PT-622 Cardio-Pulm Final

Tidal Volume (TV)

Air inhaled/exhaled at rest w/ each breath

Normal: approx. 350-500 mL

Defibrillator

VT w/ a pulse

V-Fib

SVT = Urgent

VT = Emergency

V-Fib

Code Blue

Lingula location

Between 4th and 6th IC space

Arterial Doppler =

Ankle-Brachial Index (PAD)

4 factors of BNP

-LV Systolic dysfunction

-LV Diastolic dysfunction

-RV dysfunction

-Valvular dysfunction

S2 = Atria >>> Ventricle (SL valves closing)

S1 = Ventricle >>> Out (AV valves closing)

S2 = Ventricular filling

Longer than S1

Ventilatory rate / Respiratory rate

Breathes per minute at rest

Normal: 10-15 breaths

Expiratory reserve volume (ERV)

Additional volume of air that can be let out beyond the normal tidal exhalation

Inspiratory reserve volume (IRV)

Additional volume of air that can be taken into the lungs beyond normal tidal inhalation

Total lung capacity (TLC)

Maximum volume to which the lungs can be expanded

sum of all pulmonary volumes

Residual volume (RV)

Volume of air that remains in the lungs after forceful expiration

Inspiratory capacity (IC)

Maximum amount of air that can be inhaled after a normal tidal expiration

Sum of the TV + IRV

Functional residual capacity (FRC)

The amount of air remaining in the lungs at the end of a normal tidal exhalation

Sum of ERV + RV

Vital capacity (VC)

Maximum amount of air that can be exhaled following a maximum inhalation

Sum of IRV + TV + ERV

What effects ventilation and perfusion matching?

-

Lung capacities diagram

Pulmonary ventilation

movement of air into and out of the lungs

Pulmonary respiration

the exchange of oxygen and carbon dioxide between the alveoli and circulating blood in the pulmonary capillaries

Majority of oxygen is transported to peripheral tissue bound to hemoglobin within RBC's

Very small portion (2%) is dissolved in plasma within blood

Oxygen-carrying capacity

Concentration of hemoglobin

Normal:

12-16 (women)

13-18 (men)

What causes acidemia (pH < 7.4)

1) Low HCO3 produces metabolic acidosis

2) High CO2 produces respiratory acidosis

What causes alkalemia (pH > 7.4)

1) High HCO3 causes metabolic alkalosis

2) Low CO2 causes respiratory alkalosis

If a disease causes decreased HCO3 (metabolic) the body would respond by...

Decreasing the CO2 (respiratory) to return pH to normal

Preload

Volume of blood returning to the heart

or

Amount of stretch on the myocardial wall before contraction

Correlated w/ End-Diastolic Volume (EDV)

Directly proportional to Stroke Volume (SV)

End Diastolic Volume (EDV)

Maximum amount of blood that can be in the ventricles immediately before contraction

Contractility

Myocardial contractility is influenced by intrinsic and extrinsic factors

Intrinsic control of contraction strength is a result of the degree of myocardial stretch caused by changes in the EDV

The extrinsic control of contractility depends on the activity of the sympathoadrenal system

Epinephrine from the adrenal medulla and norepinephrine from the sympathetic nerve endings produce a positive ionotropic effect, or increase myocardial contractility,

Conversely, a reduction in sympathetic stimulation and reduction in heart rate results in reduced myocardial contractility.

Afterload

Pressure at which the heart has to overcome to pump blood into the aorta

Afterload is inversely proportional to Stroke Volume (SV)

Pulse classification

Blood pressure

Measurement of force exerted against the arterial walls during ventricular systole (SBP) and ventricular diastole (DBP)

ALWAYS CHECK FOR POSTED SIGNS FIRST!!

-May be contraindicated to take BP in upper extremity (lymphedema, neglect, dialysis access, PICC line, etc)

Use appropriate fitting cuff

Width=40%

Length=80%

Blood pressure procedure

1) Cuff should be 2.5 cm above antecubital space

2)Rest arm at level of the heart

3) Place bell of stethoscope over brachial artery

4) Inflate to 30-40 mmHg above SBP

5) Slowly deflate (rate of 2-3 mmHg per second)

6) Listen for onset of tapping sounds

-Systolic BP—blood starts to flow through artery

7) Listen of disappearance of tapping

-Diastolic BP—normal blood flow & no compression on artery

BP classification

Mean Arterial Pressure (MAP)

SBP + DBP + DBP

3

Average pressure during a single cardiac cycle

Tells us that perfusion is adequate to the end organs

MAP values

Blood oxygen levels Pulse Oximeter

85-90 during exercise = stop

Stethoscope diagram

Bell of stethoscope may be better for low-pitched sound (heart)

Diaphragm may be better for high-pitched sounds (lungs)

Auscultation—Heart

Aortic - Aortic valve heard during S2

Tricuspid - Tricuspid valve is heard during S1

Mitral - Mitral valve is heard during S1

Pulmonary - Pulmonary valve is heard during S2

Aortic valve auscultation location

2nd intercostal space

Right sternal border

Pulmonary valve auscultation location

Second intercostal space

Left sternal border

Mitral valve auscultation location

Fifth intercostal space

Mid-clavicular line

Tricuspid valve auscultation location

Fifth intercostal space

Left sternal border

S1 >> S2 = Systole

S2 >> S1 = Diastole

Abnormal heart sounds occur during

Diastole

Just after S2 (S3)

or

Just before S1 (S4)

Mitral valve prolapse sounds

clicking noted in middle of ventricular systole

Extra heart sounds - S3

(lub-dub-dub)—ventricular filling; early in diastole

Considered normal in healthy children and young adults*

Extra heart sounds - S4

(la-lub-dub)—atrial contraction; late in diastole

“atrial gallop”—not normal; associated with increased resistance to ventricular filing

-Hypertension

-Ventricular hypertrophy

-Stenosis

Distension

Increased RA pressure

Heart murmurs

1) High rates of flow through normal or abnormal valves

2) Forward flow through a constricted (stenotic) or deformed valve; or by flow into a dilated vessel or chamber

3) Backward flow through a valve (regurgitation)

-Systolic most common, usually heard between S1 and S2

-Diastolic are rare and usually heard immediately following S2

-Mitral valve prolapse—clicking sound noted in the middle of ventricular systole

ANTERIOR LUNG LANDMARKS

SUPERIOR LOBE—above first rib/clavicle to rib 4 (right)

-above first rib/clavicle to rib 6 (left side)

MIDDLE LOBE—from base of rib 4 - 6 (right side only)

LOWER LOBE—laterally from rib 6 - 8

POSTERIOR LUNG LANDMARKS

SUPERIOR LOBE—T1-T4 vertebral bodies

MIDDLE LOBE—not present posteriorly

LOWER LOBE—T4-T10 (with inhalation, can extend to T12)

Anterior auscultations

Posterior auscultations

Normal breath sounds - Bronchial

Loud, high pitched

hollow quality

Expiration > Inspiration

distinct pause between in/out

Normal breath sounds - Bronchovesicular

I:E = 1:1

Intercostal space #1 & #2

Normal breath sounds - Vesicular

Soft

low pitched

no pause between in/out

Inspiration > Expiration

Normal breath sounds - Tracheal

Similar to bronchial, but louder

pause between in/out

Crackles

movement of secretions during inspiration (if wet);

sudden closing of airways—atelectasis/fibrosis/pulm edema/pleural effusion (dry)—

usually lung bases.

I > E

Restrictive & Obstructive

"pop"

Pulmonary friction rub

inflamed visceral and parietal pleurae rub together—usually over site of pain

Both I & E

"crackling"

Rhonchi

air passing through an obstructed airway

Both I & E

Obstructive

Bronchi/Bronchioles

"Gurgling"

Stridor

Upper airway obstruction

Both I & E

Obstructive

Severe asthma attack

"wheeze"

Wheeze

Variable may be heard one breath and not another,

vibrations of the walls of small airways d/t bronchospasm,

airway collapse of foreign object

Obstructive

typical asthma attack

"whistle"

Bronchophony

Pt says "99"

If you hear muffled noises = normal

If you hear "99" = abnormal

Egophony

Have pt say "E"

If you hear "A" sound = abnormal

Whispered pectoriloquy

Have pt whisper "1, 2, 3"

If you can hear "1, 2, 3" = abnormal

Percussion - Resonant

normal air-filled lung

Percussion - Hyper-resonant

overinflated but not hollow

Percussion - Tympanic

loud, long and hollow

Percussion - Dull or flat

increased density (“thud”)

Palpation—Tactile fremitus

Hands flat on thorax, or ulnar border of hands on thorax

Patient speaks quietly, 1-2-3, 99, etc.

Feel vibration of chest

Increased with consolidation, decreased with more air

CI's for taking BP on UE

Dialysis access

Lymphedema

Central lines

Neglect

-No sensation to sense pressure

Alternate BP locations

Must hear pulse before inflating cuff in foot

Decreased breathing sounds >>> Assess fremitus

Posture

Schamroth's sign

Inspiration:Expiration is 1:2

Respiratory Rate Norms: Newborns

33-45

Respiratory Rate Norms: 1 year

25-35

Respiratory Rate Norms: 10 years

15-20

Respiratory Rate Norms: Adult

12 -20

Hemoglobin molecule consists of 4 iron-containing hemes.

This allows hemoglobin to carry 4 O2 molecules to peripheral tissue

Deoxyhemoglobin = Released its O2

Oxyhemoglobin = Contains O2

Carboxyhemoglobin = Carbon monoxide instead of O2

Percent hemoglobin in systemic arteries = 97%

Gold standard to measure = analysis of arterial blood gases

Can also use pulse oximeter

Meaning that 97% of hemoglobin molecules in blood are bound to O2

Remaining 3% reflects deoxyhemoglobin, methemoglobin, carboxyhemoglobin

Secondary polycythemia

Increase in RBC's

Where can you auscultate heart murmurs?

3rd left IC space

Troponin

Leakage of the protein into the blood indicates damage to the heart muscle

Normal Troponin levels

Cardiac Troponin I (cTnI)— < 0.03 ng/mL

Cardiac Troponin T (cTnT)— < 0.1 ng/mL

high sensitivity Troponin T (hsTnT)—: women < 14 ng/L, men < 22 ng/L

Creatinine Kinase-MB

Commonly elevated in myocardial infarction within 3-6 hours of cardiac injury and then returns to normal within 2-3 days

(peaks 18-24 hours).

Useful for diagnosing re-infarction.

Might be elevated in cases of carbon monoxide poisoning, pulmonary embolism, hypothyroidism, crush injuries, and muscular dystrophy.

Brain Natriuretic Peptide (BNP)

Released in association with a stretch on the ventricular wall

>400 pg/mL is consistent with Heart Failure diagnosis

Helps determine severity of treatment and effectiveness of treatment

Has a precursor called NT-pro-BNP measured at some facilities

< 300 pg/mL is normal

Normal values for Brain Natriuretic Peptide (BNP)

Normal: < 300 pg/mL

Heart failure: > 400 pg/mL

BNP < 100 pg/mL

Indicates no heart failure.

100–300 pg/mL Class I

Cardiac disease, but no symptoms and no limitation in ordinary physical activity, e.g. no shortness of breath when walking, climbing stairs etc.

Symptoms-based approach when determining appropriateness for activity.

> 300 pg/mL Class II

Mild symptoms

slight limitation during ordinary activity.

> 600 pg/mL Class III

Marked limitation in activity due to symptoms, even during less-than-ordinary activity, e.g. walking short distances (20–100 m).

Comfortable only at rest.

> 900 pg/mL Class IV

Severe limitations.

Experiences symptoms even while at rest.

Cholesterol

main lipid associated with cardiovascular disease.

Desirable: 140-199

Borderline high: 240-239

High: >240

Triglycerides

Assesses the body’s ability to metabolize fat and cardiovascular disease risk

Desirable: < 150

Borderline high: 150-199

High: 200-499

Very high: > 500

Lipoproteins HDL

remove excess cholesterol deposits from the arterial lining.

Higher levels can reduce the incidence of cardiovascular disease