24. Cardiopulmonary Interventions

Review:

• Blood Pressure:

• HR:

• RPP:

• CO:

• SV:

• Blood Pressure:

  • Force of blood against vessel walls

• HR:

  • Number of beats per minute (bpm)

• RPP:

  • Measure used to estimate myocardial workload and oxygen demand of the heart

• CO:

  • Blood pumped per minute

• SV:

  • Total amount of blood ejected by the left ventricle per beat

Respiratory System:

• How my lobes does the ___ have:

  • L Lung:

  • R Lung:

• L Lung » 2 Lobes

  • Superior/Upper

  • Inferior/Lower

• R Lung » 3 Lobes

  • Superior/Upper

  • Middle

  • Inferior/Lower

Scenario Based Q 1:

Which of the following is the MOST LIKELY treatment?

A. Bicarbonate infusion to decrease metabolic acidosis

B. Have the patient to 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

How to Manage/Treat:

• Respiratory Acidosis:

• Respiratory Alkalosis:

• Metabolic Acidosis:

• Metabolic Alkalosis:

• Respiratory Acidosis:

  • Supplemental O2 Administrations

  • Medications

  • Brochodialtors

• Respiratory Alkalosis:

  • Breath into paper bag // rebreather mask

• Metabolic Acidosis:

  • Bicarbonate Infusion

• Metabolic Alkalosis:

  • Medications to reduce it

Scenario Based Q 2:

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

• Describe:

  • Inspiratory muscle training

  • Pursed lip breathing exercises (3)

  • Segmental breathing exercises

  • Incentive spirometry

• Inspiratory muscle training

  • Strengthen inspiratory muscles in CHRONIC COPD pts but not ACUTE COPD

• Pursed lip breathing exercises

  • Helps maintain POSITIVE BACKWARD PRESSURE

  • Prevents early airway closure

  • Helps remove air from lungs

• Segmental breathing exercises

  • Appropriate to expand a segment/lobe of the lung with RESTRICTIVE issues

• Incentive spirometry

  • Inflate collapsed lung post op and/or after atelectasis

Scenario Based Q 3:

The physical therapist decided to use postural drainage for airway clearance. The physical therapist 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 ___ to the ground.

• Using ___, these positions assist the mucociliary transport system in removing ___ ___ from the tree.

• Indications: (3)

• Maintain each position for:

• Secretions cleared by:

• Perpendicular

• Gravity; Excessive Secretions

• Indications:

  • Pulmonary Complications

  • Weak/Elderly pts

  • Atelectasis, PNA, COPD

• Maintain: 5-10 mins

• Secretions Cleared: Coughing or Suctioning

NOTE:

• Bad Lung (Has Secretions) = Facing UP

Key Positions:

• Prone lying on a bed with two pillows under pelvis:

• Sitting on a chair, leaning forwards over folded pillow:

• Supine lying on a bed with pillows under knee:

• Sitting in a recliner, leaning slightly backwards:

• Prone lying on a bed with two pillows under pelvis:

  • Superior Segments of the Lower Lobe

• Sitting on a chair, leaning forwards over folded pillow:

  • Posterior Apical Segment of the Upper Lobe

• Supine lying on a bed with pillows under knee:

  • Anterior Segment of the Upper Lobes

• Sitting in a recliner, leaning slightly backwards:

  • Anterior Apical Segments of the Upper Lobes

Practice Q 2:

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 and Precautions to Postural Drainage:

Practice Q 3:

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

A. Frequent turning and positioning every 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. Gentle coughing and deep breathing exercises every 4 hours

C. Vigorous chest vibrations, with the foot of the bed elevated, 4 times per day

How to Predict HR:

• 2 Age Predicted Formulas:

• Karvoven’s Formula:

  • Example:

• Age Predicted:

  • HR Max = 220 - age (NPTE)

  • HR MAX = 207 - 0.7 x age (ACSM)

• Karvonen’s Formula:

  • HR Reserve multiplied by the percentage of intensity plus Resting HR

    • Ex:

      • Max HR = 200

      • HR Resting = 7

      • HR Reserve » HR Max (200) - HR Resting (70) = 130 HR Reserve

NOTE:

• Starting Early: Lower % HR Max

• Elite: Higher % HR Max

Practice Q 4:

A 65-year-old individual has limited endurance with no history of cardiorespiratory problems. Exercise tolerance test was negative for coronary heart disease. What is the BEST initial exercise prescription for this individual?

A. 90-100% HR max

B. 60-70% HR max

C. 40-50% HR max

D. 30-40% of HR max

B. 60-70% HR max

Practice Q 5:

A clinician 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

Abnormal Responses to Exercises: Exercise Termination Criteria

• Exercise HTN:

• Systolic HYPOtension

• Unusual Heart Response:

• Symptoms:

• Signs:

• ECG Abnormalities:

Cardiac Rehabilitation:

• When does Cardiac Rehab:

  • Begin:

  • Extends:

• Phase I =

• Phase II =

• Phase III =

• Phase IV =

• When does Cardiac Rehab:

  • Begin: In the hospital

  • Extends: Indefinitely into the maintenance phase

• Phase I = Acute Phase // Monitoring Phase

• Phase II = Subacute Phase // Conditioning Phase

• Phase III = Training Phase // Intensive Rehab Phase

• Phase IV = Maintenance Period // Prevention Period

Cardiac Rehab » Phase I and II:

• Inpatient Phase I can be initiated when?

• Resistance Training? YES OR NO

• F:

• I:

• T:

• T:

• Patients commonly undergo what test at how many weeks after MI?

• Inpatient Phase I can be initiated:

  • after 24 hours of being stable

• Resistance Training? NO

• F:

  • Short Sessions 2-3x a day

• I:

  • 50% - 70% HR Max

• T:

  • 10-15 mins (Phase I)

  • 30 mins (Phase II)

• T:

  • ADLs

  • Supervised Ambulation

• Patients commonly undergo:

  • Symptom Limited Maximal Stress Test (ETT)

  • 4-6 weeks after MI

Practice Q 6:

A patient is undergoing cardiac rehabilitation post complicated myocardial infarction in the hospital. On day two, 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 the visitor’s 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

Cardiac Rehab » Phase 3 FITT

• Resistance Training: YES OR NO

• F:

• I:

• T:

• T:

• Resistance Training: YES

  • Phase III is beginning of Resistance Training

• F:

  • 2-3 sessions/week

• I:

  • 70%-85% of the peak achieved on the test (HR Max)

• T:

  • 30-60 minutes

  • 5-10 min warm up and cool down

• T:

  • Single mode of training (Walking)

  • Multiple modes of Training (Treadmills, Cycle, Ergometer)

Cardiac Rehab » Phase III Strength Training Guidelines

• (3)

• Begin with the use of elastic band and light hand weights (1-3 lbs) OR 30%-50% of max weight used to complete 1RM

• Begin c 8-10 reps » Progress to 12-15 reps

• Avoid UE Resistance as soft tissue is still healing

  • Sternal Precautions

Practice Q 7:

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

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 2-pound hand weights

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

A. 30 minutes walking at 3 mph with no incline

Cardiac Rehab » Phase IV

• Location: (3)

• Conditions Allowed to Exercise: (2)

• Progression: (3)

• Discharge:

• Location:

  • Community Centers

  • YMCA

  • Clinical Facilities

• Conditions Allowed to Exercise:

  • Clinically Stable Angina

  • Medically Controlled Arrhythmias

• Progression:

  • 50-85% of Functional Capacity

  • 3-4x/week

  • 45 min or more per session

• Discharge:

  • Typically, 6-12 months

Educational Component:

• What can a PT educate the patient? (7)

Practice Q 8:

A patient with a BMI of 31 kg/m² has been walking three days/week for 20 minutes, for the past three weeks. Which of the following 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 the duration at 20 minutes

C. Walk 5 days/week and decrease the 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 min/week:

• F:

• I:

• T:

• T:

• Minimum min/week:

  • 250-300 min/week required

• F:

  • Greater than 5 days/week to maximize caloric expenditure

• I:

  • Initially Moderate » 40-60% VO2, Progression to > 60%

• T:

  • 45-60 min/day

• T:

  • Moderate Exercise

    • Aerobic

    • Resistance

    • Flexibility

CardioPulm Postural Drainage Lab

Upper Lobe » Apical Segment

• Long Sitting Position

• Lean Back 30 degrees

Upper Lobe » Anterior Segment

• Supine with the Table Level

Upper Lobe » Posterior Segment

• Seated, Leaning Forwards 30 deg

Middle Lobe

• Left Sidelying

• head Down 15 deg

• ¼ Turn Backwards

NOTE:

• FOR R Lung » Only R Lung has Middle Lobe

Lingula

• Right Side Lying

• Head Down 15 degrees

• ¼ Turn Backwards

NOTE:

• FOR L LUNG » Only L Lung had Lingula

Lower Lobe » Superior Segment

• Prone with the Table Level

Lower Lobe » Anterior Basal Segement

• R or L Side Lying with Head Down 30 deg

Lower Lobe » Posterior Basal Segment

• Prone c Head Down 30 deg

Lower Lobe » Lateral Basal Segment

• R or L Side Lying

• Head Down 30 deg

• ¼ Turn Forward