Cardiopulm Bootcamp

Which of the following is the MOST LIKELY treatment?

a. bicarbonate infusion to decrease metabolic acidosis

b. have the patient breath into a rebreathing mask to decrease respiratory alkalosis

c. fluid and saline infusion to decrease metabolic alkalosis

d. use of supplemental oxygen to decrease respiratory acidosis

d. use of supplemental oxygen to decrease respiratory acidosis

Which of the following exercises would be MOST LIKELY recommended for this patient?

a. inspiratory muscle training

b. pursed lip breathing exercises

c. segmental breathing exercises

d. incentive spirometry

b. pursed lip breathing exercises

the PT decided to use postural drainage for airway clearance. the PT positions the patient in a seated position leaning forward over a folded pillow. based on this position, which lobe is MOST LIKELY being drained?

a. posterior apical segments of upper lobe

b. anterior apical segments of upper lobes

c. superior segments of the lower lobes

d. anterior basal segments of lower lobes

a. posterior apical segments of upper lobe

Postural Drainage

bronchus of the involved lung segment is perpendicular to the ground using gravity, these positions assist the mucociliary transport system in removing excessive secretions from the tree

postural drainage indication

pulmonary complications

weak/elderly patients

atelectasis, pneumonia, COPD

maintain each position for 5-10 minutes

secretions cleared by coughing or suctioning

superior segment of lower lobe postural drainage

prone lying on a bed with two pillows under the pelvis

posterior apical segments of the upper lobes postural drainage

sitting on a chair, leaning forward over a folded pillow

anterior segments of upper lobes postural drainage

supine lying on a bed with pillows under the knees

anterior apical segments of the upper lobes postural drainage

sitting in a recliner leaning slightly backward

a clinician is educating the patient’s parents on postural drainage. the clinician places the patient in a position, as shown in the image below. Which of the following segments of the lungs is MOST LIKELY being drained?

a. right lateral basal segment

b. right middle lobe

c. left lingular segment

d. left lateral basal segment

d. left lateral basal segment

contraindications to postural drainage - precautions

pulmonary edema, hemoptysis, massive obesity, large pleural effusion, massive ascites

contraindications to postural drainage - relative contraindications

increased intracranial pressure, hemodynamically unstable, recent esophageal anastomosis, recent spinal fusion or injury, recent head trauma, diaphragmatic hernia

a patient with chronic congestive heart failure was recently admitted to the hopsital. Which of the following plans for prophylactic respiratory care is most likely to be contraindicated?

a. frequent turning and positioning ever 2 waking hours

b. gentle percussion 2 times per day

c. vigorous chest vibrations, with the foot of the bed elevated 4 times per day

d. gently coughing and deep breathing exercises every 4 hours

c. vigorous chest vibrations, with the foot of the bed elevated 4 times per day

Age Predicted Heart Rate

HR max = 220 - age

HR max = 207 - 0.7xage

Karvonen’s formula

heart rate reserve multiplied by the percentage of intensity plus resting heart rate

HR Reserve = HR max - HR Rest

an older adult presents with limited endurance but has no history of cardiopulmonary disease. An exercise tolerance test is negative for coronary artery disease. Which of the following is MOST APPROPRIATE initial aerobic exercise intensity for this individual

a. 90-100% HR max

b. 60-70% HR max

c. 40-50% HR max

d. 30-40% HR max

b. 60-70% HR max

a clinican is supervising a patient with a history of cardiovascular disease during an exercise session.

Baseline vitals: HR = 72 bpm, SpO2= 98%, BP 116/78 mmHg

Which of the following findings would be considered MOST LIKELY to require termination of exercise?

a. systolic BP increases to 160 mmHg

b. diastolic BP drops to 74 mmHg

c. HR drops to 60 bpm

d. HR increases to 110 bpm

c. HR drops to 60 bpm

Exercise Hypertension

SBP >240 mmHg

DBP >110 mmHg or until controlled

systolic hypotension

>10 mmHg drop of SBP is CAUTION

>20 mmHg drop fo SBP is STOP

unusual heart response

too rapid increase in HR

failure to increase in HR

decrease in HR with increased exercise intensity/duration

exercise termination symptom criteria

significant anginal response

severe leg claudication

undue dyspnea

excessive fatigue

dizziness

exercise termination criteria signs

pallor

cold sweats

ataxia

new murmur

pulmonary rales

onset of significant third heart sound

ECG abnormalities exercise termination

second or third degree heart block

onset of right or left bundle branch block

acute ST changes

Cardiac Rehab Acute Phase

monitoring phase

begins when patient is medically stable

cardiac rehab acute phase: exercise prescription

patient education

hemodynamic and ECG monitoring

Cardiac Rehab Subacute Phase

conditioning phase

begins as early as 24 hours after discharge up to 6 weeks

Cardiac Rehab Subacute Phase : exercise prescription

50-70% HR max

Cardiac Rehab Training Phase (Phase III)

intensive rehab

~5-6 from discharge extends indefinitely

Cardiac Rehab Training Phase exercise prescription

70-85% of HRmax

resistance training begins

Cardiac Rehab Conditioning Phase (Phase IV)

maintenance or prevention

lasts up to 6-12 months

exercise prescription same as phase III

Phase I and II FITT

no resistance training

F - short sesions, 2-3 times a day

I - 50-70% HR max

T - 10-15 minutes (phase I), 30 minutes (phase II) per session

T - ADLs, supervised ambulation

patients commonly undergo a symptom limited maximal stress test at 4-6 weeks post MI

a patient is undergoing cardiac rehabilitation post complicated myocardial infarction in the hospital. on day 2, the clinician wants to progress the patient to sitting. Which of the following is an APPROPRIATE INITIAL task for this patient?

a. make the patient stand and do weight bearing activities

b. make the patient sit on the upright chair during visitor time

c. make the patient sit on reclining chair and check vitals

d. patient is not ready for upright posture yet

c. make the patient sit on reclining chair and check vitals

Phase III FITT

F - 2-3 sessions/week

I - 70-85% of the peack achieved on the test (HR max)

T - 30-60 minutes with 5-10 min of warm up and cool down

T - single mode of training (walking) or multiple modes (treadmill, cycle, ergometer)

Strength Training Phase III Guidelines

begin with the use of elastic bands and light hand weights (1-3 pounts) or 30-50% of max weight used to complete 1RM

begin with 8-10 reps, progress to 12-15 reps

avoid upper extremity resistance as soft tissue is healing

a patient with uncomplicated myocardial infarction has been discharged from acute care. Which of the following activities would be MOST APPROPRIATE during early phaes 2 rehab?

a. 30 minutes walking at 3 mph with no incline

b. 15 minutes of elastic band training with yellow elastic bands

c. 15 minutes upper limb workout with 2lb hand weights

d. 30 minutes walking at 5 mph with 5% incline

a. 30 minutes walking at 3 mph with no incline

Phase IV

location: community centers, YMCA, clinical facilities

exercise: clinically stable angina, medically controlled arrhythmias during exercise

progression: 50-85% of functional capacity, 3-4/week, 45 minutes or more/session

discharge: typically, 6-12 months

Cardiac Rehab Educational Component

disease process and prognosis

individual’s risk factors and recommendations for behavior modification

general activity guidelines: role of exercise, activity pacing, HEP

medications

nutrition and prescribed diet

self monitoring techniques

what to do in an emergency

a patient with a BMI of 31 kg/m has been walking 3 days/weel for 20 minutes, for the past 3 weeks. Which of the follwoing modifications is MOST APPROPRIATE to achieve the goal of weight loss?

a. walk 6 days/week at current walking speed and increase the duration to 45 minutes

b. increase the walking speed and keep duration at 20 minutes

c. walk 5 days/week and decrease duration to 10 minutes

d. decrease the walking speed and increase the duration at 25 minutes

a. walk 6 days/week at current walking speed and increase the duration to 45 minutes

Weight Reduction Guidelines for Obesity

minimum: 250-300 min/week required

frequency: greater than 5 days/week to maximize caloric expenditure

intensity: initially moderate - 40-60% VO2, progression to >60%

time: 45-60 min/day

type: moderate exercise - aerobic, resistance, and flexibility

Sinoatrial Node

pacemaker

initiates depolarization

atrioventricular node

passess depolarization to ventricles

brief delay to allow for ventricular filling

bundle branches

to left and right ventricle

purkinje fibers

throughout ventricles

electrocardiogram

records the electrical activity of the heart

P wave (ECG)

atrial depolarization

QRS complex (ECG)

ventricular depolarization and atrial repolarization

T wave (ECG)

ventricular repolarization

A PT examines the output from a single lead ECG of a patient in an inpatient clinic. the 6 second ECG strip is shown in picture below. What should the PT determine the heart rate of the patient as?

a. 110 bpm

b. 70 bpm

c. 90 bpm

d. 60 bpm

c. 90 bpm

AV Block: 1st degree heart block

delay in conduction

AV Block: 2nd degree

partially blocked conduction

AV Block: 3rd degree

fully blocked conduction

1st degree AV nodal disease

PR interval > 0.2 seconds

each P is followed by a QRS

seen also in athletes, with increased vagal tone (activity)

generally won’t progress benign condition

2nd degree block

Mobitz or Wenckebach

dropped QRS

increased time between P and QRS start - increasing PR interval before the QRS is dropped, cycle repeated

pattern can be discerned

disease of the AV node

2nd degree block type 2

Mobitz type II

PR intervals constant and QRS dropped intermittently

no discerned pattern

disease of the bundles of his and purkinje fibers

3rd degree AV block

the atrial rate is independent of the ventricular rate (P wave and QRS march out separately)

no relationship at all, of the PR intervals

the PR interval is constantly changing and the QRS is usually wide and bizarre because it is ventricular origin

While walking on a treadmill the PT sees the ECG pattern, as shown. What is the MOST APPROPRIATE diagnosis?

a. first degree heart block

b. Mobitz type I heart block

c. Mobitz type II heart block

d. third degree heart block

a. first degree heart block

Based on the diagnosis condition what would be the MOST APPROPRIATE response by the phyiscal therapist?

a. stop the treadmill session immediately and contact the cardiologist

b. continue exercising at the current intensity without any modifications

c. lower the exercise intensity and monitor patient closely

d. have the patient rest, then reassess before resuming exericse

b. continue exercising at the current intensity without any modifications

the patient did not come for PT for 3 consecutive visits. On following up with the patient’s caretake they mentioned thart the patient was taken to the ER as they were experiencing increased SOB at rest and cough with no evident peripheral edema. Which of the fllowing is MOST LIKELY cuasing the patient’s symptoms?

a. biventricular heart failure

b. right sided heart failure

c. cor pulmonale

d. left sided heart failure

d. left sided heart failure

myocardial ischemia

decreased blood supply

ST segment depression

T wave flattened or inverted

myocardial infarction

complete occlusion of blood supply and cell death

ST segment elevation

A patient is walking on a treadmill with ECG leads attached. The PT observes the ECG as shown in the image below. What is the MOST LIKELY diagnosis and intervention?

a. myocardial ischemia that has an elevation of the ST segment greater than 1 mm and the PT should stop the protocol

b. myocardial infarction that has an elevation of the ST segment less than 1 mm and the PT should stop the protocol and call 911

c. myocardial ischemia that has an elevation of the ST segment less than 1 mm and the PT should stop the protocol

d. myocardial infarction that has an elevation of the ST segment greater than 1 mm and the PT should stop the protocol and call 911

d. myocardial infarction that has an elevation of the ST segment greater than 1 mm and the PT should stop the protocol and call 911

atrial tachycardia rate

100-250 bpm

atrial flutter rate

250-350 bpm

atrial fibrillation rate

400-600

a physical therapist is ambulating a patient and they report palpitations, SOB and fatigue. What should be the interpretation and immediate action according on the ECG strip shown below?

a. ventricular fibrillation, call for a defibrillator

b. premature ventricular contractions; take them to their bed and monitor for changes in ECG

c. atrial fibrillation; stop exercise and report the physician

d. 3rd degree heart block; activate emergency

c. atrial fibrillation; stop exercise and report the physician

while exercising a patient on the treadmill, the PT notices the ECG as shown in the image. What should their INITIAL response be?

a. continue walking at same intensity

b. continue walking at lower intensity

c. stop the treatment and monitor ECG for 10 minutes

d. activate the emergency system or call 911

d. activate the emergency system or call 911

premature ventricular contraction

heartbeat initiated by purkinje fibers; skipped beat or palpitations

ventricles contract before the atria, cannot be filled optimally

no P, wide bizarre QRS

PVCs that occur 3 or more in a row - ventricular tachycardia

bigeminy

1 normal beat followed by 1 PVC

trigeminy

2 normal beats followed by 1 PVC

multifocal PVC

more than 1 PVC is present and 2 do not appear similar in configuration

STOP exercise and immediately refer (call 911)

couplet

2 consecutive PVCs together with no normal beat between them

stop exercise

if 2 or more couplets, immediately refer (call 911)

Ventricular Tachycardia

3 or more PVC in row

stop and call 911

physical therapist is working with a patient who is 4 months post myocardial infarction, in a cardiac rehab facility. Upon increasing the workload, the PT observes a unifocal PVC on patients ECG. which of the following is the MOST APPROPRIATE action by the PT?

a. continue to exercise and increase intensity

b. stop exercise because patient is undergoing ischemia

c. keep exercising at lower intensity; consultation with physician is not required here

d. stop exercise and consult with phyisican before starting any exercise

c. keep exercising at lower intensity; consultation with physician is not required here

a clinician is auscultating a patients lungs. During auscultation the clinician hear low pitched gurgling and snoring sounds. Which of the following sounds is the clinician MOST LIKELY hearing?

a. vesicular

b. wheezes

c. bronchial

d. rhonchi

d. rhonchi

a patient with dyspnea on exertion and has an FEV1/FVC ratio of 65%. They report chest tightness and frequent coughing. Which lung volume would be decreased compared to a patient with a healthy pulmonary system?

a. functional residual capacity

b. residual volume

c. total lung capacity

d. expiratory reserve volume

d. expiratory reserve volume

when a physical therapist auscultates the paitent’s heart, they hear an S4 sound. When can this heart sound be heard and what condition does it MOST LIKELY indicate?

a. abnormal sound heard in early diastole; congestive heart failure

b. abnormal sound heard in late diastole; congestive heart failure

c. abnormal sound heard in early diastole; myocardial infarction

d. abnormal sound heard in late diastole; hypertension

d. abnormal sound heard in late diastole; hypertension

a patient demonstrates an increased residual volume on pulmonary function testing. Which of the following conditions is MOST LIKELY responsible for this finding?

a. parkinson disease

b. pregnancy

c. scoliosis

d. emphysema

d. emphysema

a physical therapy initiates aquatic therapy at chest depth water level for a patient with general reconditioning. which cardiovascular response is most likely to occur during immersion?

a. decreased venous return

b. increased heart rate

c. increased venous return

d. decreased stroke volume

c. increased venous return