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PHTY300 - Cardioresp 2 (ICU + Rehab) - Coggle Diagram
PHTY300 - Cardioresp 2 (ICU + Rehab)
ICU
why in ICU?
Respiratory Failure
Hypoxaemic RF = PaO2 < 60 but PaCO2 fine --> indicates lung failure
Hypercapnic RF = PaCO2 > 50 and PaO2 low ---> indicates pump failure
Acute vs. Chronic RF + acute on chronic
Medical Mx
Mechanical Ventilation
(for pump issues / splint airways open) - also used in ICU settings for altered consciousness, major surgery needing sedation
NIV
{list types of NIV}
Contraindications
Intubation
Reasons for intubation
maintain patent upper AW
protect lower resp. tract
Allow Mech. Vent.
Facilitate AW clearance
ETT/Intubation problems :warning:
Increased Raw (airway resistance)
reduced Secretion Movement (MCC + cough)
Increased risk of infection --> VAP
increased risk of trauma to AW --> trache
Increased dead space
Tracheostomy tube rather than ETT for prolonged intubation to prevent/allow
Vocal chord damage + promotes pt communication
tracheal stenosis/injury
reduced sedation
facilitate weaning
SIMV synchronised intermittent mandatory vent.
Pressure Controlled
Volume Controlled
PSV pressure support vent.
decrease muscle atrophy
decrease need for sedative/analgesia bc more confortable
weaning method from SIMV
Can be used in adjunct to SIMV to allow for supported spontaneous breathing
Mech. Vent. problems :warning:
reduce lung compliance + FRC
VILI - risk of baro/volu-trauma
Altered distribution of ventilation
Respiratory muscle deconditioning
positive pressure squashes thoracic veins (vena cava) --> decrease Venous Return --> decrease cardiac output --> decrease BP
Weaning: criteria
is the ventilatory failure resolved?
pt medically stable?
for uncomplicated weaning :reduce sedation --> allow spontaneous breathing effort --> reduced PEEP to 5 --> reduce PS to 10 --> reduce FiO2 to <0.3 --> still medically stable --> extubate
Adequate spontaneous respiratory effort?
conscious enough?
protected airway / minimal secretion load
Options for complex pt:
Inspiratory Muscle training
T-piece + humidified O2
NIV
Tracheostomy
O2 Therapy (for hypoxaemia)
Fixed Performance O2
Variable Performance O2
Dangers: Haldane effect, oxygen toxicity, absorption atelectasis, oxygen-induced-hypercapnia
Domiciliary O2
{List modes of O2 therapy}
Humidification
Nebulisation
Other Medical Therapies (hyperbaric chamber, Nitrous Oxide, ECMO)
Sepsis
Aspiration/Ventilator Acquired Pneumonia - can cause sepsis
Cardiac conditions
Non-Modifiable Risk factors:
older age
male (earlier onset)
Family Hx
Modifiable Behavioural Risk Factors:
smoking
sedentary
diet
Modifiable Biomedical Risk Factors:
high BP (HTN)
high blood cholesterol
diabetes
high BMI
depression
Heart Failure
CVD/CAD
Post-Sx complicated
Neurological emergencies
TBI
Primary injury
Haemorrhage, Contusion, Diffuse Axonal Injury
Secondary injury due to hypoxia from change in Cerebral Perfusion pressure | increased ICP without increased MAP = decreased CPP
see cerebral causes in YTvideo -
https://www.youtube.com/watch?v=dIBbSP9Q64c
SCI, GBS, Myasthenia Gravis
motor impairment to resp. muscles
Paradoxical breathing
Diaphragm innervation C3-5
Cough impairment
Manual Assisted Cough
Cough Assist Device
Resp muscle fatigue
abdominal binder, supine, NIV
Inspiratory Muscle Training
trauma
Chest Trauma
Direct lung trauma
Aspiration
Non-fatal drowning
Inhalation injury
Blunt Chest wall trauma
Rib/sternal # --> Flail chest
Lung Contusion
Haemothorax, pneumothorax, subcutaneous emphysema
ARDS -->
https://youtu.be/bXWksu3APic
organ failure
Burns
Inhalation injury
Monitoring
ECG (for rhythm)
Pulse Oximeter (SpO2 + HR)
IDC (urine output)
Arterial Line (MAP)
CVC central venous catheter (CVP)
ABGs
etCO2 end tidal CO2
PiCCO Pulse index Continuous Cardiac Output (combined measure of haemodynamics)
PICC peripheral inserted central catheter
PA Catheter pulmonary artery
Ventilator Monitor (airway pressures)
GCS glasgow coma scale (level of consciousness)
ICP monitoring intracranial pressure
UWSD (monitoring pneumo/haemo-thorax
ICUAW :!!:
PICS post intensive care syndrome
PT techniques
General positioning
Suction -->Manual/Ventilator Hyperinflation --> suction
Preintervention Ax + time with pain relief
baseline clearance suction (can use saline)
specific positioning/MGAD based on impairment
Manual techniques
Pulmonary Rehab
Pulmonary Limitations to PA
UL
LL
Benefits
Increase exercise capacity
Improve QoL
decrease dyspnoea
Very High level evidence for COPD + high level for other resp. conditions
Psychosocial benefits
Reduced readmission + bed stay = reduced hospital burden
Respiratory Drugs
Outcome Measures / Questionnaires
St George Respiratory Questionnaire (QoL)
MRC - dyspnoea
SF-36 (QoL)
6MWD
CRQ
FITT
2xsupervised sessions and 1+ HEP
3-4mBORG; 80% of Max from 6MWT (can be reduced to 60% initially)
30min of aerobic (endurance LL) - can be done in intervals
functional strength training of UL and LL 1-2x 8-12RM
UL endurance training
Balance, Flexibility, Pelvic Floor Exercises
Cardiac Rehab
Cardiac Limitations to PA
CV drugs
Beta-blockers
ends in 'lol'
Arrythmia, Hypertension, Angina
slows/blunts HR, decreases heart contraction force
Side-effects: fatigue, hypoglycaemia, bronchoconstriction
If on Beta-Blockers - don't use predicted HR for exercising
Nitrates
Quickly treats angina
arterial vasodilation
Side-effects: orthostatic hypotension, syncope
ACE-inhibitors
ends in 'pril'
for hypertension, HF
prevents vasoconstriction and fluid retention
Side-effects: hypotension, dizziness
Cardiac Glycocides
congestive HF, AF
decreases HR but increases force of contraction
Side-effects: fatigue, headaches, ECG changes, vision disturbances
Statins
lower lipids (cholesterol)
Side-effects: myopathy, headaches
Anticoagulants
reduce risk of embolism after MI
interferes with clotting
caution: bleeding
Antiplatelets
prevent thrombus forming
caution: bleeding
Diuretics
helps excretion of built up fluid
PHASES:
Phase 1:
Inpatient Care
MDT educates pt and family
advice on resumption of ADLs
referral to Cardiac rehab
prevention of bedrest effect
Immediately post-D/C (2-6wks recovery at home)
low-level PA
resumption of active lifestyle
emphasis on risk-reducing strategies
Phase 2:
6-8wks of centre-based grouprehab
+/- HEP
safe, monitored PA
educate of self-monitoring, educate about risk modification
wait time depends on waitlist too
FITT
2-3x/wk increasing to 5-7
11-13 RPE (light to somewhat hard)
30-40min of Continuous Training
or intermittent (eg. 3x10min)
or 4x4min HIIT sessions (3min rest)
Aerobic
Resistance
not isometric (breath holds)
not w sternotomy
Phase 3
Maintenance
encourage continuation of PA and risk reduction
periodic R/V on exercise sessions
Benefits:
Restore individuals to wellbeing
improve survival after acute cardiac events
reduce readmission and likelihood of cardiac event
facilitate behavioural change and awareness of self-management of risk factors
pt Ax, monitoring and ReAx
Indicated/eligible:
ACS
CAD or high risk of CAD
post revascularisation
stable HF
AF
post pacemaker/non coronary Heart surgery
Risk Stratification:
S/E before exercise (contraindications)
progressive worsening of exercise tolerance / dyspnoea at rest
recent embolism
new onset of AF
acute illness/fever
O/E
Baseline Measures: Weight, BP, HR, SpO2, BSL (if diabetic)
OBS: SOB, cyanosis, ankle oedema
Wound healing and skin integrity
Outcome measures / questionnaires
Anthropometrics - BMI, waist
Exercise reTest
QoL - SF-36
Exercise Testing
SubMax
6MWT
ISWT incremental shuttle walk test
Queens College Step Test
Incremental Unsupported UL Exercise Test
Maximal
CPET cardiopulmonary exercise testing (max, laboratory) tests
exercise tolerance
undiagnosed exercise intolerance
pt with CV and/or Resp diseases
prescription of rehab
Cycle ergometer vs treadmill
Peripheral Measurements
Muscle tiredness
claudication pain
R/RER --> anaerobic = >1
Resp measurements
mBORG
SpO2
CV measurements
HR
Rhythm
BP
watch for chest pain
Overall exercise capacity
Work (watts)
VO2max
RPE
Overcoming Barriers to Rehab