gold standard in diagnosis PE Bronchoscopy Permits direct visualization of previously inaccessible areas of the bronchial tree - Provides information about integrity of airways, function of respiratory musculature, condition of lung tissues Indicated to: assess for infection, may be used to clear viscous secretions Pulmonary function - Noninvasive test that measures the volume of flow of air testing (PFT) during inhalation and exhalation - Tests of lung volume and capacity - Classifies disease into obstructive, restrictive, or combined - Recommended for all smokers >45 years old and any individual presenting with dyspnea Total lung capacity (TLC) = vital capacity + residual volume Obstructive = slow slope → issues with expiration and have more air trapped in lungs Tidal volume (VT) - Amount of air inhaled or exhaled during normal breathing Minute volume (MV) - Total amount of air exhaled per minute Vital capacity (VC) - Total volume of air that can be exhaled after inhaling as much as you can Functional residual capacity (FRC) - Amount of air left in lungs after exhaling normally Residual volume - Amount of air left in the lungs after exhaling as much has you can Total lung capacity - Total volume of the lungs when filled with as much air as possible Forced vital capacity (FVC) - Amount of air exhaled forcefully and quickly after inhaling as much as you can Forced expiratory volume (FEV) - Amount of air expired during the first, second, and third seconds of the FVC test Forced expiratory flow (FEF) - Average rate of flow during middle half of the FVC test Peak expiratory flow rate (PEFR) - The fastest rate you can force air out of your lungs Also Indications for PFTs  Risks - Dizziness, SOB, coughing, asthma attack secondary to deep inhalation Contraindications - Uncooperative patient - Recent eye surgery - Recent abdominal/chest surgery - Chest pain, recent heart attack, or an unstable heart condition - Aneurysm in the chest, abdomen, or brain - Active TB or respiratory infection, such as cold or flu Patient positioning - Semi-fowler's position with no abdominal binder and add nose clips - If in chair - ensure they are sitting as upright as possible → legs uncrossed, arms relaxed Patient instruction also have them empty bladder PFTs specifics Tidal volume “Close your lips tightly around the mouth piece and take 3-4 normal breaths in and out” Vital capacity “Please empty your lungs totally and then inhale as much air as you can, close your lips tightly around the mouthpiece and blow out at a steady rate.” do not hold breath @ max inhalation longer than 1 second and do not change posture nose clips are essential for VC as air can leak out due to the low flow Expiratory reserve “Take a normal breath, once you exhale forcibly exhale further until all volume of the fair feels to be out of your lungs” amount of air moved out of lungs during forced expiration Inspiratory reserve “Take a normal breath, followed by a deep fast breath back in after volume breathing all the way out” FVC “Please inhale as much air as you can. Close your lips tightly around the mouthpiece and then blast all the air out of your lungs as quickly FEV1 and forcefully as you can.” Interpretation - normal Interpretation - FEV1