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Basics of Cardiopulmonary Physical Therapy
Rajni Malik
1: INTRODUCTION TO CARDIOPULMONARY SYSTEM
1:
Brief Anatomy of Cardiovascular System
ANATOMY OF THE HEART
LOCATION OF THE HEART
LAYERS OF THE HEART WALL
CHAMBERS OF THE HEART
VALVES OF THE HEART
PATHWAY OF BLOOD THROUGH THE HEART
THE PULMONARY AND SYSTEMIC CIRCUITS AND THE BLOOD SUPPLY TO THE HEART
BLOOD SUPPLY TO MYOCARDIUM
2:
Physiology of Cardiovascular System
CARDIAC CYCLE
Phase I: Atrial Contraction (AV Valves Open, Semilunar Valves Closed)
Phase II: Isovolumetric Contraction (All Valves Closed)
Phase III: Rapid Ejection (Aortic and Pulmonary Valves Open; AV Valves Remain Closed)
Phase IV: Reduced Ejection (Aortic and Pulmonary Valves Open; AV Valves Remain Closed)
Phase V: Isovolumetric Relaxation (All Valves Closed)
Phase VI: Rapid Filling (AV Valves Open)
Phase VII: Reduced Filling (AV Valves Open)
PRESSURE CHANGES DURING CARDIAC CYCLE (FIG. 2.2)
Phase I: Atrial Contraction
Phase II
Phase III
Phase IV
Phase V
Phase VI
Phase VII
ELECTROCARDIOGRAM
PROPERTIES OF THE HEART MUSCLES
Mechanical Properties
IMPORTANCE OF FRANK-STARLING'S LAW
By Altering the Contractility (Force of Contraction)
Factors Affecting Contractility
All or None Law
Electrical Properties of the Heart Muscle
Excitability
Conductivity
Metabolic Properties
3:
Brief Anatomy of Respiratory System
INTRODUCTION
ANATOMICAL FEATURES OF THE LUNGS (FIG. 3.2)
PLEURA
Functions of Pleura (Table 3.1)
LUNGS
Apex of the Lung
Base of the Lung
Root of the Lung
Hilum of the Lung
Lobes and Fissures of the Lung
Left Lung
Right Lung
Surfaces of the Lung
Costal Surface of the Lung
Mediastinal Surface
Diaphragmatic Surface
Borders of the Lung
Anterior Border of the Lung
Posterior Border of the Lung
Inferior Border of the Lung
SURFACE MARKING OF THE LUNGS (FIG. 3.6)
On the Right
On the Left
FISSURES OF THE LUNGS
BRONCHOPULMONARY SEGMENTS (FIG. 3.8)
Bronchopulmonary Segments of Right Lung
Bronchopulmonary Segments of Left Lung
4:
Physiology of Respiratory System
COMPOSITION OF AIR
DEFINITION OF RESPIRATION
FUNCTIONS OF RESPIRATORY SYSTEM
STRUCTURE OF RESPIRATORY TRACT (FIG. 4.4)
CONTROL OF RESPIRATION
MECHANICS OF BREATHING (FIGS 4.5A AND B)
Inspiration
Expiration
Motions of Ribs
LUNG VOLUMES AND CAPACITIES
Terms, Abbreviations, and Normal (Adult) Values of Lung Volumes and Capacities (Fig. 4.8)
Tidal Volume
Inspiratory Reserve Volume
Expiratory Reserve Volume
Residual Volume
Inspiratory Capacity
Functional Residual Capacity
Vital Capacity
Total Lung Capacity
2: ROLE OF PHYSIOTHERAPY IN CARDIOPULMONARY DISEASES
5:
Cardiac Rehabilitation
DEFINITION
GOALS OF CARDIAC REHABILITATION (FIG. 5.1)
Cardiac Rehabilitation Benefits
Patient Selection and Risk Stratification
Patient Selection
Risk Stratification
Functional Capacity
Myocardial Ischemia
Ventricular Dysfunction
Arrhythmias
Educational and Psychosocial Status
Alternative Approaches to Cardiac Rehabilitation
Exercise Testing and Exercise Prescription
Indications
Modifications of Exercise
Contraindications
Exercise Testing
Exercise Prescription and Surveillance
Exercise Initiation
Progression
Phases of Cardiac Rehabilitation
Phase 1: In-hospital Phase
Postdischarge Phase
Phase 2: Supervised Exercise
Phase 3: Maintenance Phase
Response of Cardiovascular System to Exercise
Skeletal Muscle Blood Flow
Neural Control of Blood Flow to Skeletal Muscle
Local Metabolites
Systemic Circulatory Changes during Exercise
6:
Pulmonary Rehabilitation
ECONOMIC IMPACT OF LUNG DISEASE (FIG. 6.1)
MULTIDISCIPLINARY NATURE OF PULMONARY REHABILITATION
Definition
Consequences of Respiratory Disease
Goals of Pulmonary Rehabilitation
Benefits of Pulmonary Rehabilitation
Accepted Benefits
Potential Benefits
Unlikely or Likely Benefits
Indications and Contraindications for Pulmonary Rehabilitation
Indications
Contraindications
PHYSIOLOGY OF MUSCULAR EXERCISE (FLOW CHART 6.2)
Physiology of Madins Muscular Exercise
Oxygen Debt
Respiratory Adjustments
Pulmonary Ventilation
Oxygen Uptake in the Lungs
Circulatory Adjustments
Change at Tissue Level
3: RESPIRATORY SYSTEM
7:
Respiratory System Assessment
SUBJECTIVE ASSESSMENT
INSPECTION
Breathing Pattern
Chest Shape and Configuration
Use of Respiratory Muscles
Skin Color (Table 7.10)
Clubbing (Figs 7.7A and B)
Edema
PALPATION
Symmetry of Chest Expansion/Chest Excursion
Position of the Trachea
Fremitus
Steps to Perform/Palpate Tactile Fremitus (Flow Chart 7.1)
PERCUSSION
Evaluation of Lung Density
Evaluation of Diaphragmatic Excursion
AUSCULTATION
LABORATORY EVALUATION
8:
Respiratory Diseases and their Physiotherapy Management
DEFINITION
RISK FACTORS FOR COPD
Host Factors
Exposure
Pathogenesis of COPD (Flow Chart 8.2)
Pathology of COPD (Flow Chart 8.3)
Diagnosis of COPD
Spirometry Classification of COPD (Table 8.1)
Important Physical Findings in Patients with COPD
Extrathoracic
Thoracic
Common Chest Radiographic Findings in Patients with COPD
Evidence of Hyperinflation
Evidence of Cor Pulmonale
Management/Treatment of COPD (Table 8.2)
Physiotherapy Management of COPD
Goals of Physiotherapy (PT) Treatment
Physiotherapy Treatment of a Patient (Table 8.3)
Therapeutic Maneuvers
Indications
Contraindications
Absolute
Relative
Relaxation Positions
Percussion and Vibration
Contraindications
Percussion Technique
Vibration Technique
Directed Cough
Indications
Contraindications
Forced Expiratory Technique
Autogenic Drainage
Positive Airway Pressure Adjuncts
Indications
Breathing Exercises
Indications
Graded Exercises
Complications and Adverse Effects of Chest Physical Therapy
DEFINITION
PATHOPHYSIOLOGY
Bronchoconstriction
Bronchial Inflammation
Signs and Symptoms (Fig. 8.7) (Table 8.6)
CLASSIFICATION OF ASTHMA
DIAGNOSIS
LABORATORY EVALUATION
Pulmonary Function Tests
Spirometry
Peak Expiratory Flow Rate
Skin Tests
Blood Tests
Peripheral Blood Eosinophils
Radiology Tests
TREATMENT
Asthma Therapy: Goals and Treatment Strategies
Goals
Management Strategies
Physiotherapy Treatment
DEFINITION
RISK FACTORS
SYMPTOMS
PATHOGENESIS
CLINICAL MANIFESTATIONS
Pulmonary Tuberculosis
Pleura
Extrapulmonary Tuberculosis
Miliary Tuberculosis
Pericardium
Meninges
Kidney
Bone
Peritoneum
Intestines
Lymph Nodes
Skin
DIAGNOSIS
Microscopy
Culture
Radiology
Chest X-ray
Skeletal X-ray
Mantoux
Biopsy
Enzyme-linked Immunosorbent Spot (ELISPOT) Assay and Experimental Tests
Pharmacological Treatment (Table 8.7)
Physiotherapy Treatment
DEFINITION
ACUTE VERSUS CHRONIC RESPIRATORY FAILURE
Acute Respiratory Failure
Chronic Respiratory Failure
Acute on Chronic Respiratory Failure
Management
Physiotherapy Management of a Patient with Respiratory Failure
Goals
Patient Evaluation
Physical Therapy Treatment Program
Objectives of the Program
TREATMENT
Breathing-retraining Exercises
Coordination of Breathing Exercises and Mechanical Ventilation
Diaphragmatic Breathing
Deep Breathing
Segmental Breathing
Abdominal Breathing
Breathing-retraining and the Weaning Process
Pulmonary Hygiene
Joint Ranges of Motion Exercises
Strengthening Exercises
Ambulation Activities
Self-care Activities
9:
Respiratory Care in Intensive Care Unit
DEFINITION
PURPOSE
Monitoring Gas Exchange
Arterial Blood Gas Analysis
Arterial O2 Tension and Saturation
Acid-base Status, pH, and PaCO2
Monitoring Oxygenation
Arterial Pulse Oximetry
Oxygen Consumption
Monitoring of Exhaled Gas
Monitoring Lung and Chest Wall Mechanics
Mechanics of Breathing
Monitoring Strength and Muscle Reserve
Strength Measures
Vital Capacity
Maximal Inspiratory Pressure
Monitoring of Cardiac Output, Stroke Volume and Shock (Table 9.1)
Interpretation of CVP
Complications of CVP Lines
Measurement of Blood Pressure
Invasive Measurement
ROLE OF PHYSIOTHERAPIST IN INTENSIVE CARE UNIT
4: CARDIOVASCULAR SYSTEM
10:
Assessment of Cardiovascular System
DEFINITION
CLUBBING
SPLINTER HEMORRHAGES
CYANOSIS
ARTERIAL PULSES
RATE AND RHYTHM
AMPLITUDE AND CONTOUR
Character
Slow Rising Pulse
Collapsing (Water Hammer) Pulse
Bisferiens Pulse
Pulsus Paradoxus
Pulsus Alternans
Bigeminal Pulse (Pulsus Bigeminus)
VOLUME
Delay
Measurement of Blood Pressure
THE VENOUS PULSE
Jugular Venous Pressure
Jugular Venous Pressure Wave
To Measure Jugular Venous Pressure (Fig. 10.7)
Examination of the Precordium
Inspection
Palpation
Percussion
Auscultation
Where to Place your Stethoscope
HEART SOUNDS
First Heart Sound
Intensity of 1st Heart Sound
Second Heart Sound
Normal Physiologic Splitting
Abnormal Splitting/Fixed Splitting
Third Heart Sound
Fourth Heart Sound
Additional Heart Sounds
Heart Murmurs
Murmur Grades
11:
Cardiovascular Diseases and their Physiotherapy Management
DEFINITION
Classification of Hypertension
Signs and Symptoms of Hypertension
Symptoms of Hypertension
Signs of Hypertension
CAUSES OF HYPERTENSION
Primary/Essential/ldiopathic Hypertension
Secondary Hypertension
Renal
Endocrine
Coarctation of Aorta
Pregnancy-induced Hypertension
Neurologic Disorders
Acute Stress, including Surgery
Increased Intra-vascular Volume
Alcohol and Drug Use
Increased Cardiac Output
PATHOPHYSIOLOGY
TREATMENT
Life-style Modifications for Hypertensive Patients
Physiotherapy Treatment
Statement of Educational Goals
Cardiac Rehabilitation
For Hypertension
New Patient Evaluations
Continuity Experience
Dietary Counseling
Smoking Cessation
Improved Psychosocial Well-being
Reduction of Stress
Enhanced Social Adjustment and Functioning
Return to Work
Reduced Mortality
DEFINITION
CAUSES OF HEART FAILURE
Risk Factors of Heart Failure
Classifications of Heart Failure
Right vs Left Sided Heart Failure
Systolic vs Diastolic Dysfunction (Fig. 11.3)
Forward Heart Failure vs Backward Heart Failure
The Stages of Heart Failure—New York Heart Association (NYHA) Classification
Common Symptoms of Heart Failure (Fig. 11.4)
Swollen Ankles or Legs
Shortness of Breath
Angina
Weight Gain or Loss
Fatigue
Loss of Appetite
DIAGNOSIS
Physical Findings in Patients with Heart Failure
Vital Signs
Cardiovascular Signs
Neurologic Signs
Pulmonary Signs
Abdominal Signs
Systemic Signs
Initial Tests
Follow-up Tests
TREATMENT (TABLE 11.5)
General Measures
Prevention of Heart Failure
Diet
Correction of Underlying Cause
Identify and Remove the Precipitating Factors
Prevention of Deterioration of Cardiac Functions
Physiotherapy Treatment
Recommended Activities
Some Useful Exercise Tips
TREATMENT FOR HEART FAILURE PATIENT
Exercise Initiation
Exercise Training
General Considerations
Training Tolerability and Electrocardiographic Monitoring
Education of the Patient for Exercise Training
Endurance Training
Prescriptive Considerations
Intensity of Training
Types of Activities
Resistance Training
Progression
DEFINITION
ETIOPATHOGENESIS
Coronary Atherosclerosis
Superadded Changes in Coronary Atherosclerosis
Acute Changes in Chronic Atheromatous Plaque
Coronary Artery Thrombosis
Local Platelet Aggregation and Coronary Artery Spasm
Nonatherosclerotic Causes
RISK FACTORS FOR CORONARY ARTERY DISEASE (TABLE 11.6)
High Blood Cholesterol Level
Diabetes Mellitus
Hypertension
Tobacco Use
Male Gender
Age
Family History
EFFECTS OF MYOCARDIAL ISCHEMIA
Myocardial Infarction
Prevalence
Etiopathogenesis
PATHOPHYSIOLOGY
Mechanisms of Occlusion
Mechanisms of Myocardial Damage
Signs and Symptoms
Diagnosis
Electrocardiography
Blood Tests
Echocardiography
COMPLICATIONS OF MYOCARDIAL INFARCTION (TABLE 11.9)
Treatment
Medical Treatment
Surgical Treatment
Cardiac Stress Testing
Lipid Management
Long-term Medications
Implantable Cardiac Defibrillators
Cardiac Rehabilitation
Rehabilitation of Patient with MI (Table 11.11)
CLASSIFICATION
Atrial Septal Defect
Symptoms and Signs
Ventricular Septal Defect
Patent Ductus Arteriosus
Risk Factors
Signs and Symptoms of PDA
Tetralogy of Fallot
Causes
Signs and Symptoms
Transposition of Great Arteries
Signs and Symptoms
Coarctation of Aorta
Symptoms
Aortic Stenosis
Symptoms
Pulmonary Stenosis
Symptoms
DIAGNOSIS
History and Physical Examination
Chest X-ray
Electrocardiogram
Echocardiogram
Exercise Test
Heart Catheterization
Electrophysiology Study
Magnetic Resonance Imaging
TREATMENT
Atrial Septal Defect Repair
Ventricular Septal Defect Repair
Patent Ductus Arteriosus Ligation
Tetralogy of Fallot Repair
Transposition of the Great Vessels Repair
Coarctation of the Aorta Repair
Physiotherapy Treatment (Table 11.14)
PATHOLOGY
Clinical Features
Carditis Manifests
Investigations
Treatment
Treatment for Streptococcus Infection
Anti-inflammatory Medications
Bed Rest
Physiotherapy Treatment
12:
Mechanical Ventilation
DEFINITION
CLINICAL OBJECTIVES OF MECHANICAL VENTILATION
INDICATIONS
HAZARDS AND COMPLICATIONS OF MECHANICAL VENTILATION
Classifications of Positive-pressure Ventilators
Mechanical Ventilators are Flow Generators
Initial Ventilator Set-up
Modes of Ventilation
13:
Humidity and Aerosol Therapy
CLINICAL INDICATIONS FOR DELIVERY OF HUMIDIFIED GASES AND AEROSOLS
DEFINITION
Humidity
Aerosol
GENERAL PRINCIPLES OF EQUIPMENT OPERATION
HUMIDIFIERS
General Principles
Temperature
Surface Area
Contact Time
Types of Humidifier
(1) Bubble Type Humidifiers
(2) Passover-type Humidifiers
Heating System
Heat and Moisture Exchanger
AEROSOL THERAPY
Methods of Measuring Aerosols
Factors Affecting Particle Deposition
Gravity
Kinetic Activity
Particle Inertia
Physical Nature of Particle
Temperature and Humidity
Ventilatory Pattern
Nebulizers
Jet Nebulizer
Small Volume Nebulizers
Factors Affecting SVN Performance
Characteristics of Drug Nebulized
Large Volume Nebulizer
Metered Dose Inhaler
Accessory Devices with MDI
Ultrasonic Nebulizer
Complications and Hazards of Aerosol Therapy
14:
Medical Gas Therapy
GOALS OF MEDICAL GAS THERAPY/OXYGEN THERAPY
(I) Correcting Hypoxemia
(II) Decreasing the Symptoms of Hypoxemia
(III) Minimizing Cardiopulmonary Workload
HARMFULL EFFECTS
(I) Oxygen Toxicity
(II) Retinopathy of Prematurity
(III) Absorption Atelectasis
(IV) Depression of Ciliary and/or Leukocyte Function and Altered Surfactant Production/Activity
(V) Unwanted Closure of Ductus Arteriosus
(VI) Alterations in Pulmonary Blood Flow
OXYGEN DELIVERY DEVICES
Variable Performance Devices
Fixed Performance Devices
LOW FLOW SYSTEMS
(I) Nasal Cannula (Fig. 14.3)
Advantages
Disadvantages
(II) Nasal Catheter
(III) Simple Mask
(IV) Reservoir System
HIGH FLOW SYSTEMS
Air Entrainment System
Air Entrainment Masks
Blending Systems
15:
Airway Care and Management
AIRWAY MANAGEMENT
Indications for Resuscitation or Airway Management
Manual Techniques
Head Tilt/Chin Lift
Jaw-thrust Maneuver
Tongue-jaw Lift
Manual Methods to Clear and Obstructed Airway
Mechanical Adjunctions to Airway Management
Airway Clearance Techniques
Airway Aspiration (Suctioning)
Indication for Artificial Airways
Relieving Airway Obstructions
Secretion Removal
Protecting the Airway
Positive-pressure Ventilation
Selecting and Establishing an Artificial Airway
Tracheal Airways
Equipment Necessary for Endotracheal Intubation
Airway Maintenance
Securing the Airway and Confirming Placement
Providing for the Patient Communication
Assuring Adequate Humidification
Minimizing Nosocomial Infection
Facilitating Clearance of Secretions
Providing Cuff Care
Trouble-shooting Airway Emergencies
INDEX
TOC
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