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The lungs consist of two cone shaped spongy organs that contain alveoli and trap air for gas exchange. The lung is designed for gas exchange. Its prime function is to allow oxygen to move from the air into the venous blood and carbon dioxide to move out. Although the lung performs other functions, its primary responsibility is to exchange gas. Oxygen and carbon dioxide (CO2) move between air and blood by simple diffusion that is from an area of high to low partial pressure. Ficks Law of diffusion states that the amount of gas that moves across a sheet of tissue is proportional to the area of the sheet but inversely proportional to its thickness. The airways consist of a series of branching tubes which become narrower, shorter, and more numerous as they penetrate deeper into the lung. The trachea divides into right and left main bronchi, which in turn divide into lobar, then segmental bronchi. The process continues down to the terminal bronchioles, which are the smallest airways outside the alveoli. All these bronchi make u p the conducting airways. Their function is to lead inspired a ir to the gas exchanging regions of the lungs. Since conducting airways contain no alveoli, they do not participate in gas exchange. The terminal bronchioles divide into respiratory bronchioles, which have few alveoli. Finally, we come the alveolar ducts that are completely lined with alveoli. This alleviated area of the lung where gas exchange occurs is called the respiratory zone. During inspiration, the volume of the thoracic cavity increases and air is drawn into the lung. The increase in volume is brought about partly by contraction of the diaphragm and partly by the actions of the intercostals muscles. These muscular actions increase the size of the thoracic cavity and air flows in due to the reduced pressure inside the chest (inhalation; governed by Boyles law which states that the pressure of a gas is inversely proportional to its volume). Inspired air flows down to the terminal bronchioles by bulk flow. Beyond that point, the combined cross-sectional area of the airways is so enormous because of the large number of branches, that the forward velocity of the gas becomes very small. Diffusion of gas within the airways then takes over as the dominant mechanism of ventilation in the respiratory zone. The rate of diffusion within the airways is so rapid, and the distances covered arson short, that differences in concentration within the alveoli are virtually abolished within a second. An increase in thoracic volume results in a decrease in intrapulmonary pressure causing air to be pushed out of the lungs (exhalation). The lung is elastic and returns passively to its pre-aspiratory volume during resting breathing. It is remarkably easy to distend. For example, a normal breath of about 500 ml requires distending pressure of 3 cm water. By contrast, a balloon may need a pressure of up to 30 cm water f or the same change in volume. Blood in need of oxygenation enters both lungs via the pulmonary arteries (from the hearts right ventricle). Oxygenated blood leaves the lungs through the pulmonary veins to the hearts left atrium. Air inspired through the nose, is passed through the trachea and bronchea, eventually entering the terminal bronchioles which supply the alveoli or
air sacs, each 0.2mm in diameter. An estimated 300 million alveoli are contained in the lungs, generating up to 50 square metres of internal surface area at a lung volume of 3000ml.(The area of an average tennis court). This gives rise to a total lung capacity of: 3.6 litres to 9.4 litres in an adult male. 2.5 litres to 6.9 litres in an adult female.
Respiration is the interchange of gases between an organism and the medium in which it lives. Internal respiration is the exchange of gases between the blood stream and nearby cells.
The mechanics of respiration
Inspiration results from the contraction of the diaphragm and intercostal muscles. The rib cage swings upwards and outwards. The enlarged cavity housing the lungs undergoes a pressure reduction (-3 mm Hg) with respect to the pressure existing outside the body. Since the lungs are passive (no muscle tissue), they expand due to the positive external pressure. e.g. if the environmental pressure is 760 mm Hg, the lung pressure is 757 mm Hg upon inspiration. Expiration results from the relaxation of the diaphragm and intercostal muscles. The rib cage moves inward and downwards. The elastic recoil of the lungs creates a higher than atmospheric intrapulmonic pressure (plus 3 mm Hg) that forces air out of the lungs.
Parameters of respiration
Tidal Volume The volume of gas inspired or expired during each respiratory cycle. Typically 500 ml. Inspiratory reserve volume The maximum amount of gas that can be inspired from the end-aspiratory position. Expiratory reserve volume Amount of air that can be forced out of lungs after normal expiration Typically 1200 ml Residual volume The volume of gas remaining in the lungs at the end of a maximum expiration. Typically 1200 ml.
it is nevertheless useful in practice as a measure of the comparative stiffness of the lung.reserve volume. Inspiritory reserve volume Additional volume that can be inspired after a normal inspiration. Typ. static and dynamic. While clearly not a complete description of the pressurevolume properties of the lung. plus exp.Totaling capacity The amount of gas contained in the lung at the end of a maximum inspiration. The static compliance of the lung is the change in volume for a given change in transpulmonary pressure with zero gas flow. It is increased in pulmonary emphysema and also with age. Compliance is reduced by diseases which cause an accumulation of fibrous tissue in the lung or by oedema in the alveolar spaces.eserve volume. Essentially. Inspiratory capacity The maximum volume of gas that can be inspired from the resting expiratory position. Should be qualified either inspiratory or expiratory. In clinical terms it is defined as the volume increase in the lungs per unit increase in the lung pressure. Typically 4800 ml. Typically 3100 ml. Total lung capacity Amount of gas contained in lungs at end of maximum inspiration Typically 6000 ml. There are two types of compliance. Lung compliance (The pulmonary volume change per unit pressure change). Vital capacity The maximum volume of gas that can be expelled from the lungs following a maximum inspiration. Functional residual capacity The volume of gas remaining in the lungs at the resting end-expiratory position. Maximum voluntary ventilation The maximum volume of air that can be ventilated per minute (also referred to a Maximum Breathing Capacity). Tidal volume. . The stiffer the lung. lung compliance is the ability of the alveoli and lung tissue to expand on inspiration.3600 ml. the less the compliance. plus insp. probably because of alterations in the elastic tissue in both cases. Minute volume The total volume of air ventilated over a minute period. Typically 2400 ml.
It is a pneumatic analogy of hydraulic or electrical resistance(R=V/I) and. Intra alveolar pressure is of importance in maintaining proper respiration and gas exchange to and from the blood. intra alveolar pressure and airflow measurements are required. Conversely. Higher resistance occurs in smaller tubes such as bronchioles and alveoli that have not emptied properly. The intra alveolar pressure is given in cm water and the flow in litres per second. Compliance values are given as litres per cm of water. helium). during expiration. (within the trachea) or tracheostomy tube (through an artificial opening in the trachea via the throat). These are critical to proper inspiration (negative internal pressure) and expiration (positive internal pressure). Airway resistance Airway resistance relates to the ease with which air flows through tubular respiratory structures. while intra thoracic pressure measurements are taken during the instance of zero air flow that occur at the end inspiritory and expiratory levels with each breath.Dynamic compliance measurements are made by monitoring the tidal volume used. Fortunately. Patient lung ventilators Patients lung ventilators connect to the patients airway and are designed to replace or augment the patients ventilation automatically. endotracheal tube. known as 'dead air' and fills dead spaces consisting of and 150 ml. The lungs should return to rest state easily to ensure sufficient exhaust of gas. airway resistance is not constant over the respiratory cycle. Expiration is usually . As pressure in the thoracic cavity becomes more negative. Lung compliance varies with the size of the lungs. Intrathoracic pressure is the positive and negative pressure occurring within the thoracic cavity. The volume of air that is not available for gas exchange with the blood resides in the conducting spaces. They are used with a mask. over the tidal volume range in which dynamic compliance measurements are usually performed. As was the case with compliance. Lung elasticity Lung elasticity is the ability of the lung elastic tissues to recoil during expiration. when the pressure in the thorax becomes positive. Thus for the determination of airway resistance. as such. the airways are widened and the resistance is lowered. Furthermore the volume-pressure curve is not linear. oxygen. Most ventilators are positive pressure during inhalation to inflate the lungs with various gases or mixture of gases (air. a child has a smaller compliance than an adult does. is a ratio of pressure to flow. the airways are narrowed and resistance is increased. the airway resistance is expressed in cm water per litre per second. hence compliance does not remain constant. the relationship is approximately linear and a constant compliance is assumed. carbon dioxide. Only a portion of the air entering the respiratory system actually reaches the alveoli.
. although under certain conditions pressure may be applied during expiratory phase as well. Assistor/controller mode. Most ventilators are operated in any of three modes Assistor mode. In this mode. asthmatics. Ventilators in clinical use can be classified into two main groups: Pressure cycled Volume cycled. or for whom the breathing requires too much effort (i. a timer automatically triggers the ventilator to inflate the lungs. Pressure cycled. These three modes differ only in the method by which inspiration is initiated. However. controller or assistor/controller type. A pressure sensor responds to the slight negative pressure that occurs each time a patient attempts to inhale and triggers are equipment to begin inflating the lungs. Assistor/controller mode: The ventilator is normally triggered when the patient attempts to breathe (as in the assistor mode). the equipment will sense the attempt and operate in the assist mode immediately. the ventilator has complete control over the patients respiration and does not respond to any respiratory effort on the part of the patient.e.passive. irrespective of which part of the control phase it had reached. but if he should fail to do so. Thus. the ventilator helps the patient inspire when he wants to breathe. On the other hand. positive pressure. Controller mode.) Controller mode: Breathing is controlled by a timer set to provide the desired respiration rate. A sensitivity adjustment is provided to select the amount of patient effort required to trigger the ventilator. the equipment is able to take-over for him. if the patient fails to breathe within a pre-determined time. If the patient attempts to breathe during controlled ventilation. Only in rare circumstances is negative airway pressure utilised during expiration. this mode can be used to wean the patient from the controlled ventilation. etc. Assistor mode: Inspiration is triggered by the patient. pulmonary pneumonia. Controlled ventilation is required for patients who are unable to breathe on their own. in order to improve arterial oxygen tension. Thus the patient controls his own breathing as long as he can. The assistor mode is used for patients who are able to control the breathing but are unable to inhale a sufficient amount of air without assistance.
Volume cycle ventilators used in most intensive care units are always supplied with a spirometer to permit accurate monitoring of the patients ventilation. it relies on the use of masks and mouthpieces to deliver air.This device is powered pneumatically from a source of gas and requires no electrical power. and optional capabilities for negative pressure and positive end expiratory pressure (P. permit adjustment of the sensitivity of the triggering mechanism and the desired pressure level. Timing for operation in the controller mode is accomplished by filling a chamber with a gas and letting it bleed off through an adjustable needle valve. Most volume-cycled equipments have adjustable pressure limits and alarms for safety. mixed air and oxygen. . can be used in conjunction with the volume setting to ensure therapeutic pulmonary function in the patient who needs it most. but at the same time they can incorporate all the necessary equipment to control the flow of gas. this type of ventilator is preferred. Also. The equipment in this category may contain an electrically powered compressor. a special type of valve senses the small negative pressure created by patients attempts to breathe. and both inspiritory and expiratory times. sense the patients efforts to inspire. Other available features may include a humidifier. This ability to set independent pressures during inhalation and exhalation result in lower average airway pressures than those produced by nasal CPAP. BiPAP differs from CPAP in that the pressure during expiration may be adjusted separately from the pressure delivered during inspiration. Pressure cycle ventilators can be quite small. and even generate negative pressure to assist expiration of some devices. P. It is much larger than the pneumatically operated ventilator and electrically operated to provide a much greater degree of control over the ventilation than the pressure cycle types. or can be used with a separate compressor to commence ventilation with ambient air. In the intensive care setting where patients have pulmonary abnormalities and require calculated volumes (derived from blood gas analysis) and concentrations of gas. In the assistor/controller type. E. The use of Bi-PAP machines is often called non-invasive face mask ventilation. their provision for adjusting pressure limits. This is because the trachea is not intubated so there is less trauma to the airway and more importantly there is a lower incidence of nosocomial infections. E. Bi-PAP stands for Bilevel Positive Airway Pressure.invasive ventilation (CPAP/BiPAP) Use of CPAP and BiPAP There is evidence that CPAP (Continuous Positive Airway Pressure) and BiPAP (Bilevel Positive Airway Pressure) are effective in preventing need for intubation and also decreasing mortality in patients with Acute Respiratory Failure in properly selected patients.) Non. Volume cycled ventilators use either a piston or bellows to dispense precisely controlled volume for each breath. terminate inspiration when the desired pressure is reached. Noninvasive treatment doesn't involve the use of surgery to provide breathing assistance.
This is delivered throughout the respiratory cycle and has been described as being similar to breathing with your head stuck out of a moving car. This is because the trachea is not intubated so there is less trauma to the airway and more importantly there is a lower incidence of nosocomial infections. pressure drops. This form of ventilation has been used for years in patients with chronic respiratory failure due to neuromuscular problems or chest wall abnormalities. Bi-PAP is a registered trademark of Respironics. Other manufacturers make VPAP and Bilevel machines that provide this same basic feature. For those patients who present to the emergency department with acute respiratory failure but with normal levels of consciousness. BiPAP (Bilevel) means that the pressure varies during each breath cycle. Inhale. C-PAP can actually increase the work of breathing and be lethal to some patients. When the user inhales. . There are also more types of masks available and this has has improved patient comfort and compliance. The ST stands for Spontaneous Timed. Sometimes you will see a "ST" behind Bi-PAP. In patients with respiratory failure. The levels are adjusted based on patient comfort tidal volume achieved and blood gases. As the use of BiPAP machines has increased. or Bilevel. no major secretion problems and who are hemodynamically stable. When they exhale. This means that if the user does not breath on their own. This positive pressure wave during inspirations unloads the diaphragm decreasing the work of breathing. The use of BiPAP machines is often called non-invasive face mask ventilation.CPAP delivers a continuous positive air pressure. a trial of BiPAP or CPAP could be attempted prior to considering intubation and a mechanical ventilator. the pressure is similar to C-PAP. making it much easier to breath. This feature is very useful in treating central sleep apnea and a host of pulmonary disorders. VPAP. a common technique is begin with the expiratory level at 5 and the inspiratory level at 15. most frequently at about 10 cm of water. Inc. BiPAP delivers CPAP but also senses when an inspiratory effort is being made and delivers a higher pressure during inspiration. the pressure returns to the CPAP level. the machine will initiate a breath for them. pressure rises. When flow stops. exhale. their cost has gone down. Continuous means that the pressure delivered to the patient is the same for any given breath. the pressure drops.
or irregular. This device uses electrical pulses to prompt the heart to beat at a normal rate. Third-degree AV block may occur at any anatomic level. especially when the QRS is wide. Seconddegree. Second-degree. These abnormal heart rhythms are called arrhythmias. but an ICD can use higher energy electrical pulses to treat certain . fast. second-.ACQUIRED ATRIOVENTRICULAR AND FASCICULAR BLOCKS IN ADULTS Atrioventricular (AV) block is classified as first-. The decision to implant a pacemaker in a patient with abnormal AV conduction depends on the presence of symptoms related to bradycardia or ventricular arrhythmias and their prognostic implications. BASIC FACTS A pacemaker is a small device that's placed under the skin of your chest or abdomen to help control irregular heartbeats. A pacemaker is similar to an implantable cardioverter defibrillator (ICD). and can help people who have arrhythmias resume a more active lifestyle. Pacemakers can relieve some symptoms related to arrhythmias. Pacemakers are used to treat heart rhythms that are too slow. First-degree and type I second-degree AV block usually are caused by delayed conduction in the AV node irrespective of QRS duration. Mobitz type II AV block demonstrates a constant PR interval before a dropped QRS and usually is associated with a wide QRS complex. Advanced AV block refers to blockage of two or more consecutive P waves. First-degree AV block is defined as an abnormally prolonged PR interval. Mobitz type I AV block (Wenckebach) is manifested by progressive prolongation of the PR interval eventuating in a dropped QRS complex. Type II second-degree AV block usually is infra-nodal. whereas complete (third-degree) AV block is defined as absence of all atrioventricular conduction. or third-degree. such as fatigue (tiredness) and fainting. It usually is associated with a narrow QRS complex.
any medicines you take. shortness of breath. and the wires carry pulses to and from various chambers of your heart and the generator. Your doctor will confirm whether you need a pacemaker based on your symptoms. Most people can return to normal activities within a few days. A pacemaker is similar to an implantable cardioverter defibrillator (ICD). any medicines you take. heart disease.dangerous arrhythmias. Problems from pacemaker surgery are rare. The generator sends the electrical pulses that correct or set your heart rhythm. too fast. After you have fully recovered from surgery. discuss with your doctor how much and what kinds of physical activity are safe for you. and fatigue (tiredness) may be due to an irregular heartbeat that a pacemaker could correct. (To treat fast heart rhythms. but an ICD can use higher energy electrical pulses to treat certain dangerous arrhythmias. and wires. heart disease. a pacemaker is combined with an ICD in a single device. The surgery takes just a few hours. . a computerized generator. Symptoms such as fainting. and test results. and fatigue (tiredness) may be due to an irregular heartbeat that a pacemaker could correct. Symptoms such as fainting. and test results. or other factors make your heart beat too slow. or irregularly. shortness of breath.) Your doctor may recommend a pacemaker if aging. (To treat fast heart rhythms. or irregularly. or other factors make your heart beat too slow. You will be given medicine to help you relax. A pacemaker consists of a battery. The generator sends the electrical pulses that correct or set your heart rhythm. a pacemaker is combined with an ICD in a single device. Your doctor may ask you to avoid any vigorous exercise or heavy lifting for a short period after your surgery. but you will stay in the hospital overnight so your doctor can monitor your heart rhythm and make sure your pacemaker is working properly. A pacemaker consists of a battery. Pacemaker surgery is usually done in a hospital or special heart treatment laboratory. and wires.) Your doctor may recommend a pacemaker if aging. too fast. Your doctor will confirm whether you need a pacemaker based on your symptoms. and the wires carry pulses to and from various chambers of your heart and the generator. a computerized generator.
Have your pacemaker checked regularly. Such damage can make your heart beat too slow. Your doctor can tell you whether you need to replace your pacemaker or its wires. or it can cause long pauses between heartbeats. A pacemaker can help regulate your heartbeat after the procedure. The electrical signals between your heart's upper and lower chambers are partially or completely blocked or slowed down (this is called heart block). The wires of your pacemaker also may need to be replaced eventually. dentists. You have had a medical procedure to treat an arrhythmia called atrial fibrillation. Some pacemaker functions can be checked remotely through a telephone call or a computer connection to the Internet. Aging. but these medicines slow down your heartbeat too much. In you have this condition. damage to the heart from a heart attack. You also need to avoid certain medical procedures that can disrupt your pacemaker. just quickly turning your neck can cause your heart to beat slower than normal. You have heart muscle problems that cause electrical signals to travel through your heart muscle too slow. and medical technicians know that you have a pacemaker. You often faint due to a slow heartbeat. this may happen if the main artery in your neck that supplies your brain with blood is sensitive to pressure. depending on how active your pacemaker is. You need to take certain heart medicines (such as beta blockers). When that happens. Back to Top WHO NEEDS A PACEMAKER? Doctors recommend pacemakers to patients for a number of reasons. not enough blood may flow to your brain. you have to avoid close or prolonged contact with electrical devices or devices that have strong magnetic fields.) . Let all of your doctors. Your doctor may ask you to come to his or her office to check your pacemaker. For example. Pacemaker batteries have to be replaced every 5 to 15 years. Once you have a pacemaker. (Your pacemaker will provide cardiac resynchronization therapy for this problem. or other heart conditions can prevent electrical signals from reaching all the heart's chambers. The damage also can cause your heart rhythm to alternate between slow and fast. A pacemaker may be helpful if: Aging or heart disease damages your sinus node's ability to set the correct pace for your heartbeat. The most common reason is when a patient's heart is beating too slow or there are long pauses between heartbeats. causing you to faint.
or 48-hour period. and the results of heart tests. records the electrical signals of your heart for a full 24. He or she also will consider whether you have a history of heart disease. During the 24 or 48 hours. or hung around your neck. or shortness of breath.To decide whether a pacemaker will benefit you. It also records the strength and timing of electrical signals as they pass through each part of the heart. Echocardiogram This test uses sound waves to create a moving picture of your heart. unexplained fainting. An EKG shows how fast the heart is beating and the heart's rhythm (steady or irregular). noting any symptoms you have and the time they occur. such as dizziness. Holter Monitor A Holter monitor. You wear small patches called electrodes on your chest that are connected by wires to a small. Your doctor may recommend some or all of these tests. and to find heart problems that may occur for only a few minutes out of the day. The purpose of a Holter monitor is to record heart signals during typical daily activities and while sleeping. also called an ambulatory EKG. Electrophysiology Study . kept in a pocket. A pacemaker won't be recommended unless your heart tests show that you have irregular heartbeats. EKG (Electrocardiogram) This simple and painless test detects and records the electrical activity of the heart. Your doctor can see how your heart was beating at the time you had symptoms. you do your usual daily activities and keep a notebook. The test can identify areas of heart muscle that aren't contracting normally or getting enough blood flow. what medicines you're currently taking. An echocardiogram shows the size and shape of your heart and how well your heart is pumping blood. your doctor will consider any symptoms you have of an irregular heartbeat. TESTS THAT HELP DETERMINE WHETHER YOU NEED A PACEMAKER A number of tests are used to detect an arrhythmia. portable recorder. You then return both the recorder and the notebook to your doctor to read the results. The recorder can be clipped to a belt.
a computerized generator. The wires in a dual-chamber pacemaker carry pulses between the right atrium and the right ventricle and the generator. The wires in your pacemaker send electrical pulses to and from your heart and the generator. The battery powers the generator. your doctor threads a small. flexible wire from a blood vessel in your arm or leg to your heart. The computer chip also records your heart's electrical activity and heart rhythms. It also may use information from sensors in the wires that detect your movement. The pulses help coordinate the timing of these two chambers' contractions. . The wires in a single-chamber pacemaker usually carry pulses between the right ventricle (the lower right chamber of your heart) and the generator. HOW DOES A PACEMAKER WORK? A pacemaker consists of a battery. and wires with electrodes on one end. The wires connect the generator to the heart. or other factors that indicate your level of physical activity. The pulses help coordinate the timing of the two ventricles with each other.For an electrophysiology study. A computer chip figures out what types of electrical pulses to send to the heart and when those pulses are needed. such as an EKG or echocardiogram. are performed. Your doctor can program the computer in the pacemaker without having to use needles or directly contacting the pacemaker. During stress testing. breathing. Stress Test Some heart problems are easier to diagnose when your heart is working harder and beating faster than when it's at rest. it can make your heart beat faster when you exercise. Pacemakers have one to three wires that are each placed in different chambers of the heart. The wires in a triple-chamber pacemaker are used for heart muscle weakness and carry pulses between an atrium and both ventricles and the generator. and a thin metal box surrounds both it and the generator. Your doctor will use these recordings to set your pacemaker so it works better at making sure you have a normal heart rhythm. The wire electrically stimulates your heart to see how your heart's electrical system responds. The pacemaker's generator sends the electrical pulses that correct or set your heart rhythm. blood temperature. you exercise to make your heart work harder and beat faster while heart tests. To do this. The electrical stimulation helps to find where the heart 's electrical system is damaged. the computer chip uses the information it receives from the wires connected to the heart. That way.
your doctor will sew up the cut. your doctor will make a small cut into the skin of your chest or abdomen. A demand pacemaker monitors your heart rhythm. the rate-responsive pacemaker monitors your sinus node rate. The entire surgery takes a few hours. If you have diabetes. your doctor will place a needle in a large vein. The doctor will then use the needle to thread the pacemaker wires into a vein and to the correct location in your heart. which is usually done in a hospital or special heart treatment laboratory. An x-ray "movie" of the wires as they pass through your vein and into your heart will help your doctor place the wires. First. How Do I Prepare for the Biventricular Pacemaker Implant? Ask your doctor what medications you are allowed to take before getting your biventricular pacemaker. or other factors to determine your activity level. You will be given medicine right before the surgery that will help you relax and may make you fall nearly asleep. blood temperature. It only electrically stimulates your heart if it’s beating too slow or if it misses a beat. Your doctor may ask you to stop certain medications several days before your procedure. Most people who need a pacemaker to continually set the pace of their heartbeat have rate-responsive pacemakers. Your doctor will give you a local anesthetic so you won't feel anything in the area where he or she puts the pacemaker. WHAT TO EXPECT DURING PACEMAKER SURGERY Placement of a pacemaker requires minor surgery. ask your doctor how you should adjust your diabetic medications. To do this. Once the wires are in place. He or she will then slip the pacemaker generator/battery box through the cut. breathing.TYPES OF PACEMAKER PROGRAMMING There are two main types of programming for pacemakers—demand pacing and rateresponsive pacing. Once the pacemaker is in place. usually near the shoulder opposite your dominant hand. and connect it to the wires that lead to your heart. A rate-responsive pacemaker will speed up or slow down your heart rate depending on how active you are. place it just under your skin. .
bruising. bleeding.Do not eat or drink anything after midnight the night before the procedure. When you come to the hospital. Most people return to normal activities within a few days of having pacemaker surgery. WHAT TO EXPECT AFTER PACEMAKER SURGERY Expect to stay in the hospital overnight so your heartbeat can be monitored and your doctor can make sure your pacemaker is working properly. For a few days to weeks after surgery. Leave all jewelry and valuables at home. you may have pain. or tenderness in the area where your pacemaker was placed. Consult with your doctor before taking any pain medicines. or infection in the area where the pacemaker was placed Blood vessel or nerve damage A collapsed lung A bad reaction to the medicine used to make you sleep during the procedure Infections that can become difficult to treat Risks of Pacemaker Surgery Nerve damage at the incision site Damage to the tissues or blood vessels around the heart or the incision site Pneumothorax (collapsed lung) Bruising at the site of placement (this is an expected effect of surgery) . You probably will have to arrange for a ride to and from the hospital because your doctor may not want you to drive yourself. The pain is usually mild and often relieved by over-the-counter medicines. drink only small sips of water to help you swallow your pills. These problems may include: Swelling. swelling. You will change into a hospital gown for the procedure. wear comfortable clothes. If you must take medications. Back to Top WHAT ARE THE RISKS OF PACEMAKER SURGERY? Your chance of having any problems from pacemaker surgery is less than 5 percent. Your doctor also may ask you to avoid any vigorous activities and heavy lifting for about a month.
You can walk through security system metal detectors at your normal pace. If you strap your iPod to your arm while listening to it. but avoid close and prolonged exposure. Faulty pacemaker that does not function as intended after the surgery (very rare) Faulty lead wires that connect the pacemaker to the heart (very rare) Lead wires that become dislodged after surgery due to activity or poor placement HOW WILL A PACEMAKER AFFECT MY LIFESTYLE? Once you have a pacemaker. as it may interfere with your pacemaker. you have to avoid close or prolonged contact with electrical devices or devices that have strong magnetic fields. Stay at least 2 feet away from industrial welders or electrical generators. You can still use household appliances. You should avoid sitting or standing close to a security system metal detector. put it on the arm farthest from your pacemaker. These procedures include: Magnetic resonance imaging (also called MRI) . How likely a device is to disrupt your pacemaker depends on how long you're exposed to it and how close it is to your pacemaker. You also need to avoid some medical procedures that can disrupt your pacemaker. To be on the safe side. You may want to hold the cell phone up to the ear that’s opposite the site where your pacemaker was implanted. Devices for which close and prolonged exposure can interfere with a pacemaker include: Cell phones iPods Appliances. You may not be able to tell whether your pacemaker has been affected. some experts recommend not putting your cell phone or iPod in a shirt pocket over your pacemaker (if they are turned on). You also can be checked with a metal detector wand as long as it isn't held for too long over your pacemaker site. such as microwave ovens High-tension wires Metal detectors Industrial welders Electrical generators These devices can disrupt the electrical signaling of your pacemaker and stop it from working properly.
dentists. or radio waves have disrupted its electrical signaling To check your pacemaker. including strenuous activities. such as football. Some pacemaker functions can be checked remotely through a telephone call or a computer connection to the Internet. having a pacemaker won't limit you from doing sports and exercise. Your doctor will replace the generator along with the battery before the battery begins to run down. Such contact could damage your pacemaker or shake loose the wires in your heart. depending on how active the pacemaker is. Replacement of the generator/battery is a less involved surgery than the original surgery to implant the pacemaker. a pacemaker can stop working properly because: Its wires get dislodged or broken Its battery fails Your heart disease progresses Devices giving off strong electrical. Shock-wave lithotripsy to get rid of kidney stones Electrocauterization to stop bleeding during surgery Let all of your doctors. WAVEFORMS . Carry this card in your wallet. Over time. Your doctor can tell you whether you need to replace your pacemaker or its wires. You may need to avoid full-contact sports. and medical technicians know that you have a pacemaker. PHYSICAL ACTIVITY In most cases. Your doctor can give you a card that states what kind of pacemaker you have. You also should notify airport screeners. Ask your doctor how much and what kinds of physical activity are safe for you. The wires of your pacemaker also may need to be replaced eventually. magnetic. Your doctor also may ask you to have an EKG (electrocardiogram) to monitor changes in the electrical activity of your heart. BATTERY REPLACEMENT Pacemaker batteries last between 5 and 15 years. FOLLOWUP Your doctor will want to check your pacemaker regularly. your doctor may ask you to come in for an office visit several times a year.
If the heart is viable. biphasic waveforms are found to be safe and effective in lower doses than monophasic waveforms. Recurrence of VF should not be considered as a failure of the shock. Two types of waveforms for biphasic shock are 1) biphasic truncated exponential waveform and 2) rectilinear biphasic waveform. Hence lower energies are selected with this waveform initially. Automatic external defibrillators have been programmed to deliver fixed or escalating energy levels on repeated shock. delivers current in only one direction. 2005. Biphasic shocks of 200 Joules seem to have efficacy similar.112:IV-35 – IV-46). Since the process of depolarisation of the critical amount of myocardial cells occurs in the 300 to 500 seconds after delivery of shock. . Though no waveform is consistently associated with higher return of spontaneous circulation or survival. Monophasic as the name implies. High efficacy of biphasic shocks would mean that final outcome will depend more on the interval between collapse and CPR or defibrillation. the natural pacemaker of the heart takes over after a variable pause. the current returns to baseline gradually while in the monophasic truncated expontenial waveform. Shock success cannot be equated to restoration of a perfusing rhythm or survival. Waveforms of defibrillation can be monophasic or biphasic. Older defibrillators deliver monophasic waveforms while the newer ones deliver biphasic wave form.The principle of defibrillation is to deliver a current to depolarise a critical amount of myocardium so that ventricular fibrillation (VF) is abolished. if not better than 360 Joules of monophasic shocks. In monophasic damped sinusoidal waveform. Selected and delivered energies differ for rectilinear biphasic waveform in the usual range of thoracic impedance. though evidence if favour of either protocol is lacking (Circulation. successful defibrillation is defined as termination of ventricular fibrillation for at least 5 seconds following a shock. usually the delivered energy is higher than that selected. current abruptly returns to baseline of zero.
When we express it in a formula. it is generally stated as follows: Joules (Energy) = Voltage X Current X Time Joules have become a surrogate for current in modern defibrillator language. Biphasic Waveforms: A type of defibrillation waveform where a shock is delivered to the heart via two vectors. The amount of impedance in a patient is difficult to determine as it relates to body mass. Impedance is expressed in ohms. time. Biphasic waveforms were initially .UNDERSTANDING DEFIBRILLATION WAVEFORMS Before we start. temperature. there is no ability to adjust for patient impedance. Current: Current is what actually defibrillates the heart. In this waveform. A joule is the unit of work associated with one amp of current passed through one ohm of resistance for one second. It is also expressed as Voltage/Impedance (resistance). diaphoresis quality of the contact with paddles or pads. Impedance: Resistance to Flow. Monophasic Waveforms: A type of defibrillation waveform where a shock is delivered to the heart from one vector as shown below. there is resistance in the electrical circuit itself as well as in the patient. and it is generally recommended that all monophasic defibrillators deliver 360J of energy in adult patients to insure maximum current is delivered in the face of an inability to detect patient impedance. It is shown graphically as current vs. let’s define a few terms: Energy: Energy in a defibrillator is expressed in joules.
you might see the following differences in the waveform when patient impedance differs: . Physio Control uses what they term a ―high energy‖ biphasic waveform. Physio Control energy settings go up to 360 joules of energy and they essentially distribute the voltage and current available over a wider range of energy settings. though they use different energy settings with the waveform. Both Physio Control and Philips use the biphasic truncated exponential (BTE) waveform originally developed for internal defibrillators. Defibrillator manufacturers have approached biphasic defibrillation differently. there are two types of waveforms used in external defibrillators. with a Physio Control BTE Waveform. Additionally they vary the voltage and extend the duration of the shock in higher impedance patients. These are shown below.developed for use in implantable defibrillators and have since become the standard in external defibrillators. While all biphasic waveforms have been shown to allow termination of VF at lower current than monophasic defibrillators. which they term ADAPTIV™ Biphasic. Therefore.
and it differs from both of the BTE waveform devices. for a 200J energy setting. however this maximum represents more voltage on the capacitor than either Physio Control or Philips has available.1 which indicates that the defibrillation threshold decreases with increasing time up to a point around 10-12 msec.Philips Medical also uses the biphasic truncated exponential waveform in their SMART Biphasic device. the duration of the ZOLL RBE waveform is fixed at 10 msec based upon work by Gliner et al. the ZOLL RBW adjusts the equipment-based impedance. ZOLL chooses not to go beyond that threshold. but in this case. such as voltage and time. Additionally. For example. ZOLL fixes voltage at the maximum and varies resistance in order to deliver constant current across the broad range of patients. The Rectilinear Biphasic Waveform (RBW) is used by ZOLL Medical. Like Philips.2 The ZOLL RBW defibrillator actually divides impedance into two components: equipment-based impedance and patient-based impedance. the ZOLL RBW charges the capacitor to the maximum voltage regardless of patient impedance. 200 Joules is the maximum setting on the defibrillator. roughly equivalent to that delivered by the Physio Control device at 360J. Rather than adjusting the secondary variables. and adds or subtracts resistors in the equipment as required to control for an essentially ―constant‖ current during the course of the first phase. In the . after which is begins to increase. As there is concern in the literature about the effects of current on myocardial stunning. they distribute the voltage and current available over a more narrow range of energy with the maximum current delivered at 200J.
For a patient with 150 ohms of impedance.92:1634-45 Provide postoperative monitoring. and the full amount of current is delivered to the patient. no equipment-based resistors are added. Circulation 1995. A postoperative chest X-ray is used to identify lead location and detect possible complications. ZOLL delivered 27. typically a maximum of 1A. at 200J. In laboratory bench tests.5A average current to a 150 ohm resistor. the defibrillator controller adds ohms of resistance to effectively ―dampen‖ the amount of current being delivered to the patient. At energy settings less than 200J. . Gliner et al. analgesia.0A average current to a 50 ohm resistor. the difference between peak and average current is even less.8A peak current and 12.8A peak current and 24. and 14. and care • Obtain a chest X-ray as ordered. Note: It is really not a good idea to try to compare manufacturers’ biphasic waveforms as each is appropriate for the device in which it is found and none has been shown to be superior to others despite a number of clinical trials.case of a patient with 50 ohms of impedance. 1.
or inappropriate sensing.such as pneumothorax or pleural effusion. beginning 24 hours after pacemaker implantation. The electrical output of the pacemaker may not be adequate. • Position for comfort. damage or dislodgement of pacer wires. Restricting movement minimizes discomfort on the operative side and allows the leads to become anchored. or the lead may be dis . Report pacemaker problems to the physician: • Failure to pace. This may indicate battery depletion. • Failure to capture (the pacemaker stimulus is not followed by ventricular depolarization). reducing the risk of dislodging. ROM exercises help restore normal shoulder movement and prevent contractures on the affected side. Minimize movement of the affected arm and shoulder during the initial postoperative period. • Monitor pacemaker function with cardiac monitoring or intermittent ECGs. • Assist with gentle ROM exercises at least three times daily.