Chapter 1: Cardiovascular, Pulmonary & Lymphatic Systems PDF

ANATOMY & PHYSIOLOGY OF THE CARDIOVASCULAR SYSTEM Chapter 1: Cardiovascular, Pulmonary & Lymphatic Systems Anatomy & Physiology of the Cardiovascular System Topology Pericardium: fibrous protective sac enclosing heart Epicardium: inner layer of pericardium Myocardium: heart...

ANATOMY & PHYSIOLOGY OF THE CARDIOVASCULAR SYSTEM Chapter 1: Cardiovascular, Pulmonary & Lymphatic Systems Anatomy & Physiology of the Cardiovascular System Topology Pericardium: fibrous protective sac enclosing heart Epicardium: inner layer of pericardium Myocardium: heart muscle, the major portion of the heart Endocardium: smooth lining of the inner surface and cavities of the heart Apex: Lowest part of the heart that is pointy and part of the left ventricle. o Auscultated at the 5th intercostal space (ICS) left of the midclavicular line Base: Upper border below the second rib in the 2nd ICS For a more comprehensive review, click here CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 1  ANATOMY & PHYSIOLOGY OF THE CARDIOVASCULAR SYSTEM Cardiac Valves Atrioventricular valves: Prevent backflow of blood intro atria during ventricular systole; anchored by chordae tendinae to papillary muscles; valves close when ventricular walls contract Semilunar valves: Prevent backflow of blood from aorta and pulmonary arteries into the ventricles during diastole In order of blood flow: 1. Tricuspid 2. Pulmonary semilunar 3. Bicuspid (mitral) 4. Aortic semilunar Interior view of the heart Cardiac Chambers Right atrium: receives deoxygenated blood from systemic circulation from the superior and inferior vena cava Right ventricle: receives blood from the right atrium and pumps blood via the pulmonary artery to the lungs for oxygenation; the low-pressure pulmonary pump Left atrium: receives oxygenated blood from the lungs and four pulmonary veins Left Ventricle: receives blood from the left atrium and pumps blood via the aorta throughout the entire systemic circulation; the high pressure systemic pump. The walls of the left ventricle are thicker & stronger than the right ventricle and form most of the left side and apex of heart. CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 2  ANATOMY & PHYSIOLOGY OF THE CARDIOVASCULAR SYSTEM Cardiac Vessels Aorta: exits left ventricle Arch gives rise to brachiocephalic, left carotid, and left subclavian arteries, in that order Vena Cava: drains venous blood into right atrium Right and Left Coronary Arteries: Right coronary artery yields the marginal artery, and later to the post interventricular artery Left coronary artery immediately branches to the anterior interventricular and circumflex artery The right coronary and left circumflex arteries anastomose posteriorly For a more comprehensive review of the anatomy of the heart, click here Cardiac Cycle Atrial systole: The contraction of the right and left atria pushing blood into the ventricles Atrial diastole: Period between atrial contractions when the atria are repolarizing Ventricular systole: Contraction of the right and left ventricles pushing blood into the pulmonary artery and aorta. Ventricular diastole: Period between ventricular contractions when the ventricles are repolarizing For a more comprehensive review, click here CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 3  ANATOMY & PHYSIOLOGY OF THE CARDIOVASCULAR SYSTEM Rhythm (Abnormal) Abnormal Appearance Notable Features Rhythms Ventricular P-wave: absent Occurs occasionally in majority of normal population. (PVC) QRS: wide (>0.10 sec) and Can occur by themselves or groups bizarre Originates in the ventricle. PVCs that come from Serious PVCs: >6 per min different ectopic sites within the ventricle are multifocal paired or in sequential runs, PVCs and are more serious than unifocal PVCs. very early PVC (R on T phenomenon) If PVCs increase with activity, the activity should be stopped. Ventricular P-wave: absent Occurs when ventricles don’t contract and instead Fibrillation fibrillate QRS: none Pulseless, an emergency situation requiring emergency Generally irregular medical treatment Patient will die without electrical defibrillation being used. Ventricular P-wave: absent Run of 3 or more PVCs occurring sequentially. Tachycardia Rate: fast (100-250 bpm) Usually result of ischemic ventricle (3 PVC in a row) QRS: wide (>.10 sec) and bizarre Atrial Flutter Saw tooth pattern -- Rate: 250-350 bpm for atrial, ventricular rate is often slower Atrial P-wave: merged with T-wave Multifocal Atrial Tachycardia: p-wave often changing Tachycardia shape and size from beat to beat (at least 3 different Rate: 150-250 bpm forms) Atrial P-Wave: absent or erratic Patient can usually exercise if heart rate and blood Fibrillation waves present. pressure are stable Rate: >350 bpm but ventricular If resting hear rate is above 115 bpm or the patient is rate may be slow, normal or uncomfortable or responds poorly to exercise, then the fast (irregular rhythm) patient should stop the intervention and seek medical consultation Atrial (PAC) An irregular rhythm Occurs with an ectopic beat that originates in the atria These will usually not compromise cardiac output For a more comprehensive review, click here CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 4  ANATOMY & PHYSIOLOGY OF THE CARDIOVASCULAR SYSTEM Pacemakers (Biological and Artificial) Biological A specialized conduction tissue allows rapid transmission of electrical impulses throughout the myocardium Pacemakers Location Function Innervation SA Node At the junction of superior Main pacemaker of heart; Sympathetic & vena cava & right atrium initiates impulse at rate of 60- parasympathetic (heart & 100bpm strength contraction) AV Node At the junction of right Intrinsic firing rate of 40-60 Sympathetic & atrium and right ventricle bpm parasympathetic innervation Purkinje Right & left bundle Electrical impulses terminate branches of the AV node in Purkinje fibers; specialized are located on either side conducting tissue spread of intraventricular septum throughout the ventricles -- Intrinsic firing rate of 20-40 bpm For a more comprehensive review, click here Artificial A medical device which uses electrical impulses to regulate the heartbeat of the patient. These are generally used if there are issues with the biological pacemakers (not frequent enough) or the heart’s electrical system. For a more comprehensive review, click here CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 5  ANATOMY & PHYSIOLOGY OF THE CARDIOVASCULAR SYSTEM Normal/Abnormal Heart Enzymes Enzyme Normal Time Used to… Markers Appear  Peak  Back to Normal CK-MB 2-4 hrs.  12-24 hrs.  2-3 days May be able to detect a myocardial infraction as soon as 2-4 hours after initial onset Cardiac 2-4 hrs.  24-48 hrs.  14 days Sole marker for myocardial infraction; stays elevated Troponin the longest CK 6 hrs.  12 hrs. 2-3 days Diagnose a myocardial infraction SGOT/AST 12 hrs.  24-48 hrs.  3-5 days Diagnose a myocardial infraction LDH 18 hrs.  2-3 days  7 days Diagnose a myocardial infraction For a more comprehensive review, click here Normal Blood Gases Normal Values Partial pressure of oxygen (PaO2) Greater than 80 mm Hg Partial pressure of carbon dioxide (PaCO2) 35–45 mm Hg pH 7.35–7.45 Bicarbonate (HCO3) 22–26 mEq/L (22–26 mmol/L) Oxygen saturation (O2Sat) 95%–100% For a more comprehensive review, click here CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 6  ANATOMY & PHYSIOLOGY OF THE CARDIOVASCULAR SYSTEM Normal Blood Values and Blood Pressure Hemostasis (Clotting/Bleeding) Normal Time Factors for abnormal times Prothrombin: 11-15 sec Higher in factor hemorrhagic disease, cirrhosis, hepatitis drugs Partial thromboplastin: 25-40 sec Higher in factor VII, IX, and X deficiency INR: 0.9-1.1 sec DVT, PE, AF Bleeding: 2-10 min Higher in platelet disorders, Blood Pressure 106−110 Infant: 60−65 113−116 Child: 70−75 1mm) in leads of poor perfusion (cyanosis & J point becomes depressed without diagnostic Q waves pallor), patient requests to terminate test, sustained ST segment becomes sharply up Increase PR interval supraventricular or ventricular sloping tachycardia, drop in SBP >10 Missing Q wave mmHg from baseline (despite an Q-T interval shortens increase in workload, when Missing P wave accompanied by other evidence of T wave decreases in height ischemia), hypertensive response Increase/decrease wave time Normal and Abnormal Heart Rate Values Age or fitness level Normal BPM Babies to age 1 100-160 Children age 1 to 10 60-140 Children age 10+ and adults 60-100 Well-conditioned Athletes 40-60 CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 15  CARDIOVASCULAR TESTS & MEASURES Abnormal Pulse What’s Happening Can Indicate Irregular Variation in force and frequency Arrhythmias, myocarditis Weak (Thready) Low stroke volume Cardiogenic shock Bounding Shortened ventricular systole and decreased Aortic insufficiency peripheral pressure Methods for Determining Heart Rate Values Count beats for 10 seconds x 6 Used for heart rate approximation Count beats for 15 seconds x4 Most common and is almost as accurate Count beats for 30 seconds x 2 Can detect rhythm changes Count beats for 60 seconds Most accurate for determining rhythm changes Most accurate for determining heart rate CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 16  CARDIOVASCULAR TESTS & MEASURES Heart blocks A heart block is a heart electrical system disease, as opposed to coronary artery disease which is in the blood vessels. AV Block: delay or interruption in transmission of an impulse from atria to ventricles due to an anatomical or functional impairment in the conduction system. AV Blocks st 1 Degree PR interval lengthened > 0.20 sec. Delayed conducting from atria to ventricles through AV node. (Enhanced vagal tone: athletes, myocarditis, acute MI) Asymptomatic. Incidental finding on ECG Type I Progressive long PR interval dropped QRS complex 2nd degree Asymptomatic, but in some patients, sensed irregularities of heartbeat, presyncope, syncope may occur. May manifest on physical exam as bradycardia Type II Disease of distal conduction system (His-Purkinje system). 2nd degree P-R Intervals steady, Occasional dropped QRS complex May progress rapidly to complete heart block. 3rd degree AV block Block in the His-Purkinje system Life threatening Requires atropine, surgical implantation of pace maker Associated with fatigue, dizziness, light headed, presyncope, syncope, profound bradycardia For more information, click here CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 17  CARDIOVASCULAR TESTS & MEASURES Electrode placement Lead 1 – LA – RA Lead 2 – LL – RA Lead 3 – LL – LA AVL – LA – RA/LL AVR – RA – LL/LA AVF – LL – LA/RA Precordial leads 1. 4th intercostal/ R sternal border 2. 4th intercostal/ L sternal border 3. midway between 2 and 4 4. 5th intercostal at L midclavicular line 5. L ant axillary line same level as V 4 6. L mid axillary line same level as V4 CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 18  CARDIOVASCULAR TESTS & MEASURES Heart Diagnostic Imaging Angiogram: x-ray of vessels after injection of a contrast medium to show plaques in the cardiac vessels and level of occlusion Carotid ultrasound: using real time US to visualize the structure and function of the carotid arteries to screen for blockages and risk for stroke/evaluate stent placement Fluoroscopy: continuous x-ray procedure to visualize the heart and lungs. Has been largely replaced due to high radiation dose PET scans: radioactive material is introduced that cumulates in areas of higher chemical activity i.e. heart disease or cancer Cardiac catheterization: a catheter inserted in a peripheral artery is advanced to the coronary arteries and a contrast is injected to allow imaging of stenosis or occlusion of the vessels. Also, a type of procedure in which a stent, angioplasty etc. may be performed. Myocardial Perfusion Imaging: used to diagnosis and evaluate ischemic heart disease and MI Thallium is used to identify blood flow & areas of stress-induced ischemia. Used with exercise test Echocardiogram: noninvasive test that uses ultrasound to assess internal structures: size of chambers, wall thickness, EF, movement of valves, septum, and abnormal wall movement Central Line (Swan-Ganz Catheter): inserted through vessels into right side of heart. Measures central venous pressure, pulmonary artery pressure, and pulmonary capillary wedge pressures CXR: reveal abnormalities of lung fluids, overall cardiac shape and size, and aneurysm CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 19  CARDIOVASCULAR TESTS & MEASURES Signs and symptoms of cardiac distress Angina: chest pain described as squeezing, tightness, aching, burning or choking. Generally substernal and may radiate to arms, jaw, neck or back. Dyspnea: short of breath with activity or rest (note activity and time needed to resolve). At rest with a respiratory rate over 30 may require EMS (this is also a sign of acute CHF). Diaphoresis: cold, clammy sweat Orthopnea: dyspnea brought on by lying flat (count the number of pillows that patient needs to breathe comfortably during sleep). Blood Pressure: a drop over 10 of systolic blood pressure Dizziness: patient is feeling faint, weak, or unsteady Nausea/Emesis: vomiting or signs that the patient feels sick to stomach Ataxia: patient lacks muscle control of voluntary movements Cyanosis: skin takes on a bluish coloration due to lack of circulation or oxygenation of the blood Pallor: patient is pale, and generally unhealthy looking Ventricular Tachycardia: see Rhythm for complete definition CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 20  CARDIOVASCULAR TESTS & MEASURES MET values Intensity Endurance Promoting Activity Associated 1.5-2 Very low energy level Desk work, driving auto, washing clothes, standing, METs strolling (1 MPH), sewing/knitting 2-3 Low in energy level unless capacity is Auto repair, riding lawnmower, level walking (2 MPH), METs very low biking (5 MPH), bowling, canoeing 3-4 Yes, if continuous and if target HR Brick laying, plastering, machine assembly, mopping METs reached floors, vacuuming, pushing lawnmower, walking (3 MPH), biking (6 MPH), volleyball, golfing, archery 4-5 Recreational activities promote Painting, masonry, raking leaves, walking (3.5 MPH), METs endurance; occupation activities must be biking (8 MPH) continuous, lasting longer than 2 min 5-6 Yes Digging garden, walking (4 MPH), biking (10 MPH), ice METs or roller skating 6-7 Yes Shoveling 10x/min or 10 LB, splitting wood, walking METs (5 MPH), biking (11 MPH), skiing, swimming 7-8 Yes Carrying 80 LB, jogging (5 MPH), biking (12 MPH), METs basketball, mountain climbing 8-9 Yes Shoveling 10x/min or 14 LB, running (6 MPH), biking METs (13 MPH), rope skipping 10+ Yes Shoveling 10x/min or 16 LB, running (6 MPH=10 METs, METs 7 MPH=11.5 METs, 8 MPH=13.5 METs, 9 MPH=15 METs, 10 MPH=17 METs) Peripheral pulses Ankle-Brachial Index: This is a ratio that compares and divides the lower extremity (LE) pressure by the upper extremity (UE) pressure. This ratio helps determine if there is a vascular problem. The test is performed with patients who have arterial disease to determine if the lower extremity is getting enough blood and oxygen. This in turn will help with determine if a wound will heal well. Procedure: use the brachial artery for the upper extremity and the dorsal pedis or tibial posterior artery for the lower extremity Dorsal Pedis: located just lateral to the extensor hallucis longus tendon and is best palpated proximal to the first metatarsal-cuneiform joint CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 21  CARDIOVASCULAR TESTS & MEASURES Tibial Posterior Artery: muscle tendon runs down behind the medial malleolus and ends by segregating into main, plantar, and recurrent portions ABI Significance Values >1.2 Indicates non-compliant arteries, falsely elevated, arterial disease, diabetes 0.95-1.2 Normal 0.75-0.94 Mild arterial disease, and intermittent claudication 0.50-0.74 Moderate arterial disease, and rest pain ≤0.50 Risk for critical limb ischemia; may have pain at rest, Severe arterial disease Circulation Tests Doppler Ultrasound: Connected to earphones. Determines blood flow in a vessel; used for in both venous and arterial diseases. Doppler probe placed over large vessel; US signal given transcutaneously; movement of blood causes audible shift in signal frequency Venous Circulation Tests Percussion test: determines competence of greater saphenous vein. While patient is standing, palpate a segment of vein, at the same time percussing vein 20 cm higher. The intervening valves are incompetent if the pulse wave is felt in lower hand. Trendelenburg test: determines competence of communicating veins and saphenous system. Patient is supine with legs elevated to 60°, which empties venous blood. Tourniquet placed on proximal thigh, which blocks venous flow in superficial veins. The patient stands, and the PT note whether veins fill in normal pattern (should take 30 sec) Venous Filling Time: time necessary to refill veins after emptying. When supine, patient passively elevates lower extremity to 45° for 1 minute, then is placed in dependent position. Note time for veins to refill. Delayed filling (>15 seconds) means a venous insufficiency CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 22  CARDIOVASCULAR TESTS & MEASURES Air Plethysmography (APG): pneumatic device used to measure the flow (whether obstructed or not) of venous system Artery Circulation Tests Rubor of dependency: changes in skin color during elevation of foot followed by dependency (seated/ hanging position) Intermittent claudication: exercise induced pain or cramping in legs that is absent at rest. Have patient walk on level grade, 1 mile/ hour. Test is stopped with claudication pain. Note time of test. Grade I: minimal discomfort/ pain Grade II: moderate discomfort or pain, patient’s vein can be diverted Grade III: intense pain, patient’s vein cannot be diverted Grade IV: Excruciating and unbearable pain CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 23  CARDIOVASCULAR DISEASES & CONDITIONS: DEFINITION & PROGNOSIS Cardiovascular Diseases & Conditions: Definition & Prognosis Condition Definition Diagnosis Prognosis Aneurysm Abnormal dilation in the Plaque formation erodes High mortality rates wall of an artery, a vein or the vessel wall, the heart (diameter at predisposing the vessel to least 50% greater than stretching of the inner and normal) outer layers of the artery Angina Pectoris Chest pain or pressure Caused by an imbalance Depends on type of angina due to ischemia between cardiac workload (stable or not); heart is and oxygen supply to vulnerable to arrhythmias myocardial tissue; usually and myocardial infractions secondary to CAD which can be fatal Aortic Stenosis Impairment of blood flow Is a result of aortic valve Once symptoms appear, from left ventricle to disease or obstruction just prognosis is poor without aorta above or below the valve surgery but excellent with valve replacement Claudication Impairment in walking, or Is often a symptom of Often, because of its pain/discomfort in the another disorder (such as connection to another legs when walking. PAD) disorder, outcome is poor CHF Left Side The heart is unable to Occurs when the left Poor pump sufficient blood for ventricle can no longer the body maintain a normal cardiac output CHF Right Side The heart is unable to Is secondary to left-sided Poor pump sufficient blood for failure, or pulmonary the body disease Cor Pulmonale Enlargement of the right As pulmonary HTN creates Poor, since it occurs late ventricle; secondary to long-term pressure during the course of COPD pulmonary HTN overload in the right and other irreversible ventricle, cor-pulmonale diseases develops. Coronary Artery Narrowed arteries, which Caused by plaque build-up Is a common cause of heart Disease reduces blood flow to along inner walls of the attacks (CAD) heart heart arteries Deep Vein Formation of a blood clot Caused by venous stasis, A frequent complication is Thrombosis in a deep vein, often in changes in endothelial post-thrombotic syndrome; the legs blood vessel linings, and death from DVT is generally hypercoagulability rare Hypertension A persistent elevation of Increased peripheral Treatment prolongs life and diastolic/systolic blood resistance caused by anti-hypertensive pressure (> 90 and 140 narrowing of the arterioles medications reduce mortality mmHg respectively) rate CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 24  CARDIOVASCULAR DISEASES & CONDITIONS: DEFINITION & PROGNOSIS Condition Definition Diagnosis Prognosis Mitral Valve The mitral valve and Variation in the shape of Affects men and women Prolapse related structures do not the mitral valve allows one equally; not life threatening, function properly part to billow back into the and rarely results in left atrium during complications contraction of the ventricle Mitral Valve Mitral valve fails to open When the heart pumps, May be present for a lifetime Stenosis as wide as it should blood pressure forces the with few or no symptoms or mitral valve flaps open and may become severe. allows blood to flow from the left atrium to the left ventricle Myocardial Heart attack Caused by improper blood First 24 hours after symptoms Infraction flow (often from a is highest risk for death; the blockage), which injures elderly, those with the muscles because lack cardiovascular/respiratory of oxygen diseases, hypertension, and an anterior location for the MI are at a higher risk for death Orthostatic A decrease of 20 mmHg< Caused by failure of the Whenever the underlying Hypotension in systolic BP or a drop of arterial barorelfex disorder causing hypotension 10 mmHg< of both is corrected, symptoms stop systolic/diastolic BP Pericarditis Inflammation of the Causes are many, Excellent when there is no or pericardium including infection, minimal myocardial idiopathic, uremic involvement; w/out pericarditis, etc. intervention, shock and death can occur Peripheral Artery Obstruction of large Caused by acute and Patients are at high risk for Disease arteries not in the chronic ischemia cardiovascular events and coronary/aortic diseases, which will often be arch/brain the cause of death CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 25  DIFFERENTIAL DIAGNOSIS OF THE CARDIOVASCULAR SYSTEM Differential Diagnosis of the Cardiovascular System Condition Features Aneurysm Substernal/back/neck/jaw pain, extreme/sharp pain felt at base of neck, acute MI, acute chest pains, ischemia of arms/legs Angina Pectoris Temporary pain, discomfort that starts suddenly in chest and radiates, squeezing, burning, heartburn, indigestion, choking Aortic Stenosis Dyspnea on exertion, fatigue, angina, palpitations, orthopnea, systolic ejection murmurs radiating to neck Claudication Pain in the legs, often the calves (though not always); pain is relieved by rest CHF Left Side Dyspnea, orthopnea, productive spasmodic cough, pulmonary edema, cerebral hypoxia, fatigue, muscular weakness, renal changes CHF Right Side Progressive failure, dependent edema, jugular vein distention, abdominal pain/distention, weight gain, right-upper quad pain, cardiac cirrhosis, anorexia, nausea Cor pulmonale Chronic productive cough, wheezing, easy fatigability, sudden/severe central chest pain, (pulmonary heart rapid pulse, sweating, hypotension, distended neck veins, clubbing disease) Coronary Artery Regular angina, both stable and unstable Disease Deep Vein Pain, swelling, redness, warmth, engorged superficial veins; symptoms are often not Thrombosis enough to diagnose a patient since many other disorders share similar symptoms HTN Asymptomatic in the early stages; headache, vertigo, flushed face, blurred vision, sleep disordered breathing Mitral Valve Most people are asymptomatic, profound fatigue (not from exercise/stress), Prolapse palpitations, dyspnea, joint hypermobility, mild scoliosis, tremors, swelling of the extremities, low back pain, dizziness, difficulty in concentrating Mitral Valve Atrial fibrillation, dyspnea, orthopnea, fatigue, reduced cardiac output, Distinctive heart Stenosis murmur and specific heart sound, swelling especially in the legs, ankles and feet, bulging neck veins, fine crackles heard in the lungs, flushing of the cheek Myocardial Pain is constant, lasting 30 minutes up to hours, crushing/squeezing chest pain, profuse Infraction (Heart perspiration, skin cool and clammy, nausea/vomiting, pain spreads from chest to Attack) neck/jaw/shoulders/arms, fast/irregular heart beat Orthostatic Dizziness, blurring/loss of vision, fainting, unexpected/unexplained falls Hypotension Pericarditis Pleuritic chest pains, substernal pains, fever, joint pain, dyspnea, difficulty swallowing Peripheral Artery Mild PAD can be asymptomatic; claudication, sores/wounds that heal slowly or never, Disease changes in color and temp, diminished hair/nail growth on affected limbs CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 26  PHARMACOLOGICAL MANAGEMENT Pharmacological Management Cardiac pharmacology Class Examples Action Indication Side Effects Alpha Minipress, Reduces blood HTN, BPH Dizziness, orthostatic Adrenergic Prazosin, pressure by dilating hypotension, drowsiness Antagonist doxazosin, peripheral arterioles Agents terazosin and veins “zosin” ACE inhibitor Lisinopril, Reduce BP by HTN, CHF Hypotension, dizziness, (angiotensin captopril, Suppresses the dry cough, hyperkalemia converting enalapril, enzyme that converts and natremia enzyme) Ramipril “pril” angiotensin 1 to 2 Angiotensin II Losartan, Reduce BP by Block HTN, CHF Dizziness, back and leg receptor candesartan, angiotensin II pain, angina antagonist valsartan receptors to limit Agent “sartan” vasoconstriction Anti-arrhythmic Depend on Class 1: sodium Arrhythmia Depend on subtype Agents subtype, look channel blockers at respected Class 2: beta blockers area Class 3: inhibit potassium and sodium Class 4: calcium channel blocker Anti-coagulants Heparin, Inhibit platelet Heart valve Hemorrhage, GI distress Coumadin, aggregation surgery, Warfarin, angioplasty, Lovenox bypass, etc. Antihyperlipide Lipitor, Zocor, Break down LDL, High cholesterol, HA, GI distress, rash mic fenofibrate, decrease triglycerides, atherosclerosis atorvastatin, increase HDL and prevent simvastatin CAD “statins” Anti-thrombotic Aspirin, Bayer, Inhibit platelet Post MI, A-Fib, Hemorrhage, thrombo - (antiplatelet) Plavix formation prevent cytopenia, liver damage thrombus Beta Blocker Atenolol, Decrease HR and Tachycardia, Bradycardia, arrhythmia, metoprolol, contractility by arrhythmia, fatigue, weakness, propranolol blocking Beta heart failure, depression, blurred vision adrenergic receptors essential tremor Calcium channel Procardia, Reduce calcium entry HTN, angina, Dizziness, HA, blocker Cardizem, reducing contractility arrhythmia, CHF hypotension, peripheral Norvasc and O2 demands to edema the heart CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 27  PHARMACOLOGICAL MANAGEMENT Class Examples Action Indication Side Effects Diuretics Thiazide - Increase sodium HTN, edema due Dehydration, hypotension, diuril, Loop – excretion to reduce to CHF or polyuria, electrolyte Lasix, plasma volume to pulmonary imbalance Potassium reduce BP edema, sparing - glaucoma dyrenium Nitrates Nitrostat, Smooth muscle Angina HA, dizzy, ortho-hypo, nitroglycerin relaxation and reflex tachycardia, isordil peripheral vessel dilation Positive Digoxin, Increase force and Heart failure, A- Arrhythmia, GI distress, Inotropic Lanoxin velocity of fib dizziness, blurred vision contraction, slow HR, decrease conduction velocity Thrombolytic Urokinase, Convert plasmogen to Acute MI, PE, Hemorrhage, allergic activase, linlytic plasmin to breakdown ischemia CVA, reaction, arrhythmia, clots venous thrombosis Drug Management for COPD Drug Trade Action Side Effects Name Anticholinergic Atrovent Bronchodilator Throat Irritation, drying of tracheal secretions, tachycardia, palpitations Long-acting Serevent Bronchodilator Tachycardia, palpitations, GI distress, Beta2 agonist nervousness, tremor, headache, dizziness Steroids Flovent Reduces the Increase blood pressure, sodium retention, Prednisone Inflammatory muscle wasting, osteoporosis, GI irritation, Maintenance Response atherosclerosis, hypercholesterolemia, increased susceptibility to infection Cromolyn Intal Prevents the Throat irritation, cough, bronchospasm Sodium inflammatory response Leukotriene Singulair Blocks allergic GI distress, sore throat, upper respiratory receptor reaction tract infection, dizziness, headaches, nasal antagonist (blocking congestion leukotriene’s) Short-acting Albuterol Bronchodilator Tachycardia, palpitations, GI distress, Rescue Beta2 agonist Ventolin nervousness, tremor, headache, dizziness CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 28  CARDIOVASCULAR INTERVENTIONS: TYPES, APPLICATIONS, RESPONSES & POTENTIAL COMPLICATIONS Cardiovascular Interventions: Types, Applications, Responses & Potential Complications Disease Specific Interventions and Considerations Disease PT Intervention Affects A&P of Individual Complications Chronic Supervised exercise Walking program; helps open Rise in diastolic BP > 110 Arterial training 30-45 min, alternative small vessels mmHg Insufficiency 3x/week, at least 12 Minimal increase in collateral Decrease in systolic BP > 10 (PAD) weeks; needed to build up flow mmHg tolerance Improved nitric oxide- Significant ventricular or atrial Smoking cessation dependent vasodilation dysrhythmias Lipid-lowering Improve mitochondrial 2nd or 3rd degree heart blocks medications energetics Revascularization Decrease markers of systemic procedures inflammation No leg elevation Chronic Manage edema Rise in diastolic BP > 110mmHg Venous Elevate leg at least 18 cm Decrease in systolic BP > 10 Insufficiency above heart (avoid mmHg dependent positions) Significant ventricular or atrial Unna Boot (4-7 days) dysrhythmias Compression Therapy -- 2nd or 3rd degree heart blocks Exercise Ankle AROM (ankle pumps, circle) Cycling (seated) Ambulation (3-4x/day) Left CHF and Low level, low impact Decrease stress/load on heart Rise in diastolic BP > 110 Right CHF exercise Heart pumps more efficiently mmHg Anticoagulants, Increase endurance and Decrease in systolic BP > 10 antihypertensives, abilities/quality of life mmHg digitalis Significant ventricular or atrial Restricting sodium intake dysrhythmias Smoking cessation 2nd or 3rd degree heart blocks Limiting alcohol and Orthostatic hypotension fluids Dizziness Monitor at rest & during Hypotension activity Hyperkalemia Low level, gradually progressive aerobic training Capacities under 6 METs not candidates for resistance training Cardiac Rehab stages CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 29  CARDIOVASCULAR INTERVENTIONS: TYPES, APPLICATIONS, RESPONSES & POTENTIAL COMPLICATIONS Disease PT Intervention Affects A&P of Individual Complications Acute Smoking cessation Decrease stress/load on heart Rise in diastolic BP > 110mmHg Coronary Weight loss Heart pumps more efficiently Decrease in systolic BP > 10 Artery Heart-healthy diet Increase endurance and mmHg Syndrome Regular exercise abilities/quality of life Significant ventricular or atrial Antiplatelet agents, ACE dysrhythmias inhibitors, angiotensin II 2nd or 3rd degree heart blocks receptor blockers, statins Statins can cause liver Percutaneous damage, rash/flushing, muscle angioplasty, coronary cramps artery bypass graft surgery considered for high risk patients Myocardial Smoking cessation Decrease stress/load on heart Rise in diastolic BP > 110mmHg Infarction Moderate exercise Heart pump more efficiently Decrease in systolic BP > 10 (“heart Healthy diet Increase endurance and mmHg attack”) Weight loss abilities/quality of life Significant ventricular or atrial Stress reduction dysrhythmias Decrease alcohol intake 2nd or 3rd degree heart blocks Exercise Throbbing headache Medications: beta Flushing blockers, calcium channel Dizziness blockers, ACE inhibitors, Orthostatic hypotension nitroglycerin Deep Vein Acute bed rest with leg Decrease pain Risk for osteoporosis with Thrombosis elevated Decrease swelling prolonged use of medications Exercise contraindicated during acute phase Ambulation with compression stockings when tenderness and swelling are gone Medications: Anti- coagulants Peripheral Interval training with Decrease pain Beta blocker may decrease Vascular frequent rests Decrease swelling time for claudication or make Disease Walking program Increase endurance symptoms worse moderate intensity Pentoxifylline, dipyridamole, Exercise to point of pain aspirin, and warfarin may improve time to claudication CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 30  CARDIOVASCULAR INTERVENTIONS: TYPES, APPLICATIONS, RESPONSES & POTENTIAL COMPLICATIONS Cardiac rehab Indications Contraindications Medically stable post MI Unstable angina Stable angina Resting systolic BP >200mmHg Coronary artery bypass graft surgery (CABG) Resting diastolic BP>110mmHg Percutaneous transluminal coronary angioplasty Orthostatic BP drop of >20mmHg with symptoms (PTCA) Critical aortic stenosis Compensated congestive heart failure Acute systemic illness or fever Cardiomyopathy Uncontrolled atrial or ventricular dysrhythmias Heart, or other organ transplantation Uncontrolled sinus tachycardia >120bpm Other cardiac surgery Uncompensated CHF Peripheral arterial disease High risk CV disease ineligible for surgery Sudden cardiac death syndrome At risk for coronary artery disease with diagnosis of DM, dyslipidemia, HTN, obesity End stage renal disease Allow to Initiate Cardiac Rehab If: Medical Doctor approval/order No chest discomfort (8 hours) No new signs of decompensated heart failure No abnormal EKG changes (8 hours) CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 31 CARDIOVASCULAR INTERVENTIONS: TYPES, APPLICATIONS, RESPONSES & POTENTIAL COMPLICATIONS Phases Phase I: Patient requires 24-hour monitoring in the ICU or CCU. Patients in this phase require monitoring at rest and during activity through telemetry or wall mounted ECG. Activities focus on strength with active and active assistive exercises starting with the lower extremities and progressing to the upper extremities. Few repetitions are used with frequent rest breaks. Use a low target 60%-75% of maximal effort. Activities such as transfer training and short distance ambulation are also acceptable forms of exercise for this phase. Initial activities are low intensity in bed (1-2 METs) by having patient sit up in bed and then progressing to ≥ 5 METs by discharge. Post-MI: limited to 70% max HR and/or 5 METs until 6 weeks post-MI. Lifting activities are restricted for 6 weeks. Goals: minimal assistance levels with ADLs. Goal should be for the patient to return home (homebound) with assistance. Ideally the patient should be able to tolerate a stress level of 2.5-3 METs. Patients need to be stable at rest to be released to phase II. Phase II: The patient is home in homebound status or in a subacute unit. Length of this phase is typically 4-6 weeks to allow the muscle of the myocardium to heal. Exercise testing prior to starting program (submaximal treadmill testing). Cardiac monitoring during exercise, not at rest. Vital signs are most often used to monitor, but a pulse oximeter fix now in use as well. Exercise of both lower and upper extremities with a concentration on strength. Patient should be ambulating at least 200 ft. by the end of this phase. CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 32 CARDIOVASCULAR INTERVENTIONS: TYPES, APPLICATIONS, RESPONSES & POTENTIAL COMPLICATIONS Goals: The patient should be able to tolerate 5-6 Mets by the end of this phase. This will allow the patient to enter the community, get to outpatient cardiac rehab. This is the same level that is needed for sedentary work, such as an office job. Phase III: Outpatient cardiac rehab facility. During exercise patient is closely monitored by a professional. Telemetry is commonly used. Monitoring is done prior to exercise, during exercise and after exercise to determine recovery time. Exercise 5 times/week including activities that challenge both upper/lower extremities to achieve higher workload levels (elliptical). Educate patient to monitor their own vitals. Goals: The myocardium should be completely healed by this point. Goals should focus on endurance to enhance patient's quality of life. The patient should tolerate their expected maximal HR and be able to return to work. This phase is terminated with a patient can reliably monitor their own vital signs and demonstrate that they can increase workloads to an appropriate stress level and recognize when they are exceeding a targeted training level. Phase IV: Patient is able to monitor themselves during exercise and at rest, no professional monitoring is needed. Patients exercise at health club. Patients can come in and use equipment or attend program at YMCA. Activities focus on aerobic activities that are integrated into patient's lifestyle. CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 33  CARDIOVASCULAR INTERVENTIONS: TYPES, APPLICATIONS, RESPONSES & POTENTIAL COMPLICATIONS When a patient participates in the activities their heart rate should be within a training level for at least 20 minutes. Goals: maintain (3 times/week) or improve (5 times/week) cardiac muscle function. Improvement may be needed if a patient cannot tolerate a workload, or stress level that is required by either a job or recreational activity that they need to or want to participate. Setting Duration Initial D/C HR Exercise Duration MET MET Phase I Inpatient 3-5 days 2-3 3-5 10-20bpm 3-5 minutes initially above resting progressing to 15 HR minutes, 2-3 x day Phase II Subacute or 2-12 weeks 5 9 HR intensity 30-60 minutes, 3-4 x outpatient 60-80% week Phase III outpatient 6-12 months 5 9+ HR intensity 45 minutes + 50-85% 3-4 x week Phase IV Maintenance/home lifetime >9 3x or more/week Types of exercise Post MI or Cardiac Surgery Minimum 5 weeks after insult or surgery and 4 weeks of consistent participation in a supervised CR endurance training program Post-trans catheter procedure (PTCA) o Minimum of 3 weeks following procedure and 2 weeks of consistent participation in a supervised CR endurance training program Exercise Prescription Low resistance o One set of 10-15 reps Resistance can include o Weights 50% or more of maximum weigh used to complete one rep CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 34 CARDIOVASCULAR INTERVENTIONS: TYPES, APPLICATIONS, RESPONSES & POTENTIAL COMPLICATIONS o Elastic bands o Light 1 to 5 LB cuff and hand weights o Wall pulleys RPE-Borg Scale o Range from 11 to 13 (light to somewhat hard) Congestive Heart Failure Classes of Chronic Heart Failure Class I No limitation to normal activity up to 6.5 METS Class II Slight limitation to ordinary activity up to 4.5 METS Class III Marked limitation to < ordinary activity up to 3.0 METS Class IV Severe, unable to carry out any activity up to 1.5 METS (angina present) Monitor at rest and during activity o Use RPE o Clinical signs of exertional intolerance o HR response may be impaired  HR limited to resting HR + 10-20 bpm  Exercise HR > 115 bpm generally contraindicated Use low level, gradually progressive aerobic training o Intensities  40%-60% VO2 max o Interval training Use caution exercising in supine or prone o Due to orthopnea AVOID breath holding and Valsalva’s maneuver Pt’s with CHF with capacities under 6 METs not candidates for resistance training Cardiac transplant Heart rate alone not an appropriate measure of exercise intensity o Use CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 35 CARDIOVASCULAR INTERVENTIONS: TYPES, APPLICATIONS, RESPONSES & POTENTIAL COMPLICATIONS  RPE  METs  Dyspnea scale Use longer periods of warm up and cool down Heart is denervated and patients tend to be tachycardic Pacemakers and automatic implantable cardioverter defibrillators (AICDs) Fixed rate pacer: Heart rate will not change—impacts activity tolerance ST segment changes may be common AVOID UE aerobic or strengthening exercises initially after implant Percutaneous transluminal coronary angioplasty (PTCA) Exercise prescription o Wait 2 weeks to exercise Coronary artery bypass grafting (CABG) Limit UE exercise while sternal incision is healing AVOID lifting, pushing, pulling for 4-6 weeks post-surgery Arterial Disease Exercise training for PVD o Interval training with frequent rests o Walking program  Mod intensity 40%-70% VO2 max  Duration 2-3 times/day, 3-7 days/week o Exercise to point of pain o NWB exercise  Cycle ergometry CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 36 CARDIOVASCULAR INTERVENTIONS: TYPES, APPLICATIONS, RESPONSES & POTENTIAL COMPLICATIONS  Arm ergometry o Well-fitting shoes with insensitive feet  Proper foot inspection and care o Beta blockers may decrease time to claudication or worsen symptoms LE exercise o Modified Buerger-Allen exercises  Postural exercises plus active PF and DF of the ankle o Resistive calf exercises Venous Disease Management of edema o Positioning  Elevate extremities  AVOID dependent position o Compression therapy  Bandages  Paste bandages (Unna boot) Gauze impregnated with zinc oxide, gelatin and glycerin applied for 4-7 days  Graduated compression stockings (Jobst)  Compression pump therapy Used for 1-2-hour session twice daily o DO NOT APPLY compression therapy to a limb with an ABI < 0.8 or with evidence of active cellulitis or infection Exercise o Active ankle exercises  Muscle pump exercises CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 37 CARDIOVASCULAR INTERVENTIONS: TYPES, APPLICATIONS, RESPONSES & POTENTIAL COMPLICATIONS DF/PF Foot circles o Cycle ergometry o Early ambulation as soon as patient able to get out of bed Sternal precautions No pulling up in bed during acute care o Pt must roll into side-lying and use the top arm to assist in pushing up while allowing the feet to drop off the side of the bed as a pendulum Hand held assistance may be required initially in place of AD’s No pushing, pulling or lifting more than 10 LB for 6 weeks postop o Some precautions list 5 LB No driving motorized vehicles for 4 weeks postop Full neck, shoulder and torso ROM may be permitted as long as sternum is stable but not if a sternectomy with skin or muscle flap is present o Presence of a flap limits ROM to 90* flexion or abduction Avoid shoulder horizontal abduction with extreme ER Progression is based on client tolerance and signs of wound healing Use of more conservative precautions is advised with pts with diabetes mellitus, severe osteoporosis, or other equally compromising morbidities CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 38  CARDIOVASCULAR INTERVENTIONS: TYPES, APPLICATIONS, RESPONSES & POTENTIAL COMPLICATIONS System monitoring (including Borg RPE) Borg RPE Approximate %MHR Revised RPE 6 nothing 7 (very, very light) Very Very weak 8 Very weak 9 (very light) Weak 10 (60-70% MHR) Moderate 11 (Fairly Light) Somewhat Strong 12 Strong 13 (Somewhat hard) 14 (70-80% MHR) Very Strong 15 (Hard) 16 (80-90% MHR) 17 (Very Hard) Very, Very Strong 18 (90-100% MHR) 19 (Very, Very, Hard) -- 20 -- Complications Adverse Responses to Inpatient Exercise Leading to Exercise Termination Rise in diastolic BP >/=110mmHg Decrease in systolic BP >10mmHg Significant ventricular or atrial dysrhythmias Second or third-degree heart block Signs and symptoms of exercise intolerance o Angina o Marked dyspnea o ECG changes suggestive of ischemia CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 39  ANATOMY & PHYSIOLOGY OF THE PULMONARY SYSTEM Anatomy & Physiology of the Pulmonary System Lung anatomy and topology Mediastinum: compartment of the thoracic cavity that contains the heart and vessels, esophagus, phrenic and cardiac nerves, trachea, etc. It is located behind the lungs. Pleural cavity: the fluid-filled space between the visceral and parietal pleurae of each lung. Apex: highest point on the lung, about 1 inch above the middle third of each clavicle Base: concave and resting on the convex surface of the diaphragm Bronchioles: branches of the bronchi, the smallest passageways in which air travels to the alveoli. Control the amount of air in the lungs by constricting or dilating Alveoli: air sacs, in which the exchange of oxygen and carbon dioxide take place. These gases diffuse through the walls into the capillaries Lobes, fissures & segments Right Lung o Upper Lobe  Superior lobar bronchus Apical, Anterior, and Posterior segmental bronchi o Middle Lobe  Mid lobar bronchus CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 40  ANATOMY & PHYSIOLOGY OF THE PULMONARY SYSTEM Lateral and medial segmental bronchi o Lower Lobe  Inferior lobar bronchus Superior, Anterior basal, medial basal, lateral basal, post basal segmental bronchi Left Lung Anterior border of left lung: cardiac notch o Upper Lobe  apical posterior segment Apical, posterior, ant segmental bronchi  Ant segment superior and inferior lingular segmental bronchi o Lower Lobe  anteromedial segment Ant and medial basal segmental bronchi  Posterior Segment lateral and posterior basal segmental bronchi For a more comprehensive review, click here CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 41  ANATOMY & PHYSIOLOGY OF THE PULMONARY SYSTEM Musculature and Regions Thorax Covers and protects major organs of cardiopulmonary system Conical at both superior and inferior aspects Boundaries are the 12 thoracic vertebrae dorsally, the ribs laterally, and sternum anteriorly Sternum Breast bone: manubrium, body and xiphoid process Sternal angle “angle of Louie”: anterior angle formed by junction of manubrium and body of sternum Easily palpable; in level with 2nd costal cartilage anteriorly and thoracic vertebrae T4 – T5 posteriorly Marks bifurcation of the trachea into right and left main stem bronchi Pectus excavatum: congenital deformity of the anterior wall of the chest, in which several ribs and sternum grow abnormally Ribs Curve forward and downward from their posterior vertebral attachment toward their costal cartilages First 7 ribs: attach via their costal cartilage to the sternum; “true ribs” (vertebrosternal) Lower 5 ribs “false ribs”: Ribs 8, 9 & 10: attach to the rib above by their costal cartilages (vertebrocohondral ribs) Ribs 11 & 12: end freely “floating ribs” Muscles of ventilation External intercostals: slope obliquely between ribs, forward and downward; the attachment to the lower rib is farther forward from the axis of rotation, contraction raises the lower rib more than it depresses the upper rib Sternocleidomastoid Scalenes Serratus anterior Pectoralis minor Pectoralis major Latissimus dorsi CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 42  ANATOMY & PHYSIOLOGY OF THE PULMONARY SYSTEM Trapezius Erector spinae muscles Diaphragm o Major muscle of inspiration o Musculotendinous dome that forms floor of thorax and separates the thoracic and abdominal cavities o Innervation: Phrenic Nerve (C3 – C5) o Three major openings for various vessels to transverse the diaphragm  Inferior vena cava, esophageal opening and aortic opening o Resting position: arched high in thorax  In supine: the level of the diaphragm rises (no gravity)  In upright: dome of diaphragm is pulled down (due to gravity)  In side lying: uppermost side drops to a lower level and has less excursion than in a sitting position; the lowermost side rises higher and has a greater excursion o Quiet sitting: diaphragm normally moves 2/3 of an inch; with max ventilator effort, the diaphragm may move 2.5 – 4 inches o Patients with COPD:  Compromised ability to expire which results in flattening of the diaphragm because of the presence of hyper inflated lungs Muscles of Expiration Rectus abdominis, Transversus abdominis and Internal/external obliques Upper and Lower Respiratory Tract Upper respiratory tract Nose: Primary functions of nasal cavity are air conduction, filtration, humidification, and temperature control; also plays a role in olfactory process Pharynx: musculomembranous tube ~ 5-6 inches long; located posterior to nasal cavity; extends from base of skill to the esophagus. There are three parts: nasopharynx, oropharynx, laryngopharynx Nasopharynx: continuation of nasal cavity Oropharynx: extends from soft palate and pharyngeal isthmus superiorly to upper border of epiglottis inferiorly CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 43  ANATOMY & PHYSIOLOGY OF THE PULMONARY SYSTEM Laryngopharynx: extends from upper border of epiglottis to inferior border of cricoid cartilage and the esophagus Larynx: “voice box”, made up of several cartilages and forms a connection between the pharynx and the trachea. Controls airflow and closes to increase intrathoracic pressure to generate an effective cough Two sets of laryngeal muscles play roles in swallowing, ventilation and vocalization Lower respiratory tract Extends from level of true vocal cords in the larynx to the alveoli within the lungs Physiology of gas exchange O2 and CO2 diffuse in opposite directions across the alveolar-capillary septum into red blood cells where it combines with hemoglobin for transport For a more comprehensive review, click here Respiratory Rates Infant: 30-45 Child: 20-35 Adult (10 yrs. and older): 12-20 Bradypnea: < 12 breaths/min Tachypnea: > 20 breaths/min Eupnea: Normal Hyperpnea: Increased rate and depth of breathing Hypopnea: Decreased rate and depth of breathing CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 44  ANATOMY & PHYSIOLOGY OF THE PULMONARY SYSTEM For a more comprehensive review, click here Auscultation (normal) Vesicular: Heard over the lungs. Soft rustling heard throughout all of inspiration and the beginning of expiration. Is normal, unlabored breathing Normal Vocal Sounds: Loudest near trachea & main stem bronchi. Words should be intelligible, softer, and less clear at the more distal areas of lung Bronchovesicular: Heard over 1st and 2nd intercostal spaces and the interscapular region Bronchial: Hallow, echoing. Normally found only over the right superior anterior thorax through right main stem bronchus. All inspiration and expiration. Normally heard over the manubrium Tracheal: Heard right over the trachea For a more comprehensive review, click here CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 45  ANATOMY & PHYSIOLOGY OF THE PULMONARY SYSTEM Pulmonary Tests & Measures Abnormal blood-gas values Abnormal Values pH 7.45: Alkalemia PaCO2 >45mmHG: Hypercapnia w/ pH < 7.4: Respiratory Acidosis < 35mmHg: Hypocapnia w/pH > 7.4: Respiratory Alkalosis PaO2 60-79 mmHg: Mild Hypoxemia 40-59 mmHg: Moderate Hypoxemia < 40 mmHg: Severe Hypoxemia HCO3 < 22 mEq/L w/ pH < 7.4: Metabolic Acidosis >26 mEq/L w/ pH > 7.4: Metabolic Alkalosis For a more comprehensive review, click here FEV₁, FEV, IRV, TV, ERV, RV, VC, TLC, FEV1/FVC, etc. Spirometry: Measures the capacity of the lungs Tidal volume (TV): Volume of gas inhaled (or exhaled) during a normal resting breath (10% of TLC) Inspiratory Reserve Volume (IRV): Volume of gas that can be inhaled beyond a normal resting tidal inhalation. Makes up 50% of total lung volume Expiratory Reserve Volume (ERV): Volume of gas that can be exhaled beyond a normal resting tidal exhalation, if forced. Makes up 15% of total lung volume Residual Volume: Volume of gas that remains in the lungs after ERV has been exhaled. Makes up 25% of total lung volume CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 46  ANATOMY & PHYSIOLOGY OF THE PULMONARY SYSTEM Inspiratory Capacity (IRV+TV): The amount of air that can be inhaled at the end of tidal expiration. Makes up 60% of total lung volume Vital Capacity (IRV+TV+ERV): The amount of air that is under volitional control; conventionally measured as forced expiratory vital capacity (FVC). Makes up 75% of total lung volume Functional Residual Capacity (ERV+RV): The amount of air that resides in the lungs after normal resting tidal exhalation Total Lung Capacity (IRV+TV+ERV+RV): The total amount of air that is contained w/in the thorax during a max inspiratory effort FEV1/FVC = forced expiratory volume in 1 s / forced vial capacity < 70% is the primary indicator of obstructive impairment o 100-70= mild obstruction o 60-70 = moderate obstruction o 50-60 = moderate-severe obstruction For a more comprehensive review, click here CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 47  ANATOMY & PHYSIOLOGY OF THE PULMONARY SYSTEM Auscultation (abnormal sounds) Breathing Pattern or Sound Description Apneustic Gasping inspiration followed by short expiration Biot’s Respiration (ataxia) An irregular pattern of deep and shallow breaths; fast deep breaths interspersed with abrupt pauses in breathing Cheyne-Stokes respiration Repeated cycle of deep breathing followed by shallow breaths or cessation of breathing Hyperventilation Abnormally prolonged and deep breathing Hypoventilation Reduction in the amount of air entering the pulmonary alveoli Kussmaul’s breathing Distressing dyspnea characterized by increased respiratory rate, increased depth of respiration, panting, and labored respiration typical or air hunger Lateral-costal breathing Chest becomes flattened anteriorly with excessive flaring of the lower ribs; minimal to no upper chest expansion or accessory muscle involvement with outward flaring of the lower rib cage Used to focus expansion in areas of the chest wall that have decreased expansion Paradoxical breathing All or part of the chest wall falls in during inspiration; may be abdominal expansion during exhalation; can lead to a flattened anterior chest wall or pectus excavatum Crackles Rales, rattling or bubbling sounds that occur owing to secretions in the air passages of the respiratory tract. Apparent in patients with CHF. Indicates atelectasis (alveoli deflated), fibrosis, pulmonary edema Sigh Is a deep inspiration followed by a prolonged, audible expiration. Occasional sighs are ok, but frequent sighs are abnormal Stertor Is a snoring sound owing to partial obstruction (e.g. secretions) in the upper airway (e.g. trachea, large bronchi) Egophony Abnormal transmission of vocal sounds, nasal or bleating sound. “E” sounds are transmitted to sound like “A”. Fluid filled areas of consolidation, cavitation lesions, or pleural effusions Stridor A shrill, harsh sound heard during inspiration in the presence of laryngeal obstruction Bronchophony Abnormal transmission of vocal sound, intense clear sound during auscultation even at lung bases. Heard through fluid filled areas of consolidation, cavitation lesions or pleural effusion. Whispered pectoriloquy Abnormal transmission of vocal sounds. Whispered sounds are heard clearly during auscultations. Heard through fluid filled areas of consolidation, cavitation lesions or pleural effusion Wheezing Breathing with a rasp or whistling sound from constriction of the throat, pharynx, trachea or bronchi. Can be heard on both inspiration and expiration. Symptom of asthma and CHF CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 48  ANATOMY & PHYSIOLOGY OF THE PULMONARY SYSTEM Signs and symptoms of pulmonary distress Noisy breathing: congested or wheezing in lower airway or is pitched indicates asthma. Stridor indicates the trachea is narrowing Using accessory muscles to breathe Purse lip breathing Dyspnea: difficulty breathing, always subjective Dyspnea on exertion: classic sign of anemia Paroxysmal nocturnal dyspnea: sign of heart failure Kussmaul Respirations: increased depth and rate indicates hyperpnea, and is compensatory breathing for metabolic acidosis Labored breathing: specifically during exhalation Cheyne-Strokes: alternating deep and shallow breathing with periods of apnea which indicates a neurologic or brainstem dysfunction Hypoventilation: respiratory rate of around of 8 (normal is around 12-20) Hyperventilation: respiratory rate of around 32 (normal is around 12-20) Cough (acute or chronic): can be productive or non-productive. If coughing up yellow, green, brown phlegm, this indicates an infection. If coughing up blood, this is a classic sign of tuberculosis Cyanosis: low SaO2, hypoxemia, desaturated hemoglobin Pain: from pleura, airways, chest wall muscles, cardiac muscles, musculoskeletal muscles Clubbing of nail beds: indicates chronic hypoxia CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 49  MOVEMENT ANALYSIS AS RELATED TO THE PULMONARY SYSTEM Movement Analysis as Related to the Pulmonary System Rib cage excursion (normal motion patterns for females/males) Rib Cage Excursion Ribs 2-4: pump handle. Breathe in and out, ribs move up and down. Supine for assessment Ribs 8-10: bucket handle. Flop up and down with inhaling/ exhaling. SL for assessment Ribs 11-12: hug and expand when breathe in and out Elastic recoil of lung parenchyma pulls the lungs and therefore, visceral pleura, parietal pleura and bony thorax into a position of exhalation (inward pull) Bony thorax pulls the thorax and parietal pleura, visceral pleura and lungs into position of inspiration (outward pull) RIBS: Upper ribs: pump handle, then move upward and forward (increase chest dimension in the anterior/ posterior direction) Lower ribs: bucket handle, then move upward and lateral (increase chest dimension in the transverse/ lateral direction) Muscular activity during abnormal/normal breathing Normal Breathing Inspiration Primary muscle used: diaphragm Diaphragm contracts (central tendon pulled downward); flattening the dome and results in a protrusion of abdominal wall. Normal resting tidal volume Expiration When resting: passive relaxation of inspiratory muscles and elastic recoil tendency of lung. Diaphragm returns to normal, high dome position CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 50  MOVEMENT ANALYSIS AS RELATED TO THE PULMONARY SYSTEM Abnormal Breathing Accessory muscles are used for more rapid and deeper inhalation/disease states. The upper two ribs are raised by scalenes and sternocleidomastoid. Rest of the ribs are raised by levator costarum and serratus. Fixing shoulder girdle, the trapezius, pectorals and serratus can become muscles of inspiration Muscles used: quick/full expiration desired for exercise or disease: QL, portions of intercostals, abdomen Without Abdominal Muscles (Ex. Spinal Cord Injury) Lower resting position of diaphragm, decreasing inspiratory reserve. More upright body means lowering the diaphragm and a lower inspiratory capacity More supine is a more advantageous position of diaphragm. Abdominal Binder: may help support abdominal viscera assisting in ventilation Positional effects on pulmonary perfusion and ease of breathing Gravity affects the distribution of ventilation and perfusion. Perfusion is gravity dependent; more pulmonary blood is found at the base of the lung in the upright position Ventilation: Static point of right end-expiratory pressure. The apical alveoli are fuller than those at the base. During inspiration, more air will be delivered to the less-filled alveoli at the bases, causing a greater change in 𝑉𝑉𝐸𝐸 at the bases. Upright Position Apices: gravity independent, with the lowest blood flow or Q (still more air than blood); high V/Q ratio (dead air space) Bases: gravity dependent and have the most Q (blood flow). 𝑉𝑉𝐸𝐸 is relatively high (more blood than air); relatively low V/Q ratio (shunt) CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 51  PULMONARY DISEASES & CONDITIONS: DEFINITION & PROGNOSIS Pulmonary Diseases & Conditions: Definition & Prognosis Condition Definition Diagnosis Prognosis Asthma Reversible obstructive lung Combination of genetic and Good; mortality rates have disease caused by increased environmental factors decreased because of reaction of the airways to improvement in various stimuli management Atelectasis The collapse of normally Primary cause of atelectasis is Depends on underlying expanded and aerated lung obstruction of the bronchus disease tissue at any structural level serving the affected area. involving all or part of the lung Bronchiectasis Dilated, inflamed, & easily May result from recurrent Good collapsible bronchi due to pneumonia, cystic fibrosis, destruction of the muscle and TB and decrease in elasticity Bronchitis Inflammation of the Caused by virus or bacteria Good if treated; better (acute) bronchi; lasts several days breathing in warm moist air, to weeks worse with cold damp air Bronchitis Inflammation of the Smoking is the most common Periods where symptoms (chronic) bronchi; lasts years cause worsen, and then get better; often, patients have COPD COPD A disease state Tobacco is a common cause; Usually gets progressively characterized by airflow most people with chronic worse, which ultimately limitation that is not fully bronchitis also have it results in death; it can be reversible worsened if the underlying cause is not addressed Cystic Fibrosis Disorder of ion transport in Inherited as an autosomal Median survival age is 32 the exocrine glands recessive trait yrs., with pulmonary failure affecting the hepatic, as a common cause of death digestive, male reproductive and respiratory systems Emphysema Pathologic accumulation of Part of COPD, with smoking Can't be cured, but air in tissues, particularly in as the primary cause treatment will slow the lungs progression Lofgren’s A group of symptoms Sarcoidosis Good Syndrome present at initial onset of sarcoidosis Pancoast Apical lung tumor at the It is a type of lung cancer Poor syndrome/ superior thoracic inlet tumor Pleural Fluid within the pleural Underlying cause is often left Depends on underlying effusion space ventricular failure and disease, and how well it is cirrhosis treated Pneumonia Inflammation affecting the Can be caused by Death more common with parenchyma of the lungs bacterial/viral/mycoplasmal older individuals; there are infection, inhalation of toxic many effective treatment or caustic chemicals, smoke, methods that improve dusts or gases, or aspiration survival rates, and prevent it of food, fluids or vomitus CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 52  PULMONARY DISEASES & CONDITIONS: DEFINITION & PROGNOSIS Condition Definition Diagnosis Prognosis Pneumothorax Entry of air into the pleural The lung collapse is caused by Small/spontaneous ones space with secondary lung a separation between the usually don't require collapse visceral/parietal pleurae when treatment and will resolve air enters the pleural cavity, themselves; not life- destroying the negative threatening unless it pressure of the pleural space develops into a tension pneumothorax Pulmonary Excessive fluid in the lungs Occurs when the pulmonary Considered a medical Edema that may accumulate in the vasculature fills with fluid that emergency; it is reversible interstitial tissue, in the air leaks into the alveolar spaces, with clinical management spaces or in both decreasing the space available for gas exchange Pulmonary The lodging of a blood clot Often is a result of deep vein Small emboli resolve Embolism in a pulmonary artery with thrombosis without serious morbidity, subsequent obstruction of but large or multiple emboli blood supply to the lung have poorer prognosis. parenchyma. Pulmonary Damage to alveoli cause Most common cause is The scarring is irreversible; Fibrosis stiffening of the lung due to idiopathic; in some cases, however, some treatment scarring of the lung tissue could be chronic exposure to can improve symptoms dust, asbestos, grain dust, temporarily and improve sugar cane, etc. quality of life Pulmonary Increased blood pressure in Vasoconstriction of blood With treatment, prognosis is Hypertension the lung vasculature vessels connected to the good lungs Sarcoidosis Inflammation of the body’s Granulomas (lumps) can form Many patients do not need organs, mostly the lungs in the lungs, lymph, and skin treatment Tuberculosis Airborne infectious disease Caused by bacillus Treatable with antibiotics, that typically attacks the Mycobacterium tuberculosis but some strains can lungs become resistant. Risk of reoccurrence increases with immunosuppression (such as AIDS) CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 53  PULMONARY DISEASES & CONDITIONS: DEFINITION & PROGNOSIS Obstructive vs. Restrictive Pulmonary Disease Obstructive Disease Restrictive Disease Definition Disease characterized by airflow limitation Restrictive disease due to alterations in lung that is not fully reversible parenchyma & pleura. Difficulty expanding lungs caused by a reduction in lung volumes Airflow limitation is usually both progressive & associated with abnormal inflammation Fibrotic changes within pulmonary response of lungs to noxious particles & gases parenchyma or pleura due to idiopathic pulmonary fibrosis, asbestos, radiation, oxygen toxicity Physical Cough/sputum production/ hemoptysis Dyspnea findings Hypoxemia/hypercapnia Hypoxemia/hypocapnia Dyspnea on exertion Crackles Breath sounds decreased with adventitious Clubbing sounds Cyanosis Increased respiratory rate Shallow rapid breathing Weight loss/anorexia Reduced cough effectiveness Low diaphragm position May present with alterations in chest wall, or Pursed lip breathing may present due to alteration in Decreased elastic recoil neuromuscular apparatus Cyanosis Clubbing Chest Hyperinflation Reduced lung volumes X-ray Flattened diaphragms Diffused interstitial infiltrates Findings Hyperlucency Pleural thickening Atelectasis (in alterations in chest wall) Pulmonary Decreased FEV & FVC Reduced Vital capacity Function Increased RV & FRC Reduced FRC and TLC Tests Decreased FEV1/FVC Lung Decreased vital capacity Decreased vital capacity, residual volume, and Volumes Increased residual volume & functional residual FRC capacity Examples Cystic Fibrosis Ankylosing spondylitis COPD Scoliosis Asthma Pectus excavatum Bronchiectasis Tuberculosis Bronchitis Pneumonia Respiratory distress syndrome Arthrogryposis Bronchopulmonary dysplasia Burns Emphysema Scleroderma Pleural Effusion Pneumothorax Pulmonary Edema and Hypertension MS MD SCI CVA CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 54  DIFFERENTIAL DIAGNOSIS OF THE PULMONARY SYSTEM Differential Diagnosis of the Pulmonary System Condition Features Asthma Wheezing, chest tightness, SOB, cyanosis Atelectasis Dyspnea, tachypnea, cyanosis, elevation of temp, drop in BP, substernal retractions, shock Bronchiectasis Obstructive disease, difficulty clearing secretions; SOB, sputum with or without color, hemoptysis, crackles, wheezes, loud breath sounds Bronchitis Expectorating cough, dyspnea, wheezing, chest pains, fever, fatigue (acute) Bronchitis Expectorating cough, dyspnea, wheezing, chest pains, fever, fatigue (chronic) COPD shortness of breath, cough, sputum production, barrel chest Cystic Fibrosis persistent cough/wheezing, sputum production, excessive appetite with poor weight gain, salty skin and sweat, bulky/foul smelling stools Emphysema Mostly shortness of breath, which begins gradually and worsens Lofgren’s Fever, arthritis, enlarged lymph nodes, rash Syndrome Pancoast Shoulder/arm pain along distribution of 8th cervical nerve trunk and 1st/2nd thoracic nerve syndrome/tumor trunks, weakness and atrophy of muscles of the hand, sensory loss/motor deficit in UE Pleural effusion May be asymptomatic; dyspnea on exertion, chest discomfort, sharp/stabbing chest pains made worse by coughing/breathing Pneumonia Follows an upper respiratory infection, sudden/sharp chest pains, hacking/productive cough, headache, fatigue, fever/chills, dyspnea, cyanosis, tachypnea, rust/green colored purulent sputum. Look below to review the differences between the different types. Pneumothorax Dyspnea, sudden/sharp pleural chest pain, fall in BP, weak/rapid pulse, normal respiratory functions on the affected side cease, pain localized to affect side Pulmonary Restlessness, anxiety, persistent cough, diaphoresis, slight dyspnea, problems w/ exercise, Edema increased respirations, Pulmonary Dyspnea, pleuritic chest pain, apprehension, persistent cough, hemoptysis, diaphoresis, Embolism tachypnea, fever Pulmonary Difficulty with inspiration, SOB, dry cough, unexplained weight loss, fatigue, aching Fibrosis muscles & joints Pulmonary Shortness of breath, fatigue, non-productive cough, angina, fainting, swelling of ankles Hypertension and feet Sarcoidosis No symptoms, wheezing, coughing, SOB, fatigue, night sweats Tuberculosis fever, chills, night sweats, loss of appetite, fatigue, weight loss, chest pain, persistent cough (sometimes blood) CHAPTER 1: CARDIOVASCULAR, PULMONARY & LYMPHATIC SYSTEMS Page 55  DIFFERENTIAL DIAGNOSIS OF THE PULMONARY SYSTEM Pneumonia Aspiration Bacterial Viral Walking pneumonia Foreign materials in Bacteria enters lung with Virus invades the cells From bacterial bronchial tree (food, inhalation lining the airways and microorganism called saliva, nasal alveoli mycoplasma pneumonia secretions) Incompetent Community or hospital Virus reaches lung by Spread through contact swallowing acquired traveling in droplets with droplets from nose mechanism through mouth and nose and throat of someone who with inhalation has it Generally, the right Bacteria live in upper Invade alveoli middle and lower lung respiratory tract lobes CVA, MS, Alzheimer’s Infants, adults >65, long More common in children; Common in older children disease, intoxication, term influenza and adults 3 days no obvious cause Pulmonary Medication for initial Prevents blood & nourishment Risk for osteoporosis (with Embolism treatment from getting to a