PT - Cardiopulmonary

PT – Cardiopulmonary
Magistrado, Leandrew T. BSPT3
Vital Signs
- Vital to keeping the human organism alive
- Provides an idea about the patient’s baseline health
- May be used as an indication of improvement or decline in health status
Six Vital signs
1. Pulse
2. Respiration
3. Blood Pressure
4. Core Temperature
5. Pain
6. Walking Speed
Pulse
o Heart rate – number of times the heart contracts in a given period of time (bpm)
o Rhythm – regularity of the contractions and provides information about the electrical impulses
o Force or amplitude – strength of contraction of the left ventricle as well as the volume of the blood within the
peripheral vessels
o The time it takes for the pulse to reach its resting rate following exertion is a good indicator of cardiovascular fitness
 2 mins after submaximal exercise, HR should be at least 22 bpm less than the max HR achieved (2mins after Smax
= HR >22bpm of HRmax)
Pulse points
Pulse Point Location

Carotid Artery Just to the side of the larynx/medial to SCM
In the antebrachial fossa just medial to the biceps brachii

Brachial Artery
tendon
At the lateral aspect of the anterior wrist, lateral to the
Radial Artery
FCR tendon
At the medial aspect of the anterior wrist, just lateral to
Ulnar Artery
the FCU tendon
Below the inguinal ligament (midway between ASIS
Femoral Artery
and Pubic symphysis)
Posterior Knee at joint line or just above it (knee flexion
Popliteal Artery
to some extent)
Posterior tibial Slightly distal and posterior to the medial malleolus
Artery (relaxed PF)
Dorsal pedis (pedal) Dorsum of the foot just lateral to the EHL tendon
Assessment of Pulse
1. Place the pads of your index and middle fingers flatly and lightly on the artery
1
a. The patient should be relaxed

b. Avoid using the thumb
c. do not apply too much pressure
2. once you have located the pulse, determine your starting point on your timing device
3. Count the number of beats you feel over a 60-secs period.
a. Errors are more likely with shorter time spans
b. Initial assessment should be a full minute
c. At minimum, count for 30 secs and multiply by 2
4. While counting, note the rhythm and force of the beats.
5. Record the number of beats, the length of time, the force descriptor or number, and the rhythm.
6. Documentation
a. “Pulse: ® Radial artery: 72bpm, normal & regular”
b. “Pulse: (L) Carotid artery: 88bpm, 3+, regular”
Respiration
- Oxygenation and circulation of the blood

- Respiration rate - # of times the chest rises and falls (one respiratory cycle) in a given period of time (BPM/CPM)
- Rhythm – regularity of the respiratory cycles
2
- Depth – much less than the full capacity of the lungs; sometimes difficult to visualize
Respiration and Exertion
 Respiration rate and depth should increase

 If the depth cannot increase, respiration must increase more than normal to compensate
 Respiratory rhythm should remain regular
Assessment of Respiration
1. After taking the pulse, continue holding the patient’s wrist and begin observing the patient’s chest rise and fall
a. Observation is easiest when watching the upper thorax
b. Poor posture can reduce ability to see movement of rib cage
c. Male physicians should avoid prolonged gaze
2. Count the # of times the chest rises in a 30-secs time period and multiply by 2
a. In the presence of abnormal breathing patterns, assess for a full minute
3. While counting, note the rhythm and depth.
a. Normal inspiration to expiration time is roughly 1:2
4. Record the # of times the chest rises, the length of time the respirations were counted, and the rhythm and depth descriptors.
5. Documentation
a. Resp (seated): 18 breaths/min, regular, normal
b. Resp (supine): 22 breaths/min, irregular, shallow
Common Respiratory Difficulties
- Dyspnea – difficulty in breathing

- Orthopnea – difficulty in supine
- Paroxysmal Nocturnal Dyspnea (PND) – sudden dyspnea and orthopnea
- Apnea – absence of breathing
- Apneustic respiration – abnormal pattern of breathing characterized by deep, gasping inspiration with a pause at full
inspiration followed by a brief, insufficient release
- Platypnea – is shortness of breath (dyspnea) that is relieved when lying down, worsen when sitting or standing.
3
- Trepopnea – difficulty in breathing in side lying position
Blood Pressure
- Measure of arterial pressure when the left ventricle contracts (peak of systole) and when the heart is at rest between
contractions (diastole)
4
Other Blood Pressure Abnormalities
- Hypotension: <90/60mmHg
- Orthostatic (postural hypotension) – drop in systolic pressure by ≥ or diastolic pressure by ≥ 1-mmHg withing 2-5 minutes
after positional change
- Systole – rises with an increase in workload and then levels off

- Diastole – does not change >10mmHg
Assessment of Blood Pressure
1. Patient is seated or in supine

2. Select the arm for measurement
a. The opposite arm should be utilized if the patient has any of the following:
i. An IV line
ii. Lymphedema or risk for lymphedema (mastectomy)
iii. A peripherally inserted central catheter (PICC) line
iv. Presence of arteriovenous fistula (hemodialysis)
v. Injury to one upper extremity
3. Palpate the brachial artery (medial to the distal tendon of biceps brachii): reference for both cuff and the diaphragm of the
stethoscope
4. Apply the deflated cuff around the patient’s upper arm
a. Midline of cuff
bladder should
be in line with
the brachial
artery
b. Lower edge of
cuff should be 2-
3cm above
antecubital fossa
5
5. Ensure that the air pump valve is closed (turned clockwise)

a. Don’t over tighten
6. Place the earpieces of the stethoscope in your ears and the diaphragm of the chest piece over the patient’s brachial artery
a. Secure the diaphragm over the brachial artery with the thumb and forefinger of your nondominant hand
7. The patient’s forearm should be supported on a surface or with your own arms at the level of the heart
8. Inflate the cuff by squeezing the bulb repeatedly (until 180-220mmHg is adequate for most). Using your thumb and index
finger of your dominant hand, slowly turn the valve to the left (counterclockwise) until the air begins to release.
a. 2-3mmHg per second deflation
9. Listen for the

Korotkoff sounds as you closely watch the gauge. Note the first and final sounds.
10. Once certain, release the valve to full deflation.
11. Documentation:
a. BP: Pt. supine, (L) UE: 115/78 mmHg
b. BP: Pt. seated, ® UE: 128/86mmHg (prehypertension range)
6
Core Temperature
- (N): 37.5 degree Celsius

o Between 97.7 and 99.5 Fahrenheit (36.5 and 37.5 Celsius)
- Pyrexia – controlled elevated temperature: Fever
- Febrile – physiological status of having a fever
- Afebrile – physiological status of not having a fever
Sites of Temperature Assessment
- Pulmonary artery
- Tympanic membrane (ear)
- Oral
- Axilla
- Rectal
Assessment
Oral
1. Cover the device with a thin disposable plastic

2. Tip of the thermometer should rest under the tongue toward the back of the sublingual pocket
3. Instruct the patient to close the lips completely around the thermometer and relax the jaw
7
4. Wait for the digital device to beep or wait for 3-4 minutes if a liquid-filled thermometer was used
Tympanic
1. Cover the device with a thin disposable plastic.

2. Place the probe in the ear and direct it towards the tympanic membrane
3. Wait for the beep, remove, and check.
Edema
- Observable swelling from fluid accumulation

- Normal causes include: immobility, heat, salty food, pregnancy, some medications
- Abnormal causes include: diseases of the heart, kidneys, liver, or thyroid, blood clots, varicose veins, some autoimmune
disease, and blocked lymph channels
Types of Edema
- Pitting – persistent indentation

- Non-pitting – No indentation
Assessment of Pitting Edema
1. Patient may be seated or supine

2. Press thumb firmly but gently into the patient’s skin and hold for 5secs
3. Remove the pressure and determine the indentation depth. Also note of how long it took for the indentation to disappear (see
scale)
4. Areas to assess:
- Upper Extremity
o Over the dorsum of the hand (metacarpal region)
o Slightly proximal to the styloid process
o Middle of the dorsal forearm
- Lower Extremity
o Over the dorsum of the feet
8
o Slightly posterior and inferior to the medial malleoli

o Middle of the shin, slightly lateral to the tibial spine
5. Documentation
- Pitting edema: Dorsum ® Foot – 3+ (1cm, 20sec rebound)
- Pitting edema: Mid-tibia (L) = mild (0.5cm, 10sec rebound)
Measurement of Edema
1. Patient may be seated or supine

2. Use a flexible tape measure
3. Select circumferential areas to measure based on the location and extent of edema
- Use of bony landmarks is easiest for reassessment purposes
4. Encircle the area to measure and pull the tape measure firmly so there are no gaps
- Do not pull so tightly that the skin in indented
5. Record the measurements in centimeters
6. Compare to unaffected side, if present.
7. Documentation
- Circumference (supine): 5cm proximal to lateral malleolus: ® = 42.3cm; (L) =46.4cm
9
Oxygen Saturation
- Indicate the degree to which hemoglobin is bound to oxygen in the circulating blood
- Inpatient
- “02 sats” or “sats”
Factors to Consider
 Impaired RBC production

 Anemia
 Abnormalities of the hemoglobin molecule (sickle cell disease)
 Decrease blood volume (trauma or surgery)
 Pulmonary disease
 Kidney failure
 Chemotherapy
Oxygen Saturation Measurements
- Arterial Blood Gas (ABG) analysis

- Pulse oximetry
Pulse Oximeter
- Most commonly used by PTs

- Shines light at 2 wavelengths through a distal body part with
good arterial blood flow (finger, toe, or earlobe)
- Detects the percentage of oxygenated hemoglobin through
which the light passes
- Non-invasive, painless, immediate results, easy to use
Measurement Systems
Sa02 – measurement of oxygen saturation via ABG (a for arterial)

Sp02 – measure of oxygen saturation via pulse oximeter (p for
peripheral or pulse oximetry
Oxygen Saturation Assessment (SpO2)
1. Choose a finger with good vascularity

a. A fingernail polish (esp. dark colors) or acrylic nails may interfere with the accuracy of the sensor; polish should be
removed, a different site chosen, or sensor placed sideways on the fingertip.
2. Turn the oximeter ON
3. Place the sensor on the patient’s finger and wait for the pulse and percent of 02sat to register
10
a. Check the patient’s PR manually and compare with the oximeter to ensure correct placement of the sensor
4. Record the Sp02, pulse rate, sensor site, patient position (and activity, if appropriate).
a. If with supplemental O2, record delivery method and rate.
5. Documentation:
a. Sp02: 98% (R index finger, pt. supine); pulse: 88bpm
b. Sp02: 94% ((L) index finger, pt. amb in hall); pulse: 94bpm
Oxygen Saturation response to Exertion
- (N): stay the same or increase slightly

- Abnormal: drop and remain lower than normal
11
Ankle-Brachial Index
- Easy, economical, and reliable measure that can identify the presence and severity of impaired blood flow (ischemia) to the
extremities
- Detects Peripheral Arterial Diseases (PAD)
- Highly sensitive and specific
ABI Assessment
1. Patient should be in supine

2. The arm and leg selected for measurement should be on the SAME SIDE; the side tested should be on the one of greater
concern
a. Both sides may be assessed for a complete picture of the patient’s status
3. Take the patient’s BP in the UE (brachial aa) using the stethoscope. Record the systolic
4. Place the BP cuff around the distal lower leg (bottom of cuff superior to the malleoli).
5. Locate the pulse from either the dorsalis pedis or the posterior tibial artery using the Doppler sensor or stethoscope
6. Inflate the BP cuff 1-2

hands pumps beyond:
a. when the pulse is no longer heard (using the Doppler sensor)
b. the systolic pressure found in the arm (using a stethoscope)
7. Slowly deflate the cuff as performed when taking the brachial BP.
a. Note the systolic BP and record as ankle pressure
8. Divide the systolic pressure in the ankle by the systolic pressure in the arm
a. ABI = SBP LE/SBP UE
9. Interpret the values
10. Documentation
a. ABI (Doppler): ® 122/128-0.95; (L): 118/130 – 0.91
b. ABI (Stethoscope): ® 116/138=0.84; (L): 126/140=0.90
12
Other Common Cardiovascular and Pulmonary Test Measures
- Rating of perceived exertion

- Six-minute Walk Test (6MWT) – measure cardiovascular
endurance and tolerance for exercise
Borg Scale of Rating of Perceived Exertion (RPE)
- A valid and reliable method for estimating the actual physiological

work being performed during any given activity
- Original scale (6-20) was difficult for the patients to understand
- Modified scale (0-10)
- Documentation: Patient’s rating and activity type (type, intensity, and
duration)
6MWT Assessment
1. a 30-meter straight course is marked with tape or cones

2. The patient is instructed to walk “laps” at a comfortable pace (1 lap =
60m)
3. The timer is started upon “go”; patient walks laps for 6minutes and is then instructed to stop
4. The # of laps is recorded, including any distance at the end that did not constitute an entire lap.
5. The # of rest breaks and the # of episodes of loss of balance are recorded
6. Total distance is calculated and compared to published norms.
7. Documentation:
a. 6MWT: 740m (two 0-sec rest breaks)
b. 6MWT: 583m (four 15-sec rest breaks; use of standard cane)
PHYSICAL EXAMINTION
13
- Inspection
- Auscultation of the Lungs
- Auscultation of the Heart
- Palpation
- Mediate Percussion
- Activity Evaluation
- Evaluation
INSPECTION
- Head to Toe
- General Appearance
o Level of Consciousness
o Body Type
o Posture
o Positioning
o Skin Tone
o Need for External monitoring or support equipment
Facial Characteristics
- Facial expression
- Effort to breathe
- Facial distress
- Musculature of the Face and Neck
- Movement of the Lips to breathe
Evaluation of the Neck
- Activity of neck musculature during breathing

- Appearance of Jugular veins
Jugular Venous Distention Assessment
 Patient is sitting or recumbent in bed

 Head elevated at least 45degrees
14
 (+) JVD = Veins distend above the level of the clavicles

 JVD may be an early sign of ® CHF (cor pulmonale)
Chest Evaluation
 Symmetry
 Configuration
o Pectus Excavatum
o Pectus Carinatum
 Rib angles
 Intercostal spaces
 Musculature
Patient with rigid chest walls or the diagnosis of diffuse pulmonary fibrosis usually demonstrate a complete lack of lateral costal
expansion. Therefore, the chest wall goes up and down, but there is no outward expansion
Respiratory rates
Age
(breathes/minute)
Infant: Birth – 1 y/o 30 – 60
Toddler 1 – 3 y/o 24 – 40
Preschool 3 – 6 y/o 22 – 34
Elementary school age 6 -12 y/o 18 – 30
Adolescent 12 – 18 y/o 12 -16
Adult 18+ y/o 12 – 20
Pattern of Breathing Description

Apnea Absence of Ventilation
Fish-mouth Apnea with concomitant mouth opening and closing; associated with neck extension and bradypnea
Eupnea Normal rate, normal depth, regular rhythm
Bradypnea Slow rate, shallow or normal depth, regular rhythm: associated with drug overdose
Tachypnea Fast rate, shallow depth, regular rhythm: associated with restrictive lung disease
Hyperpnea Normal rate, increase depth, regular rhythm
Cheyne-Stokes Increasing then decreasing depth, period of apnea interspersed: somewhat regular rhythm: associated
(periodic) with critically ill patients
Biot’s Slow rate, shallow depth, apneic period, irregular rhythm: associated with CNS disorder (i.e.
meningitis)
Apneustic Slow rate, deep inspiration followed by apnea, irregular rhythm: associated with Brainstem disorders
Prolonged expiration Fast inspiration, slow and prolonged expiration yet normal rate, depth, and regular rhythm: associated
with obstructive lung disease
Orthopnea Difficulty breathing in postures other than erect
Hyperventilation Fast rate, increased depth, regular rhythm: results in decreased arterial carbon dioxide, tension: called
Kussnaul breathing in metabolic acidosis: also associated with CNS disorders (i.e. encephalitis)
Psychogenic dyspnea Normal rate, regular intervals of sighing: associated with anxiety
Dyspnea Rape rate, shallow depth, regular rhythm: associated with accessory muscle activity
Doorstop Normal rate and rhythm: characterized by abrupt cessation of inspiration when restriction is
encountered: associated with pleurisy
Phonation
- Dyspnea of phonation
o # of words expressed before the next breath
15
o “One-word dyspnea – speech is interrupted for a breath between EVERY word

- Cough and cough production
o Strength
o Effectiveness (strength, depth, length)
o Secretion (quantity, color, smell, consistency)
- Breath odor
- Appearance of the Extremities

o Fingers, toes, and calves
o Digital clubbing of fingers and toes
o Cyanosis
o Skin color changes
Auscultation of the Lungs
- The process of the listening to sounds withing the body using a stethoscope
- Most appropriate stethoscope choice:
o With adjustable ear pieces
o With adequate but not excessive tubing
o With both a diaphragm and a bell
o A valve to turn toward either the diaphragm or the bell
- Lung sounds: diaphragm, quiet environment
- Optimal position: sitting
- Removed bed clothes to expose bare skin
- Have the individual breathe deeply though an open mouth
- Auscultation should be performed over the entire lung space, with at least one breath auscultated in each
bronchopulmonary segment
- Compare right and left in the craniocaudal direction as to:
16
o Intensity
o Pitch
o Quality of the breath sounds
Precautions:
- Prevent the patient from falling if weak or if poor balance is noted

- Prevent the patient from becoming dizzy secondary to hyperventilation by auscultating slowly between pulmonary segments
- Maintain appropriate draping of the patient
- If auscultations reveal very faint or distant sounds, remind the patient to take deep breaths and to breathe in and out through the
mouth so that a recheck can be done.
Errors of Auscultation to avoid
Listening to breath sounds through the patient’s gown Placing bell or diaphragm directly against the chest wall
Allowing tubing to rub against bed rails or patient’s gown Keeping tubing free from contact with any objects during
auscultation
Attempting to auscultate in a noisy room Turning television or radio off
Interpreting chest hair sounds as adventitious lung sounds as Wetting chest hair before auscultation if thick
adventitious lung sound
Auscultating only the “convenient” areas Asking alert patient to sit up: rolling comatose patient onto side
to auscultate posterior lobes
- To understand what are bronchial breath sounds, take your stethoscope and listen to breathing over the anterior chest right near
the trachea over the sternum. The breath sound is loud. Then, listening to breathing posteriorly at the bottommost part of the
lungs. If the sounds heard anteriorly near the sternal notch are found posteriorly in any of the segments of the lungs or anteriorly
at the middle and lower parts of the ribs, these are abnormal breath sounds.
Nomenclature Pitch and Intensity Respirator cycle when Duration Location

best heard
Normal/Vesicular Soft and Low IN and first 1/3 of EX No break b/w IN and Ant (throughout)
EX Post (throughout
medially)
Bronchovesicular Softer version of IN and EX Continuous b/w IN and Junction of the
bronchial EX mainstem bronchi and
segmental bronchi
Bronchial Loud high (tubular) Equal IN and EX Break b/w IN and EX Over trachea and
17
manubrium
Increase lung tissue density = increased sound transmission
Decrease lung tissue density = decreased sound transmission
Egophony
- Patient is asked to say “E” aloud, but the auscultated sound over
the chest is “A”
Bronchophony
- Patient is asked to say “99”, and the words are auscultated clearly
over the entire chest when it should normally be muffled
- Indications: Pneumonia
Whispering petriloquy
- A patient is asked to whisper, and the whispered words are

clearly heard when it should be normally be muffled
- Indications
Adventitious Lung Sounds
- Continuous sounds: Wheezes

o Continuous adventitious lung sounds with a constant pitch and varying duration
o Frequently heard on exhalation
o Airway obstruction
o Wheeze on inspiration indicates a more severe obstruction
- Discontinuous sounds: Crackles

o Discontinuous adventitious lung sounds that sound like brief bursts of popping bubbles
o Commonly heard during inspiration
o Restrictive or obstructive respiratory disorders
o Peripheral airway collapse: atelectasis, pulmonary edema, fibrosis, or compression from pleural effusion
Stridor
- Monophonic, continuous adventitious sound heard over the upper airways of a patient with upper airway obstruction (as
when a peanut is lodged in a bronchus or when epiglottic interference occurs)
Pleural Rub
- Like two pieces of leather or sandpaper rubbing together

- Inspiration and expiration
- Lower lateral chest areas
- Pleural inflammation
Auscultations of the Heart

18
- Quiet Environment
- Stethoscope with a diaphragm and bell
- The diaphragm (high-pitched sounds) is placed firmly on the skin and is used to auscultate initially the topographic areas on
the chest wall
- The bell (low-pitched sounds) accentuates gallop rhythms
- Five areas where sounds are best heard:
o Aortic: 2nd Right Intercostal space close to sternum
o Pulmonary: 2nd Left Intercostal space close to the sternum
o Erb’s point: 3rd Left Intercostal space (heart murmurs)
o Tricuspid: 4th – 5th Left Intercostal space at the sternal border
o Mitral – 5th Left Intercostal space medial to midclavicular line
S1 S2
 “LUB”  “DUB”
 Closure of the mitral and Tricuspid valves  Closure of the Aortic and Pulmonary valves
 Onset of ventricular systole  Start of Ventricular diastole
 Sound is louder and longer and lower pitched at the  Sound has the greatest intensity at the aortic or
apex or in the tricuspid region pulmonary regions
S3 (Ventricular gallop) S4 (Atrial gallop)
 Immediately following S2 “LUB-DUB-DUB”  Just before S1 “LA-DUB-DUB
 Early diastole: Low-pitched BELL  Late diastole: Low-pitched bell
 Patient lying on the (L)  (N): Athletes
 (N): Children and young adults  Ab(N): Hypertension, CAD, Pulmonary disease, MI,
 Ab(N): CHF CABG
Sounds Event Location to auscultate Best heart with Corresponding events

S1 normal Closing of tricuspid and mitral valve Tricuspid (4th/5th ICS) Diaphragm Onset of ventricular
19
Mitral (L 5th ICS) systole

Closing of the aortic and pulmonic Aortic (2nd ICS) Start of ventricular
S2 normal Diaphragm
valves Pulmonic (2nd ICS) diastole
Possible CHF indicative of Apex of the heart (patient Early diastole
S3
ventricular dysfunction should lay 45 degree forward Bell
abnormal
left side lying)
S4 Increased resistance to ventricular Apex of the Heart Late diastole (just before
Bell
abnormal filling S1)
Murmurs
- Murmurs caused by high rate of flow either through normal or abnormal valves
- Murmurs caused by forward flow through a constricted (stenotic) or deformed valve or by flow into a dilated vessel or
chamber
- Murmurs caused by backward flow through a valve (regurgitation)
Classified according to:
- Timing
- Quality
- Intensity
- Pitch
- Location
- Radiation
- Position of the patient
- Part of the respiratory cycle
Levine’s Grading of Heart Murmurs
Grade Description
Grade I Very faint, may only be heart by an expert, not
heard in all positions, no thrill
Grade II Soft, heard in all positions, no thrill
Grade III Moderately loud, no thrill
Grade IV Loud and associated with a palpable thrill
Grade V Very loud, with thrill, heard with the
stethoscope partly off the chest
Grade VI Loudest, with thrill, head with the stethoscope
entirely off the chest (just above the
precordium, not touching the skin)
Systolic Murmurs
- Most common
- Caused by either ejection or regurgitation
- Heart between S1 and S2: “Swishing”/” lush-dub”
- Aortic stenosis: classic systolic murmur
o High-pitched, best heart at the right sternal border, 2nd ICS, frequently radiating to the neck and Carotid A.
- Valvular dysfunctions: congenital defects of the Atria and Ventricles
Diastolic Murmurs
- Uncommon
20
- Immediately following the S2 and diminishes in intensity quickly

- Aortic and Pulmonary regurgitation, mitral stenosis
Pericardial Friction Rub
- Pericarditis
- Auscultation: patient in supine with the PT listening over the 3rd or 4th ICS along the anterior axillary line
- Sounds like a “creak” or “leathery” as if two pieces of leather are being rubbed together
Palpation
Evaluate the:
- Mediastinum (tracheal shift)

- Chest motion
- Chest wall pain
- Fremitus
- Muscle activity of the chest wall and diaphragm
- Circulatory status
Mediastinum (tracheal position)
- Tracheal shift is due to DISPROPORTIONATE intrathoracic pressures or lung volumes between 2 sides of the
thorax
- Trachea shifts outward the side where there is lesser pressure or volume
- Patient’s position: patient is sitting upright with neck flexed slightly and chin positioned midline
- PT: tip of the index finger is placed in the suprasternal notch, first medially to the left SC joint and pushed inwards
towards the cervical spine: then, on to the right
Chest Motion
- Palpation is segmentally done: upper, middle, and lower lobes while the patient is (1) breathing quietly and while (2)
breathing deeply
- Components:
o Amount of movement of the hands
o Presence or absence of symmetry of movement
o Timing of the movement
Chest Motion
- Upper chest wall expansion

o PT places the palms anteriorly over the chest wall from the 4 th rib
upward: fingers should be stretched upward and over the
trapezius, and thumbs should be placed together along the midline
of the chest
o Patient is asked to take a maximal inspiration
o Note extent and symmetry of movement
- Right middle lobe and lingula segments of the Left upper love
o PT places the fingers laterally over the posterior axillary folds,
with the palms pressed firmly on the anterior chest wall; thumbs
meet at midline
o Patient should take a maximal inspiration
o Note extent and symmetry of movement
21
- Lower chest wall expansion

o PT at the back of the patient with fingers wrapped around the anterior axillary fold: thumbs meet at the spinal column
o Patient is asked to take a maximal inspiration
o Note extend and symmetry of movement
Fremitus
- Vibration produced by the voice of by the presence of

secretions in the airways and is transmitted to the chest
wall and palpated by hand
- PT’s palm is placed lightly on the chest wall while the
patient repeats some word, such as “99”
o (N): Uniform vibration throughout chest wall
o Increase fremitus: Increase secretions
o Decrease fremitus: Increase air
Evaluation of Muscle Activity of Chest Wall and Diaphragm
- Diaphragm
o Palpation of the anterior chest wall with thumbs
over the costal margins and thumb tops meeting at the Xiphoid
o With a deep inspiration, hands should travel equally apart, total circumferential diameter increasing by at
least 2-3 inches
22
Chest Wall Pain or Discomfort
- If chest pain is increased with deep inspiration or if it is increased or reproduced by direct point palpation, it is less
likely to be of cardiac origin than of skeletal muscle origin
- If a patient reports chest pain during the patient interview and can points to the exact area of pain, then palpation
should be done to assess whether the pain is of musculoskeletal origin
Evaluations Techniques Musculoskeletal Angina Pleural

Palpation increases pain X
Exertion increases pain, rest X
decreases pain
Deep breath increase pain X
Evaluation of Circulation
- Pulses throughout the extremities should be palpated during the initial evaluation because of the diffused nature of
atherosclerotic disease
- The quality of the pulse should be noted and compared to the pulses of the opposite extremity
Mediate Percussion
- Performed with the middle finger of one hand placed flat on the chest wall
along the ICS between 2 ribs (usually the nondominant hand), while all
other fingers are lifted off the chest wall. The other hand is positioned with
the wrist in dorsiflexion, acting like a fulcrum, and the hand moving forward
and back in rapid succession with the tip of the middle finger striking the
nondominant middle finger on the chest wall.
 (N) sound: when a normal lung tissue is percussed and normal resonance is
produced
 Dull sound: produced with percussion over

the liver or other dense tissues (consolidation
or tumors) “thud” Tympanic sound: loud,
long, and hollow and may be heard over an
empty stomach or a hyperinflated chest
23
Diaphragmatic Excursion
Can also be assessed by percussion
- Patient must be seated with the back exposed

- Percussion from the apex of the lungs to the bases of the lungs is performed while the patient is quietly breathing,
and a line measuring the points of demarcation between
resonance to dullness is drawn on the left side and the right
- After these lines are drawn, the PT asks the patient to take a
maximal inspiration and to hold breath
- PT continuous percussion from the line downward to determine
where the new point of dullness to resonance is located and draws
a second line
- The distance between the lines is the distance of diaphragmatic
excursion
- (N): 3-5cm
Activity Evaluation
24
Interventions for Acute Cardiopulmonary Conditions

Factors that contribute to functional loss
 Acute inflammation
 Severity of illness
 Marginal Baseline Function
 Exposure to Corticosteroids
 Neuromuscular Blockers
 Prolonged immobilization
 Length of Hospital stay
Acute Cardiopulmonary Conditions – diseases or states in which the patient’s oxygen transport system fails to meet the immediate
demands placed on it
Clinical Systemic Effects of Immobilization
Cardiovascular System
- Increase basal heart rate

- Decreased maximal heart rate
- Decreased maximal oxygen uptake
- Orthostatic hypotension
- Increased venous thrombosis risk
- Decreased total blood volume
- Decreased hemoglobin concentration
Respiratory System
- Decreased vital capacity

- Decreased residual volume
- Decreased PaO2
- Impaired ability to clear secretions
25
- Increased ventilation-perfusion mismatch
Musculoskeletal System
- Decreased strength
- Decreased girth
- Decreased efficiency of contraction
- Joint contractures
- Decubitus ulcers
Central nervous system
- Emotional and behavioral disturbances

- Intellectual deficit
- Altered sensation
Metabolic System
- Hypercalcemia
- Osteoporosis
Airway Clearance Techniques
1. Postural drainage
2. Percussion
3. Vibration
4. Cough techniques
5. Manual hyperinflation
Indications for Airway Clearance Techniques
1. Impaired mucociliary transport

2. Excessive pulmonary secretions
3. Ineffective of absent cough
 Observe hospital infection control policies and procedures (i.e. Gowns, masks, gloves, and googles)
 Assess patient before, during, and after treatment
DO’s of Airway Clearance Techniques
1. Perform before or at least 30 minutes after end of meal or tube feeding

2. pain control prn
3. Inhaled bronchodilator meds before procedure
4. Inhaled antibiotics after procedure
5. Proper body mechanics
6. Monitor vital signs
Goals of Airway Clearance Techniques
1. Optimize airway patency

2. Increase ventilation and perfusion matching
3. Promote alveolar expansion and ventilation
4. Increase gas exchange
Duration and Frequency of the techniques are based on pulmonary reevaluation at each session
26
Postural Drainage
- The assumption of one or more body positions that allow gravity to assist with draining secretions from each of the patient’s
lung segments
- The segmental bronchus of the area to be drained is arranged perpendicular to the floor
Requirements for Postural Drainage

 Adjustable bed
 Pillows or blanket rolls
 Enough personnel
 Tissue
 Sputum cup
 Air suctioning equipment
 Body substance barriers
Goals and Indications for Postural Drainage
Prevent Accumulation of Secretions in Patients at Risk for Pulmonary Complications
 Patients with pulmonary diseases that are associated with increased production or viscosity of mucus, such as chronic
bronchitis and cystic fibrosis
 Patients who are on prolonged bed rest
 Patients who have received general anesthesia and who may have painful incisions that restrict deep breathing and
coughing postoperatively
 Any patient who is on a ventilator if he or she is stable enough to tolerate the treatment
 Remove Accumulated Secretions from the Lungs
 Patients with acute or chronic lung disease, such as pneumonia, atelectasis, acute lung infections, COPD
 Patients who are generally very weak or are elderly
 Patients with artificial airway
TAKE NOTE!
 May be used exclusively or in combination with other airway clearance techniques.

 If used exclusively, each position should be maintained for 5 to 10 minutes or longer, if tolerated.
 Priority should be given to treating the most affected lung segments first.
27
 Encouraged patient to take deep breaths in the PD position and cough (or be suctioned) between positions as secretions
mobilize.
 Number of PD positions tolerated per treatment session, vary with each patient.
Signs of Treatment Intolerance
Precautions Relative contraindications

- Pulmonary edema - Increased intracranial pressure
- Hemoptysis - Hemodynamically unstable
- Massive obesity - Recent esophageal anastomosis
- Large pleural effusion - Recent Spinal fusion or injury
- Massive ascites - Recent head trauma
- Diaphragmatic hernia
- Recent eye surgery
Kisner
- Severe hemoptysis
- Untreated acute conditions
o Severe pulmonary edema
o Congestive heart failure
o Large pleural effusion
o Pulmonary embolism
o Pneumothorax
- Cardiovascular instability
o Cardiac arrhythmia
o Severe hypertension or hypotension
o Recent myocardial infarction
o Unstable angina
- Recent neurosurgery
28
o Head-down positioning may cause increase intracranial pressure; if PD is required, modified positions can be used
29
30
Guidelines for Implementing Postural Drainage (Kisner)

General Considerations
Time of the day
 Never administer postural drainage directly after a meal.

 Coordinate treatment with aerosol therapy.
 Choose a time (or times) of day likely to be of most benefit to the patient. A patient’s cough tends to be highly productive in
the early morning because of accumulation of secretions from the night before. Postural drainage in the early evening
clears the lungs prior to sleeping and helps the patient rest more easily.
Frequency of Treatments
 Depends on the type and severity of a patient’s pathology.

 Thick and copious secretions, 2-4x a day until the lungs are clear.
 If a patient is on a maintenance program, the frequency is less, perhaps once a day or only a few days a week.
Preparation for Postural Drainage
 Loosen tight or bulky clothing. It is not necessary to expose the skin. The patient may wear a light weight shirt or gown.
 Have a sputum cup or tissues available
 Have sufficient pillows for positioning and comfort.
 Explain the treatment procedure to the patient.
 Teach the patient deep breathing and an effective cough prior to beginning postural drainage.
 If the patient is producing copious amounts of sputum, instruct the patient to cough a few times or have the patient suctioned
prior to positioning.
 Make any adjustments of tubes and wires, such as chest tubes, electrocardiography wires, or catheters, so they remain clear
during positioning.
Postural Drainage Sequence
 Determine which segments of the lungs should be drained.

 Check the patient’s vital signs and breath sounds.
 Position the patient in the correct position for drainage. See that he or she is as comfortable and relaxed as possible.
 Stand in front of the patient, whenever possible, to observe his or her color.
 Maintain each position for 5-10minutes if the patient can tolerate it or as long as the position is productive.
 Have the patient breathe deeply during drainage but do not allow the patient to hyperventilate or become short of breath.
Pursed-lip breathing during expiration is sometimes used.
 Apply percussion over the segment being drained while the patient is in the correct position.
 Encourage the patient to take a deep, sharp, double cough whenever necessary. It may be more comfortable for the patient to
momentarily assume a semi upright position (resting on one elbow) and then cough.
 If the patient does not cough spontaneously during positioning with percussion, instruct the patient to take several deep
breaths or huff several times in succession as you apply vibration during expiration. This may help elicit a cough.
 If the patient’s cough is not productive after 5to10minutes of positioning, go on to the next position. Secretions that have
been mobilized during a treatment may not be coughed up by the patient until 30minutes to 1hour after treatment.
 The duration of anyone treatment should not exceed 45 to 60minutes, as the procedure is quite fatiguing for the patient.
Concluding a Treatment
 Have the patient sit up slowly and rest for a short while after the treatment. Watch for signs of postural hypotension when the
patient rises from a supine position or from a head-down position to sitting.
31
 Advise the patient that even if the cough was not productive during treatment it may be productive a short while after
treatment.
 Evaluate the effectiveness of the treatment by reassessing breath sounds.
 Note the type, color, consistency, and amount of secretions produced.
 Checkthepatient’svitalsignsaftertreatmentandnotehowthepatienttoleratedthetreatment.
Criteria for Discontinuing Postural Drainage
 If the chest radiograph is relatively clear

 If the patient is afebrile for 24to48hours
 If normal or near-normal breath sounds are heard with auscultation
 If the patient is on a regular home program
Modified Postural Drainage (Kisner)
CHF Patient  Orthopnea (SOB in bed flat position)

Neurosurgery  Trendelenburg
Thoracic Surgery  (+) Chest tubes and monitoring devices
Percussion – aimed at loosening retained secretions can be performed manually or with a mechanical device
Do’s and Don’ts for Percussion
 Apply to the affected lung segments individually and not just generally on the lungs
 Manual percussion consists of a rhythmical clapping with cupped hands over the affected lung segment.
 A hollow thumping sound should be produced. Elbows and wrists are relaxed
 Slapping sounds indicate poor technique and may cause discomfort or injury to the patient
 performed during inspiration and expiration
 Steady rhythm between 100 and 480 times per minute
 Clapping on bony prominences should be avoided while performing percussion
32
Precautions and Relative Contraindications for Percussion and Vibration
Precautions Relative Contraindications

- Uncontrolled bronchospasm - Hemoptysis
- Osteoporosis - Intreated tension pneumothorax
- Rib fractures - Platelet count below 20,000 per mm3
- Metastatic cancer to ribs - Unstable hemodynamic status
- Tumor obstruction of airway - Open wounds, burns in the thoracic area
- Anxiety - Pulmonary embolism
- Coagulopathy - Subcutaneous emphysema
- Convulsive or seizure disorder - Recent skin grafts or flaps on the thorax
- Recent pacemaker replacement
Relative Contraindications to Percussion (Kisner)
 Over fractures, spinal fusion, or osteoporotic bone

 Over tumor area
 If a patient has a pulmonary embolus
 If the patient has a condition in which hemorrhage could easily occur, such as in the presence of a low platelet count, or if the
patient is receiving anticoagulation therapy
 If the patient has unstable angina
 If the patient has chest wall pain, for example after thoracic surgery or trauma
Vibration
- An airway clearance technique that can be performed manually or with a mechanical device
- Often is used in conjunction with percussion to help move secretions to larger airways
- Applied only during the expiratory phase as the patient is deep-breathing (kisner)
Procedure
 The palmar aspect of the clinician’s hands is in full contact with the patient’s chest wall, or one hand may be partially or fully
overlapping the other
 At the end of a deep inspiration, the clinician exerts pressure on the patient’s chest wall and gently oscillates it through the
end of expiration
 Manual vibration frequency is 12 to 20 hz
 Sequence is repeated until secretions are mobilized
 Vibration may be a useful alternative to percussion in acutely ill patients with chest wall discomfort or pain
33
Cough Techniques and Assists
- Voluntary or Reflex
Four Stages of Effective Cough
1. Inspiration Greater than Tidal Volume: adequate inspiratory volumes for an effective cough are noted to be at least 60%
of the patient’s predicted VC
2. Closure of the Glottis: Traps air inside the lungs
3. Abdominal and Intercostal Muscles Contraction: producing positive intrathoracic pressure
4. Sudden opening of the Glottis: leads forceful expulsion of the inspired air (kisner)
The patient should exhibit a deep inspiration combined with trunk extension a momentary hold, and then a series of sharp expirations
while the trunks moves into flexion
Any absence or deficiency in this sequence of events is likely to result in an ineffective cough  can lead to retained secretions which
can progress to atelectasis, hypoxemia, pneumonia, and potentially respiratory failure.
Surgical patients will need to be instructed in how to splint their incision
If pain is inhibiting the patient’s ability to performed proper coughing techniques, pain medication should be administered in time for
it to be effective during the patient’s session with the Physical Therapist
Huffing
- A deep inspiration followed by a forced expiration without glottal closure

- Often used in postoperative patients who find coughing to be too painful
Active Cycle of Breathing
- Consists of a series of maneuvers performed by the patient to emphasize independence in secretion clearance and
thoracic expansion
- According to studies, as effective as airway clearance techniques performed by a therapist or caregiver
Patterns for Active Cycle of Breathing
1. Breathing control: The patient performs diaphragmatic breathing at normal tidal volume for 5 to 10 seconds.
2. Thoracic expansion exercises: In a postural drainage position the patient performs deep inhalation with relaxed exhalation at
vital capacity range. This inhalation can be coupled with or without percussion during exhalation.
3. Breathing control for 5 to 10 seconds.
4. Thoracic expansion exercises repeated three to four times.
6. Forced expiratory technique: The patient performs one to two huffs at mid to low lung volumes. The patient is to concentrate
on abdominal contraction to help force the air out. The glottis should remain open during the huffing.
According to research, although breathing exercises or ventilatory muscle training affects and possible alter a patient’s rate and depth
of ventilation these may not necessarily have nay impact on gas exchange at the alveolar level or an oxygenation.
Exercises to improve ventilation should be combined with medication, airway clearance, the use of respiratory therapy devices, and a
graded exercise (aerobic conditioning) program.
34
Breathing Exercises and Ventilatory Training are fundamental interventions for the prevention or comprehensive management of
impairments related to acute or chronic pulmonary disorders.
Goals of Breathing Exercises and Ventilatory Muscle Training
Improve or redistribute ventilation.
 Increase the effectiveness of the cough mechanism and promote airway clearance.
 Prevent postoperative pulmonary complications.
 Improve the strength, endurance, and coordination of the muscles of ventilation.
 Maintain or improve chest and thoracic spine mobility.
 Correct inefficient or abnormal breathing patterns and decrease the work of breathing.
 Promote relaxation and relieve stress.
 Teach the patient how to deal with episodes of dyspnea.
 Improve a patient’s overall functional capacity for daily living, occupational, and recreational activities.
Guidelines for Teaching Breathing Exercises
- If possible, choose a quiet area for instruction in which you can interact with the patient with minimal distractions.
- Explaintothepatienttheaimsandrationaleofbreathingexercisesorventilatorytrainingspecifictohisorherparticularimpairmentsa
ndfunctionallimitations.
- Have the patient assume a comfortable, relaxed position and loosen restrictive clothing. Initially, a semi-Fowler’s position
with the head and trunk elevated approximately 45degrees, is desirable. By supporting the head and trunk, flexing the hips
and knees, and supporting the legs with a pillow, the abdominal muscles remain relaxed. Other positions, such as supine,
sitting, or standing, may be used initially or as the patient progresses during treatment.
- Observe and assess the patient’s spontaneous breathing pattern while at rest and later with activity. Determine whether
ventilatory training is indicated.
- Establish a baseline for assessing changes, progress, and outcomes of intervention.
- If necessary, teach the patient relaxation techniques. This relaxes the muscles of the upper thorax, neck, and shoulders to
minimize the use of the accessory muscles of ventilation. Pay particular attention to relaxation of the
sternocleidomastoids, upper trapezius, and levator scapulae muscles.
- Depending on the patient’s underlying pathology and impairments, determine whether to emphasize the inspiratory or
expiratory phase of ventilation.
- Demonstrate the desired breathing pattern to the patient.
- Havethepatientpracticethecorrectbreathingpatterninavarietyofpositionsatrestandwithactivity.
Precautions for Teaching Breathing Exercises
Never allow a patient to force expiration. Expiration should be relaxed or lightly controlled.
 Do not allow a patient to take a highly prolonged expiration.

 Donotallowthepatienttoinitiateinspirationwiththeaccessorymusclesandtheupperchest.
 Allowthepatienttoperformdeepbreathingforonlythreeorfourinspirationsandexpirationsatatime.
35
Diaphragmatic Breathing
Goals:
- Designed to improve the efficiency of ventilation

- Decrease the work of breathing
- Increase the excursion (descent or ascent) of the diaphragm
- Improve gas exchange and oxygenation
Procedure
Prepare the patient in a relaxed and comfortable position in which gravity assists the diaphragm, such as a semi-Fowler’s position.
- If your examination revealed that the patient initiates the breathing pattern with the accessory muscles of inspiration
(shoulder and neck musculature), start instruction by teaching the patient how to relax those muscles (shoulder rolls or
shoulder shrugs coupled with relaxation).
- Place your hand(s)on the rectus abdominis just below the anterior costal margin. Ask the patient to breathe in slowly and
deeply through the nose. Have the patient keep the shoulders relaxed and upper chest quiet, allowing the abdomen to rises
lightly. Then tell the patient to relax and exhale slowly through the mouth.
- Have the patient practice this 3 or 4 times and then rest. Do not allow the patient to hyperventilate.
- If the patient is having difficulty using the diaphragm during inspiration, have the patient inhale several times in succession
through the nose by using a sniffing action. This action usually facilitates the diaphragm.
- To learn how to self-monitor this sequence, have the patient place his or her own hand below the anterior costal margin and
feel the movement. The patient’s hand should rise slightly during inspiration and fall during expiration.
- After the patient understands an disable to control breathing using a diaphragmatic pattern, keeping the shoulders relaxed,
practice diaphragmatic breathing in a variety of positions (sitting, standing) and during activity (walking, climbing stairs).
36
Segmental Breathing
- Controversial
- Emphasizes expansion of problem areas of the lungs or chest wall
Lateral Costal Expansion/Lateral Costal Expansion
- Technique is important for patients with a stiff lower rib cage, as is often seen with chronic bronchitis, emphysema,
or asthma
- Procedure:
o Have the patient begin in a hook-lying position; later progress to a sitting position. Place your hands along
the lateral aspect of the lower ribs to direct the patient’s attention to the areas where movement is to occur.
o Ask the patient to breathe out, and feel the ribcage move downward and inward. As the patient breathes
out, place pressure into the ribs with the palms of your hands. Just prior to inspiration, apply a quick
downward and inward stretch to the chest. This places a quick stretch on the external intercostals to
facilitate their contraction.
o Apply light manual resistance to the lower ribs to increase sensory awareness as the patient breathes in
deeply and the chest expands and ribs flare. Then, as the patient breathes out, assist by gently squeezing the
rib cage in a downward and inward direction.
o Teach the patient how to perform the maneuver independently by placing his or her hand(s) over the ribs or
applying resistance with a towel or belt around the lower ribs.
37
Segmental Breathing
Posterior Basal Expansion
- Technique is important for the postsurgical patient who is confined to bed

in a semi-reclining position for an extended period of time because
secretions often accumulate in the posterior segments of the lower
lobes
Lateral Costal Expansion/Lateral Costal Expansion
38
- Have the patient sit and lean forward on a pillow, slightly bending the hips. Place your hands over the posterior aspect of the
lower ribs, and follow the same procedure just described for lateral costal expansion
Pursed Lip Breathing
- Involves lightly pursing the lips together during controlled exhalation

- This breathing pattern often is adopted spontaneously by patients with COPD to deal with episodes of Emphysema
Studies suggest that pursed-lip breathing decreases the respiratory rate and the work of breathing (oxygen consumption), increases
the tidal volume, and improves exercise tolerance.
Precaution
- Use of forceful expiration during pursed-lip breathing must be avoided

- Have the patient assume a comfortable position and relax as much as possible.
- Have the patient breathe in slowly and deeply through the nose and then breathe out gently through lightly pursed lips as if
blowing on and bending the flame of a candle but not blowing it out.
- Explain to the patient that expiration must be relaxed and that contraction of the abdominals must be avoided. Place your
hand over the patient’s abdominal muscles to detect any contraction of the abdominals.
39
40
The Heart
- Primary pump that circulates the blood through the

entire vascular system
- It is a cone shape/inverted pyramid and tilted
forward to the left
- Relatively small roughly same size as a closed fist
- It rests above the diaphragm
- Located in mediastinum
41
o Cardiac surface is extending from the sternum to the vertebral column between the lungs
o 2/3 of the mass of Head (L) of body’s midline
Layers of the Heart

- Pericardium
o Fibrous connective sac that encloses and protects the heart
o Function: protects the heart from trauma and infection
- 2 Layers of Serous Pericardium
o Fibrous Pericardium
 Outer-most layer of pericardium
 Function: anchors the heart on mediastinum; prevents the heart from over stretching
o Serous Pericardium
 Inner-most layer of pericardium
 Function: Decreases friction in the Heart
 Located between the Visceral and Parietal Serous Pericardium
1. Visceral Serous Pericardium (Epicardium)

- adheres tightly to the heart
2. Parietal Serous Pericardium
- Outermost layer of the serous pericardium
- Adheres tightly to the fibrous pericardium
- Outer to inner (Fibrous  Parietal SP  Visceral SP)
- Myocardium
42
o Middle layer of the heart which consists of striated muscle fibers forming interlaced bundles and is the actual
contracting muscle of the heart
- Endocardium
o Innermost layer of the heart consists of thin endothelial tissue lining the inner chamber and the heart valves
Pericardial Fluid (10-20mL)
o Lubrication for cardiac contraction
o Conditions associated with disruption in the quantity of the pericardial fluid
Condition Cardiac Pericardial
Tamponade Friction Rub
Pain (-) (+)
Pericardial fluid Increased Decreased
Myocardial Pericarditis
Associated Infarction due to
Conditions inefficient pump of
blood
Surfaces of the Heart

Anterior Surface/Sternocostal Surface
- RA and RV where RV forms most Anterior surface of the Heart
Posterior Surface/Base Surface
- RA and LA where LA forms most Posterior Surface of the Heart
Inferior Surface/Diaphragmatic Surface
- RV and LV where LV forms the apex of the heart
Basic Functions of the Cardiovascular System

- Circulation of blood
- Delivery of oxygen, nutrients, and water
- Circulation of Hormones
- Regulation of Body temperature
- Removal of metabolites
- Maintenance of acid-base balance (pH)
Heart Chambers and Valves

Right Atrium (RA)
Tricuspid Valve
Right Ventricle (RV)
Pulmonary Valve
Left Atrium (LA)
Bicuspid Valve
Left Ventricle (LV)
Chambers of the Heart

1. Two upper collecting chambers (ATRIA)
Right atria – receives DEOXYGENATED BLOOD from the body via Superior and Inferior Vena cava
DP to enable filling range from 0-8mmHg (central pressure)
Left atria – receives OXYGENATED BLOOD from the lungs
DP to enable filling range from 4-12mmHg
43
2. Two lower pumping chambers (Ventricles)

Right Ventricle: Pulmonary Circulation
DP ranging from 0-8mmHg
SP ranging from 15-30mmHg
Left Ventricle: Systemic circulation which has the higher resistance
DP ranging from 4-12mmHg
SP ranging from 80-120mmHg
Septum – a muscular wall that separates the chambers of the right and the left
1. Interatrial Septum
Fossa Ovalis – Oval depression
Remnant of Foramen ovale
Fossa Ovale – opening of interatrial septum of a fetal heart
2. Interventricular Septum
The Conduction System of the Heart
Valves of the Heart

1. Atrioventricular Valves
Inlet
- Tricuspid valve
- Bicuspid valve
o both has leaflets or cusp that are attached to the
papillary muscle of the myocardium by Chordae
Tendineae
o Function: prevents backflow of blood into the
atria during ventricular contraction or systole
2. Semilunar valves
Outlet
- Pulmonic valve
- Aortic valve
o Function: prevents backflow of blood from the
aorta and pulmonary artery into the ventricles
during systole
Sinus node  Internodal pathway  AV node  AV bundles (bundle of His)  Purkinje fibers
 SA nodes depolarize (60 – 100bpm) causing Atrial contraction
 After a brief delay in the AV node to allow active ventricular filling, impulse travels to the AV bundles (bundle of His) which
then initiate Systole
 Diastole, ventricles repolarize and refills blood
 Impaired initiation of conduction of the impulse may result to:
o SA nodes = pacemaker is taken over by AV nodes (40 – 60bpm) or Ventricular pacemaker (25 – 40 bpm)
o AV node = AV, or heart, block (i.e. First degree, 2, or 3/complete), which causes delayed or failed conduction
44
o Bundle branches = RBBB/LBBB or Interventricular conduction delay which leads to late activation of one of the
ventricles
CARDIAC TISSUES BLOOD SUPPLY
 Coronary Artery
 It is responsible for the blood supple in the heart
Right Coronary Artery
- R atrium
- R ventricle (Major)
- L ventricle (Minor)
- SA Node
Left Coronary Artery
- L atrium
- L ventricle (Major)
- R ventricle (minor)
- Interventricular Septum
Possible Causes of Acute Coronary Syndrome
- MI in Right Coronary Artery is Fatal secondary to SA Node failure

- MI in Left Coronary Artery is Fatal secondary to L ventricular failure
- Most common Coronary Artery occluded – L Coronary Artery > R Coronary Artery due to more blood flow to Left leads to
greater disposition of deposits in that Artery
1. Excitability – the ability of the cardiac muscle cells to depolarize in response to a stimulus – excitability – is influenced by
hormones, electrolytes, nutrition, oxygen supple, medications, infection, and autonomic nerve activity
2. Automaticity – the ability of the cardiac pacemaker cells to initiate an impulse spontaneously and repetitively, without
external neurohormanal control.
3. Contractility – The action potential initiates the muscle contraction by release calcium through the T tubules of the cell
membrane
a. Ca reaches the sarcoplasmic reticulum, causing additional Ca release
b. Intracellular Ca diffuses to myofibrils, where it binds with troponin. When actin filaments become activated by
calcium, the heads of the cross-bridges from the myosin filament immediately becomes attracted to the active sites
of actin
45
c. Contraction occurs by power stroke repetition

d. After contraction, free Ca ions are actively pumped back into the sarcoplasmic reticulum, and muscle relaxation
begins.
4. Conductivity – the ability of the heart muscle fibers to propagate electrical impulses along and across cell membranes
a. The heart muscle must conduct the action potential from its origin throughout the heart both rapidly and smoothly so
that the atria and ventricles contracts as a unit.
Excitability – Phases of Cardiac Action Potential

 Depolarization
Phase 0
 Inward current of Na
 Initial Repolarization
Phase 1  Decrease influx of Na
 Outward current of K
 Plateau
Phase 2
 Inward current Ca
 Repolarization
Phase 3  Decrease influx of Ca
 Outward current of K
 Resting Membrane Potential
Phase 4
 Returns to -88mV
46
Conduction System
- SA Node (Pacemaker)
- AV Node
- Bundle of His and Bundle branches
- Purkinje fibers
Cardiac Muscle Innervation
- Pumping effectiveness controlled by

sympathetic and parasympathetic nerves
(Vagus – CN X)
o Sympathetic
 Increase HR
 Increase force of
contraction
 Increase volume of blood
pumped, increase ejection
pressure
o Parasympathetic
 Decrease or stop the heartbeat
 Decrease strength of heart contraction
 Vagal fibers distribute to the atria
Cardiac Cycle
- One cardiac cycle is equivalent to one complete heartbeat. It is initiated by spontaneous generation of an action potential in
the SA node and ends following the filling of the relaxed ventricles
o Diastole – period of ventricular relaxation
o Systole – period of ventricular contraction
47
Diastole
- Period of rapid filling of the ventricles: AV

Valves (open), SL Valves (closed)
48
o First third of Diastole – 7% of blood gets sent from Atrias to Ventricles “Passively”
o Middle Third of Diastole – continuous blood flow
o Last Third of Diastole – 25% of blood gets sent from Atrias to Ventricles “Passively” Atrial Systole/Atrial Kick
o Maximum blood flow occurs in the first third of Diastole
Systole
- Period of Isovolumetric Contraction

o Blood inside the ventricles
o Increased ventricular pressure
o AV valves closed; SL valves closed (only period where all valves closed)
- Period of Ejection
o Afterload – ventricular force required to open the SL valves
o LV = 80mmHg (Aorta)
o RV = 8mmHg (Pulmonary Artery)
o SL Valves – open
o First third of ejection: 70% of blood – Ventricles to Pulmonary A. & Aorta
 Fast Ejection
o Last 2/3rds of Ejection: 30% of blood-ventricles to pulmonary A. & Aorta
 Slow Ejection
- Period of Isovolumetric Relaxation
o Distention of Blood vessels
o Decreased ventricular pressure
o SL valves closed
Important Physiologic Relationships
Cardiovascular function is determined by a number of factors and relationships
- Cardiac output (CO) is the volume of blood pumped by the heart per minute and is the product of heart rate (HR) and stroke
volume (SV) i.e. CO = HR x SV)
o Normal resting HR is 60-100bpm and stroke volume is usually 50-80mL being higher in the supine position than
upright; thus. Resting CO is typically 4-5 L/min
- Preload is the resting tension or stretch on the myocardial cells, which correlates with the volume of blood in the ventricle at
the end of filling
- Afterload refers to the load or pressure against which the ventricle must work to eject blood, which corresponds to the
pressure resisting the ejection of blood during systole
- Contractility. Or inotropic state is the innate rate and intensity of force development during contraction
o Increase in inotropism during exercise, anxiety, fear – causes faster myocardial shortening at any given preload and
afterload, as well as a greater degree of shortening and force development
- Ventricular compliance refers to the ease with which the ventricle distends when it is filled with blood.
Electrocardiogram
P wave – Atrial depolarization (Pacemaker wave)

QRS – Ventricular depolarization
T wave – Ventricular repolarization
PR interval – beginning of P wave to the beginning of QRS complexes
QT interval – Beginning of QRS complexes to end of T wave
PR segment – End of P wave to beginning of QRS complexes
49
ST segment – end of QRS complex to beginning of T wave
Lungs
Mediastinum
- Moveable partition that extends:

o Superior: thoracic outlet and the root of the neck
o Inferiorly: Diaphragm
o Anteriorly: Sternum
o Posterior
50
Aortic Aneurysms
Aorta
o Largest artery
o Supplies O2 blood  Body
Aortic Aneurysms – Bulge/“Ballooning” of aorta that runs from heart  chest & abdomen
2 types:
- Thoracic Aortic Aneurysm (TAA)
- Abdominal Aortic Aneurysm
51
Shapes
- Fusiform
o Most common
- Saccular
o Caused by trauma or severe aortic ulcer
Etiology
- Atherosclerosis*
- Inflammatory disease
o Takayasu’s Arthritis
- Genetic Connective Tissue Disorders
o Marfan Syndrome (Ehlers-Danlos Syndrome) – causes the
aortic wall to weaken & possibly rupture
- Physical Trauma to chest or abdomen
Risk Factors
 Smoking
 Age
 Male gender
 Caucasian
 Family Hisotyr
Epidemiology
 Men = Women
 Older age (+65 y/o)
 White > Black population
Clinical Manifestations
1. Abdominal Aortic Aneurysms
- Manifested as pulsatile mass

- causes abdominal discomfort or pain
- expansion can cause compression on neighboring structures
o Increasing pain and radiation on groin, buttocks, or legs
- Aneurysms Dissection, or impending rupture provokes sudden, excruciating pain and distress
o Hypotension, tachycardia, pallor, diaphoresis, or shock
2. Thoracic Aortic Aneurysms

52
- Can occur in ascending or descending aorta

- symptoms vary from size and location
- Symptoms of CHF may develop in ascending AA d/t aortic valve regurgitation or rupture of an aneurysm of the sinuses of
Valsalva directly in the RV cavity, RA, or PA
o Involvement of the sinuses of Valsalva w/ direct compression or thromboembolism of the coronary arteries can lead
to Myocardial Ischemia or Infarction
- Chest pain can be induced by compression of surrounding structures, erosion into adjacent ribs, sternum, or vertebrae, or
aneurysms dissection or rupture.
3. Thoracoabdominal Aortic Aneurysms
Can cause:
- Epigastric or Left Upper Quadrant discomfort

- Back or flank pain when px. Lies in left lateral decubitus position
- Radiculopathy d/t erosion of vertebral bodies
- Peripheral atheroembolism
Rupture of Thoracic portion occurs into the left pleural space  Hemothorax and chest pain
Rupture of Abdominal portion  severe abdominal and back pain
Diagnosis
- Physical examination (size, type, location):

o CXR
o 3D-CT scans
o Ultrasound
o Aortic Angiography
o MRI scans
Treatment
- Minimize the risk of progressive atherosclerotic vascular damage

- US or CT scan every 6 months
o 4.0 – 5.5cm in diameter for men
o Smaller size for women (aneurysms rupture occurs at smaller diameters in women)
- Surgical Repair
o Synthetic aortic graft
o Expanding Endovascular Stent Grafts
 For aneurysms >5.5cm in diameter or rapidly expanding aneurysms (0.5cm/year)
- Frequent monitoring (I.e. Marfan’s syndrome)
o Higher risk of dissection and rupture
o Surgical repair when the aneurysms reach 5 cm in diameter
53
Cardiomyopathy
A. Dilated Cardiomyopathy
- Idiopathic
- Infectious and non-infectious inflammatory processes
- Alcohol abuse
Myocarditis
Diagnosis
- Echocardiography
54
o M-mode Echocardiography
- Electrocardiography (ECG)
o Ambulatory/Holter Monitoring
- Exercise and Stress Testing
o Use to determine heart complications during heart workload
o Exercise Testing – Graded exercise testing
Treatment
Dilated Cardiomyopathy Hypertrophic Myopathy Restrictive Myopathy

Clinical Manifestation
 Dyspnea initially on exertion and  Dyspnea • Impaired exercise intolerance
then at rest  Angina pectoris • Weakness and fatigue
• Nocturnal dry cough  Fatigue and weakness • Dyspnea
• Signs and symptoms of LV  Presyncope and syncope • Increased central venous pressure
failure  Palpitations leading to jugular venous distension,
• Possible signs and symptoms of  On occasion, paroxysmal nocturnal peripheral edema, enlarged liver, ascites
RV failure dyspnea and symptoms of CHF • S3, S4, or both
• Chest pain on exertion  LV lift; point of maximal impulse • Possible inspiratory increase in venous
• LV impulse displaced lateral to displaced laterally, abnormally pressure (Kussmaul’s sign)
the mid-clavicular line forceful and enlarged; possible • Symptoms of CHF
• S3–S4 summation gallop rhythm prominent presystolic apical impulse, • Diastolic dip and plateau (square root
• Systolic murmurs of mitral systolic apical thrill sign) in ventricular pressure pulse;
and/or tricuspid regurgitation prominent a wave, often of same
 Loud S4 (fourth heart sound); harsh
caused by ventricular dilatation amplitude as the v wave
diamond-shaped systolic murmur if
 Atrial enlargement, decreased • Conduction disturbances, arrhythmias,
HOCM develops, which may radiate
QRS, nonspecific ST–T changes and ST–T abnormalities on ECG
to lower sternal border, axillae, and
on ECG base of heart; possible murmur of
 Considerable cardiomegaly, mitral regurgitation
possible LA and RA  Briskly rising carotid pulse, which
enlargement, and redistribution may decline in mid-systole as
of blood flow on chest x-ray outflow obstruction develops
examination  ST–T abnormalities and sometimes
LVH on ECG; there may also be
prominent abnormal Q waves in
inferior and/or lateral leads
 Supraventricular tachycardia;
ventricular arrhythmias, including
tachycardia and fibrillation causing
sudden death; occasional atrial
fibrillation
55
Myocardial Infarction
- Zone of Infarction
o Myocardial hypoxia
o Necrosis
o Leukocytes remove dead cells
o Fibroblast produce fibrotic proteins (collagen) and form a fibrous scar within the area of infarction. (Formation: 6 –
8 weeks)
- Zone of Hypoxic Injury
o Less damage to the area
o May return to normal or may also be necrotic
o Adequate collateral function (function regains 2-3 weeks)
- Zone of Ischemia
o Causes ECG changes
o Myocardial healing, ST and T may gradually return to normal, but abnormal Q waves
56
Oxygen Deprivation
- Electrolyte disturbances, loss of:

o Potassium
o Calcium
o Magnesium
- Myocardial cells oxygen deprivation
o Lose of contractility = diminished pumping ability
Biomarkers used to identify MI:
- Positive after onset of MI: 4-6 hours (Abnormal 8 – 12hrs)
Cardiopulmonary Implications of Specific Diseases

Obesity
- Obesity is defined as an excessive accumulation of adipose tissue such that body mass index (BMI) is 30kg/m2 or more
- Obesity is a chronic disorder that is caused by a complex interplay between environmental from an excess of energy intake
compared with energy expenditure
57
Risk Factors for Obesity
- Environmental factors are involved in the prevalence of obesity

- Activity and Lifestyle
o Dietary factors promoting obesity and lower cost of high energy density foods
o Sleep deprivation
- Genetics
o Hormonal and metabolic factors
o Medical conditions (e.g. hypothyroidism, Cushing’s, GH deficiency)
- Medications
- Prenatal and Postnatal history
Obesity as Health Hazard
- Hypertension
- Coronary Artery Disease (CAD)
- Stroke
- Insulin resistance
- Glucose intolerance
- Type 2 DM
- Dyslipidemia
- Gallbladder disease
- OA
- Orthopedic problems
- Sleep-related breathing problems
- Gynecologic problems
- Obesity hypoventilation syndrome
- Pulmonary HTN
- Certain forms of cancer
- Increasing BMI = Greater risk

- More important than the amount of body fat is the location of excess fat
- Substantial evidence indicates that abdominal (or central) obesity, particularly intraabdominal or visceral adiposity, is a beer
predictor of CVD and Type 2 DM than BMI
- Visceral Adipose Tissue (VAT) is associated with increased release of free fatty acids (FFAs) by adipocytes through
lipolysis, which enter the circulation and may become deposited as ectopic fat in the skeletal muscle, liver, heart, and
pancreas and ultimately induce insulin resistance.
58
- Accumulation of fat in the Gluteofemoral areas is not associated with increased CVD risk and may even metabolically
protective by acting as a “sink” for excess circulation FFAs and thus prevent ectopic fat storage
- Waist circumference (WC) or waist-hip circumference ration (WHR) which takes into account the distribution of body fat, is
recommended when defining disease risk
o 40 inches (102cm): Men
o 35 inches (88cm): Women
o Measure along the horizontal plane at the level of the iliac crest to define central obesity.
- Development of cardiometabolic complications in obese patients appears to be related to changes in adipocyte function
induced by hyperplasia and hypertrophy of fat cells, particularly those in VAT
- Adipose tissue is recognized as the largest endocrine organ in the body, which secrets numerous proteins, including:
o Hormones, cytokines, complement factors, enzymes, and other proteins, that are essential for energy homeostasis,
glucose and lipid metabolism, cell viability, control of feeding, thermogenesis, neuroendocrine function,
reproduction, immune system function, and CV function
- CV problems associated with overweight and obesity include HTN, CAD, stroke, Heart failure (HF), and sudden death
- Major complications are related to atherosclerotic CVD, the risk of which is directly related to BMI, WC, and WHR
- Reduced adiponectin and elevated levels of leptin and several other adipokines likely play important roles in the development
of these risk factors
-
-
59
- there is a direct linear relationship between magnitude of weight gain and increases in blood pressure (BP), and even a
moderate gain of weight is associated with an increased risk of developing HTN
- Pulmonary problems that are associated with obesity include altered respiratory physiologic parameters, obstructive
sleep apnea – hypopnea syndrome (OSAHS), the obesity hypoventilation syndrome (OHS), and pulmonary venous and
arterial HTN at rest or during exercise
- Total pulmonary compliance is decreased by 25% in simple obesity and by as much as 67% in individuals with OHS
reductions in both thoracic compliance and lung compliance
- Obese individuals tend to have rapid, shallow breathing pattern, which further increases the work of breathing. The
disproportionately high amount of energy required for breathing impairs exercise tolerance and may place obese persons at
greater risk for respiratory failure when conditions provoking increased ventilatory demands develop
- Most common alterations seen on PFTs are decreased expiratory reserve volume (ERV) and functional residual capacity
(FRC), which can occur even in modest obesity, and diminished TLC in morbid obesity
- Obesity is the strongest risk factor for OSAHS; a 10% increase in body weight in 4 years is associated with a sixfold greater
risk in developing sleep apnea (complete absence of airflow) or hypopnea
- Obstructive sleep-apnea-hypopnea syndrome is characterized by five or more episodes per hour of sleep-disordered
breathing lasting at least 10secs in adults, with apnea (complete obstruction) versus loud snoring or choking (partial
obstruction), accompanied by hypersomnolence during the day and often morning headaches
Treatment of Obesity
- The most successful strategy for the treatment of obesity is a stepped-care approach
- Mild-moderate obesity is traditionally treated using caloric restriction and other diet modifications, increased physical
activity, and behavioral modifications that can be maintained for life, such as self-monitoring of eating and shopping
behaviours
- Diet modification is the most common intervention used to reduced weight and consists of altering total caloric intake
and/or dietary composition to create a negative energy balance
- For individuals with more severe obesity, medications aimed at normalizing the regulatory and metabolic disturbances that
are involved in the pathogenesis of obesity may be added to lifestyle modifcations
- For patients with extreme obesity, Bariatric surgery is the most effective treatment, inducing impressive long-term weight
loss
- Energy-restricted diets commonly reduce energy intake by 500 to 1000cal/day, which effects the loss of 1-2lb of fat per
week (a caloric deficit of 3500 cal is required to lose 1lb of adipose tissue)
Clinical Implications to PT
- Consideration should be given to the presence of any CV risk factors and medical comorbidities, the medications and
supplements the individual is taking, the presence of orthopedic complications that might affect treatment, and past exercise
experience and attitudes
- Monitoring of the physiologic responses to exercise is indicated during PT evaluation and initial treatments
o Obese individuals may exhibit a hypertensive response to exercise even when resting BP is normal, whereas those
with impared ventricular function may show a drop in BP with exercise because of reduced Cardiac output
- And endurance training program should be prescribed for all obese patients in order to increase energy expenditure, lower
CV risk factors, and improve respiratory muscle and functional efficiency
- To achieve and maintain long-term weight loss, at least 45-60mins/day of at least moderate exercise totalling at least 250-
300mins per week may be required
- Non-weight breathing exercise programs, such as cycling, swimming, or water aerobics, will decrease the stress on joints,
which often suffer from OA
60
- Resistance exercise also improves endurance as well as muscle strength and thus enhances the performance of functional
tasks and weight loss
Metabolic Syndrome
- Refers to a cluster of interrelated risk factors associated with increased of CVD events and death, type 2 DM, and chronic
kidney disease (CKD)
- Most commonly recognized metabolic risk factors are central or visceral obesity, atherogenic dyslipidemia (I.e. elevated
serum triglyceride, apolipoprotein B, and small low-density lipoprotein partciles and reduced high0density lipoprotein
cholesterol), HTN, and insulin resistance
61
Diabetes Mellitus
- DM is aroup of chronic metabolic diseases characterized by hyperglycemia, which results from defects in suling production,
insulin action, or both
- Deficiency of insulin or resistance to its action results in elevated BG levels, which eventually causes damage to the blood
vessels, heart, kidneys, eyes, and peripheral nerves, as well as increased susceptibility to periodontal disease and other
infection, particularly pneumonia, influenza, and skin infections
Different Types
- Type 1 DM (formerly insulin-dependent diabetes)
- Type 2 DM (formerly non-insulin dependent diabetes)
- Gestational DM
- DM from secondary causes
Type 1
 Caused by autoimmune destruction of B-cells in the pancreas resulting in complete lack of insulin secretion
 Usually by the age of 10-25
 Approximately 85% - 90% of patients have antibodies to islet cells or glutamic acid decarboxylase (GAD) or other
autoantibodies
 These individuals develop extreme hyperglycemia, ketosis and the associated symptomatology (polyuria, polydipsia,
weight loss, and sometimes polyphagia)
 Diabetic ketoacidosis is the most serious acute complication of uncontrolled type 1 DM
62
o Manifested by marked hyperglycemia, nausea and vomiting, polydipsia, polyuria, abdominal pain, fruity-scented
(ketotic) breath, dry skin and mouth weakness or fatigue, and rapid deep (Kussmaul) breathing
Type 2
 90%-95% causes of DM
 A genetically heterogenous disease that is characterized by insulin resistance, relative insulin deficiency, and progressive
decline in B-cell function over time
 Hyperglycemia results from an increases rate of hepatic glucose production as a consequence of hepatic insulin
resistance, as well as B-cell dysfunction and eventual failure
 Chief risk factors for developing type 2 DM are (85% - 90% obese patient), particularly abdominal obesity, age,
sedentary lifestyle, and genetic predisposition
 The symptoms of type 2 DM are often insidious and mild, consisting of fatigue, weakness, dizziness, blurred vision, and
other nonspecific complaints
 Individuals with type 2 DM, particularly obese adolescents, may exhibits overt signs of insuling resistance, such as
acanthosis nigricans, which is velvety dark hyperpigmentation of the skin occurring in the folds of the neck, axilla, and
other areas, or skin tags
 Diabetic ketoacidosis is rare in patients with type 2 DM, ecept when stressed by a severe intercurrent illness (e.g. acute
MI or septicemia), because they retain some endogenous insulin secretions
 Uncontrolled hypeglycemia leads to dehydration and a hyperosmolar hyperglycemic non ketotic syndrome (HHNS),
which is manifested as postural hypotension and focal neurologic deficits and hallucinations an is often fatal.
Diagnosis
o Measurement of Glycosylated hemoglobin (Hb A1c, or simple A1c) is considered the gold standard as an indicator of the
degree of glycemic control achieved by an individual over the preceding 2-3 month period
Cardiovascular Complications of Diabetes Mellitus

- Cardiovascular disorders are the most common cause of morbidity and mortality in people with both types of DM
63
- The vast majority of patients with DM will develop CVD as a result of atherosclerosis (macro-angiopathies) that commonly
manifests as CAD, stroke, and PAD, CKD, Peripheral neuropathies which tend to occur at an earlier age and with greater
severity than in nondiabetics
o Abnormalities of the small blood vessels (microangiopathies caused by thickening or damage to the capillary
basement membrane_ often induce damage to the eyes, kidneys, and nerves
DM & Exercise
- Sustained physical activity induces a reduction in insulin secretion and enhanced secretion of the glucagon and other
counterregulatory hormones
o Stimulation of hepatic glucose production and enhanced mobilization of muscle glycogen and FFAs
 For adequate fuel to energize the exercising muscles
Treatment of DM
- Major goal of treatment for DM
- Minimize the resultant long-term damage, dysfunction, and failure of various organs, especially the eyes, kidneys, nerves,
heart, and blood vessels
- Treatment is individualized and varies according to the type of DM and metabolic status; it may include education:
o Diet modification
 (high monounsaturated fat acid (MUFA) and high-fiber diets)
 Exercise
 Insulin therapy and/or oral hypoglycemic agents
64
Clinical Implication to PT of DM
- Caution is required when providing PT to patients with DM, given the abnormal glucoregulatory responses of diabetics to
exercise and the prevalence of cardiovascular complications
- HR and BP monitoring should be included in PT evaluation during initial treatment (patients with abnormal hemodynamic
responses)
o Exercise is contraindicated if resting SBP is higher than 200 mmHg or diastolic blood pressure (BPD) is above
100mmHg
o Autonomic dysfunction = Hypertensive to exercise, as well as post-exercise hypotension
65
Chronic Kidney Disease

- Insidious process
o Stage 1 and 2: Asymptomatic
 Microalbuminuria
 Increase Glomerular Filtration Rate (GFR)
• Later presents with symptoms of only vague general malaise and ill health
o Stage 5 (ESRD): Symptoms of Uremia:
 Accumulation of water
 Crystalloid solutes
 Water products
- Altered Electrolyte homeostasis and acid-base imbalance, GI distress, severe anemia, and multiple other abnormalities
involving the:
o Skin
o Respiratory
o CV
o Neurologic
o Musculoskeletal
o Endocrine
o Genitourinary
o Immune systems
Risk Factors
- DM
- HTN
- CVD
- Obesity
 CKD  CVD (common cause of morbidity and mortality), Anemia, Bone disease  Chronic Renal Failure (CRF)
 Renal failure sometimes results from acute kidney injury (AKI), such as poor renal blood flow while on cardiopulmonary
bypass or drug overdose, and is characterized by rapidly progressive loss of renal function, which is potentially reversible
with proper treatment, including Dialysis, until the kidneys recover sufficient function.
66
Cardiovascular & Pulmonary Complications of CKD

Cardiovascular complications
 Decreasing renal function results in a number of abnormalities involving changes in coagulation, fibrinolysis, endothelial
dysfunction, anemia, calcium–phosphorous balance, RAAS, lipid abnormalities, and arrhythmia.
 By the time patients require dialysis, 40% have evidence of CAD and 85% of these patients have abnormal LV structure
and mass.
 The annual mortality rate for patients with end-stage renal disease (ESRD) is above 20%, and approximately 50% of
deaths are related to CVD, particularly MI, CHF, and stroke. death due to CVD complications is more common in
patients with CKD than progression to CRF.
 LVH increases the incidence of myocardial ischemia, leading to further impairment of LV function
Pulmonary Complications
 Pulmonary edema (most serious) may be due to

o Fluid overload
o Hypoalbuminemia
o Possibly increased pulmonary vascular permeability (in addition to CHF)
 Fibrinous pleuritis (20% to 40%) of patients who die of CRF:
o Pleuritic chest pain with pleural rubs
o Pleural effusion or Fibrothorax.
 Other pulmonary complications
o Pulmonary calcification (secondary to Hyperparathyroidism)
o Pleural Effusion (d/t Uremia)
o Increase RTI (i.e. TB and Pneumonia, and impaired immune function)
Treatment of CRF
67
 primary goals of treatment for CKD are to retard the rate of progressive deterioration in renal function and to minimize
the complications of CRF.
 Preventive measures to limit disease progression include ACE inhibitors or ARBs to thwart RAAS and control BP,
statins for dyslipidemia, early treatment of anemia to achieve hemoglobin levels of 11 to 12 g/dL, intensive
hyperglycemia management, and smoking cessation
 Primary and secondary prevention strategies to reduce the risk of CVD and associated mortality are also essential, and
patients are usually prescribed a number of medications to provide secondary prevention following MI, and statins to
improve lipid abnormalities and inhibit inflammatory processes involved in plaque formation.
 In standard hemodialysis, patients go to an outpatient dialysis center, typically 3 days per week, to be connected to a
dialysis machine (dialyzer) through an arteriovenous fistula or venous graft; the treatment typically takes 3 to 4 hours,
but can take longer in very large individuals.
Exercise and CKD
 patients with chronic renal insufficiency, resistance training has been reported to improve muscle strength and mass,
functional performance (6- minute walk test, normal and maximal gait speed, sit-to-stand test), peak exercise capacity, and
possibly GFR
o this reduces inflammation, maintains body weight, and increases protein utilization and nitrogen retention to
counteract the catabolic effects of protein restriction, low energy intake, and uremia.
 For patients with ESRD, compliance is highest when exercise sessions are performed during dialysis, which is well tolerated
when performed within the first 1 to 2 hours of a dialysis session.
Clinical Implications for PTs
 CRF are often debilitated and have poor tolerance for activity.
o A major contributing factor appears to be physical inactivity.
o Approximately 60% of patients with ESRD participate in no physical activity beyond basic ADLs, and their
sedentary behavior may contribute to a number of adverse effects
o Sedentary patients show a 62% greater risk of mortality over 1 year compared with nonsedentary patients, given
adjustments for other
 In patients with CKD, maximal exercise capacity and muscle strength decrease as renal disease progresses long before they
develop ESRD.
o Exercise training, using both aerobic and resistance exercise, is beneficial for the prevention of physical
deterioration as the disease progresses.
Interventions and Prevention Measures for Individuals with Cardiovascular Disease, or Risk of Disease
Statistics
68
1. Cigarette Smoking – most preventable cause of disease, disability, and death in US

2. Hyperlipidemia - >50% of American have blood cholesterol level higher than 200mg/dL
3. Hypertension – 1/3 of adult americans
4. Sedentary – 45% of adult Americas are insufficiently active
5. Obesity –
PWhy
1. Compliance
2. No body pays for it
Primary Prevention
1. Reduction of total cholesterol to high-density lipoprotein (HDL) ratio
2. Reduction in low density lipoprotein (LDL) Cholesterol
3. Improvement n Aerobic capacity and exercise tolerance
4. Reduction in weight
5. Reduction in resting BP …
Cardiovascular Risk Factor Assessment (AHA) – begin at age 20 and repeated every few years
Specific Components of a Primary Prevention Program
 Therapeutic Exercise
 Dietary Counseling
 Stress Management or Biofeedback
 Smoking Cessation
 Phamacologic Management
 Education and Self-Management Technique
Framingham 10 year risk
Activity Readiness Screening Tool
- Physical Activity Readiness-Questionnaire
- Physical Activity Readiness-Questionnaire Plus (2020) – for everyone
69
Patient Population
- Primary Cardiovascular Disorder
o Acute coronary syndrome (ACS)
o Myocardial infarction (MI)
o Coronary artery bypass graft (CABG) surgery
o Heart or Heart-lung transplant, heart valve repair or replacement surgery
o Congestive Heart Failure
- Secondary Cardiovascular Disorder
o Hisotry of Coronary Artery Disordder
o CHF
o MI
Rehabilitation should be:

Multidisciplinary and composed of:
- Education
- Exercise
- Behavioral change
70
The Three Components of Physical Therapy Intervention
Phase of Cardiac Rehabilitation

Phase 1: Acute or In-hospital phase
- Begins when patient is medically stable after an MI, CABG, PTCA, Valve repair, CHF, or Heart transplantation
Phase 2: Early outpatient or intensive monitoring
- May begin within days after discharge from the hospital and last 6 – 12 weeks. Frequency of visits depend on the patient’s
clinical needs. Initiate secondary prevention of disease
Phase 3: Training and Maintenance phase
- Beings at the end of phase II and extends indefinitely. Patients exercise in larger groups and continue to progress in their
exercise program
Phase 4: Disease prevention program
- Candidates are individuals who are at risk for infarction because of their risk factor profile, as well as those who want to
continue to be followed by supervision of trained personnel
Benefits of Physical Conditioning
71
- Heart rate response

- Arterial blood pressure response in hypertensive individuals
- Myocardial oxygen uptake
- Maximum oxygen uptake
- Maximum cardiac output
- Peripheral circulation
- Pulmonary ventilation
- Autonomic nervous system benefit
- Greater emotional stability and self-esteem
72

PT - Cardiopulmonary

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

PT - Cardiopulmonary

Uploaded by

Copyright:

Available Formats

PT – Cardiopulmonary

Magistrado, Leandrew T. BSPT3

Six Vital signs

Pulse Point Location

In the antebrachial fossa just medial to the biceps brachii

a. The patient should be relaxed

- Oxygenation and circulation of the blood

Respiration and Exertion

 Respiration rate and depth should increase

Common Respiratory Difficulties

- Dyspnea – difficulty in breathing

- Trepopnea – difficulty in breathing in side lying position

Other Blood Pressure Abnormalities

- Systole – rises with an increase in workload and then levels off

Assessment of Blood Pressure

1. Patient is seated or in supine

5. Ensure that the air pump valve is closed (turned clockwise)

9. Listen for the

- (N): 37.5 degree Celsius

Sites of Temperature Assessment

1. Cover the device with a thin disposable plastic

1. Cover the device with a thin disposable plastic.

- Observable swelling from fluid accumulation

- Pitting – persistent indentation

Assessment of Pitting Edema

1. Patient may be seated or supine

o Slightly posterior and inferior to the medial malleoli

1. Patient may be seated or supine

 Impaired RBC production

Oxygen Saturation Measurements

- Arterial Blood Gas (ABG) analysis

- Most commonly used by PTs

Sa02 – measurement of oxygen saturation via ABG (a for arterial)

Oxygen Saturation Assessment (SpO2)

1. Choose a finger with good vascularity

Oxygen Saturation response to Exertion

- (N): stay the same or increase slightly

1. Patient should be in supine

6. Inflate the BP cuff 1-2

Other Common Cardiovascular and Pulmonary Test Measures

- Rating of perceived exertion

Borg Scale of Rating of Perceived Exertion (RPE)

- A valid and reliable method for estimating the actual physiological

1. a 30-meter straight course is marked with tape or cones

Evaluation of the Neck

- Activity of neck musculature during breathing

Jugular Venous Distention Assessment

 Patient is sitting or recumbent in bed

 (+) JVD = Veins distend above the level of the clavicles

Pattern of Breathing Description

o “One-word dyspnea – speech is interrupted for a breath between EVERY word

- Appearance of the Extremities

Auscultation of the Lungs

- Prevent the patient from falling if weak or if poor balance is noted

Errors of Auscultation to avoid

Nomenclature Pitch and Intensity Respirator cycle when Duration Location

- A patient is asked to whisper, and the whispered words are

Adventitious Lung Sounds

- Continuous sounds: Wheezes

- Discontinuous sounds: Crackles

- Like two pieces of leather or sandpaper rubbing together

Auscultations of the Heart

Sounds Event Location to auscultate Best heart with Corresponding events