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Diagnostic Unit 5


Cardiopulmonary stress testing is done too? evaluate general fitness, the effects of exercise on oxyhemoglobin desaturation, evaluate pt's exercise tolerance
What are indications for stress testing? diagnosing physical disorders in pt's w/ dyspnea on exertion, quantify level of impairment and determine resp/cardiac limitations, evaluate treatment effectiveness, evaluate a pt's cardiac fitness
What are some general contraindications? neurological disorders(Alzheimer,etc...) neuromuscular disorders( Lou Gehrig,etc), orthopedic disorders(quadriplegia)
What are pulmonary contraindications? FEV1<30% of predicted, Pa02 <40mmhg on RA, PaC02>70, severe pulmonary HTN, recent emboli
What are cardiovascular contraindications? CHF, recent MI, 2nd or 3rd degree blocks, atrial or ventricular tachyarrhythmias, uncontrolled HTN, angina, recent emboli
What is included in the preliminary evaluation? complete medical hx, ask the pt the amount of physical activity they can tolerate until distress, complete physical exam, 12 lead ECG, PFT test
What is the general fitness assessment? 6 minute walk test. Pt walks as fast and as far as possible for 6 mins, the further they can travel the more fit they are
What is the Harvard general fitness assessment? pt steps onto a 20in platform and then down, this is done 30 times a minute for 5 minutes, pt rests for 1 min, their pulse is taken for 30 seconds to get recovery heart rate
The lower their recovery heart rate? the greater the degree of fitness
Pre/Post exercise pulse oximetry and ABG's are for? to evaluate the effects of exercise on oxyhemoglobin, abg can be used to determine if the pt needs supplemental 02 during exertion, and are often used to get reimbursement for home 02, pulse oximetry(Sp02) is used to check pts oxygenation
Advanced stress test's have more contraindications, more hazards, and require more monitoring. These tests are? Constant work rate ( steady state), incremental (non steady) work rate
What is the constant work rate (steady state)? once pt reaches target heart rate (steady state) the timed portion of test begins, pt continues to exercise to maintain HR for 5-8 mins
How is the target heart rate determined? Max HR= 220-Age You then multiply it by 0.75, since we only work pt's at 75%
Steady state tests are most useful in? determining the pt's maximum 02 consumption (V02max)
Steady state tests are used more often with cardiac stress testing, they often will be repeated months later to see? if the pt's tolerance has improved after receiving treatment or therapy
Incremental work rate (non steady state) tests differ from steady state how? The workload levels are increased in brief increments (usually 1-3 mins). Ekg, BP, exhaled gas analysis are taken at the end of each level. Test continues until pt is exhausted, SOB, etc... Test should be done after 8 mins, pt must cool down or rest after
The non steady state is the most commonly performed stress test, it is designed too? efficiently test the pt's exercise limits, and determine V02max. The V02max reading must be taken at the pt's point of exhaustion.
There is a ramp type of test that is a variation of the non steady state? workload increase is smooth and continuous instead of incremental with plateaus
Treadmills can be used for stress testing, what are the disadvantages of this? can be difficult to set specific workload, take pt's BP, and to get an ABG while on treadmill. Noisy, take up a lot of space, danger of pt falling.
Cycle ergometers (mechanical and electromechanical) are used also, these are? Stationary bicycles, changes in pedaling rate or flywheel resistance can change workload. Cheaper, smaller, quieter, less risk of pt falling.
Mechanical ergometers? Workload adjustments made manually, pedaling rate 50-80, easy calibration
Electromechanical ergometers? Electronically controlled flywheel, workload changes made automatically, easier to do ramp testing, pedaling rate 40-60, difficult calibration
Arm ergometers are used when a pt has limited use of their lower extremities, The V02max and VEmax (max min ventilation) are? 50%-70% less than with a cycle ergometer
What devices are used to measure lung volumes during stress testing? Pneumotach, gas mixing chamber, spirometers, gas analyzers, douglas bag
The pneumotach is the most common and measures? 02 and C02 used and exhaled
The gas mixing chamber? capacity of 5-6 liters, can be used instead of volume collecting devices, made of clear plexiglass w/ baffles
Spirometers are used too? manage collection and measurement of pt's exhaled gas
Gas analyzers are usually two separate analyzers to measure? exhaled 02 and C02, or use mass spectrometer to measure both with one analyzer
The Douglas bag is used to ensure a? a well mixed sample of exhaled gas is collected to measure 02 and C02
Vital signs are measured before, during, and after the test. Most modern stress testing systems allow? a continuous EKG display and BP, SAT, etc...
What is the most common ECG recording problem during a stress test? motion artifact, the ecg quality must be good enough to allow assessment of the heart rhythm intervals and segments, a 12 lead ekg with artifact filters is the best way to evaluate heart rhythm
Significant changes in the ST segment should be? identifiable up to the pt's maximum heart rate
A sudden drop in blood pressure would be an indication too? Stop the test, also stop with exhaustion, confusion, ect....
Muscular work requires adenosine triphosphate (ATP) as an energy source, so in order for muscular work to occur? fuel for ATP production must be supplied and ATP waste products must be eliminated
What are the three mechanisms required to meet the muscle cells needs? transport, exchange, metabolism
Transport is the movement of substances, this is done by? Pulm ventilation and cardiovascular circulation
Pulm ventilation is the exchange? of gases between the atmosphere and the AC membrane, moves 02 and C02 in and out of the body
Cardiovascular circulation? transports 02 from the lungs to muscle and C02 from the muscle to the lungs
What is the cardiac output formula? C0=HR x SV, during exercise the stroke volume and heart rate increase, which increases arterial BP and CO
Exchange is the diffusion of substances, there are two types? External respiration-gas from atmosphere to lungs to pulm capillary blood Internal respiration-gas movement between capillary blood and the tissue cells (within muscles and organs)
Metabolism requires the consumption of 02 to produce ATP, because it requires 02 it is called? aerobic metabolism, C02 AND H20 are produced as waste products of this process. Normal resting metabolism is performed through processing carbs and lipids
Aerobic metabolism involves metabolizing carbs for energy, what is the formula for this? Glucose + Oxygen= ATP+C02+H20
What is the key stage in the process of aerobic metabolism? Oxidative phosphorylation
The oxygen burned is the V02, the carbon dioxide burned is the VC02. This ratio is known at the? Respiratory quotient (RQ) RQ= C02 Produced/Oxygen Consumed
What are the normal RQ values? VC02 200ml/min, V02 250ml/min RQ= 0.8
What is anaerobic metabolism? energy is produced even though tissues do not have enough 02 to complete oxidative phosphorylation
Anaerobic metabolism produces? Much less ATP and is less efficient (2 moles ATP per glucose with anaerobic, 38 moles ATP per glucose with aerobic)
What are the physiologic problems with anaerobic metabolism? lactic acid build up, lactic acidosis, increased C02 production, increased VE and increased work on the lungs ( to get rid of C02), delayed onset muscle soreness ( due to lactic acid)
Normal V02 at rest is 250ml/min, the amount of 02 consumed increases with? muscular work being performed, the V02 increases until exhaustion occurs and a max level is reached, this is your V02max
V02max is the largest amount of 02 a pt can consume during execise, the V02 determines? the capacity the pt has to perform muscular work, the normal V02 max for a sedentary adult is 1700ml/min, for a trained athlete is can be as high as 5800ml/min
What are MET's? multiples of resting 02 consumption, one MET is the amount of 02 produced at rest. The body normally consumes 250ml/min 02 at rest, this 250 in one MET
During exercise the amount of 02 consumed increases, when the amount double to 500ml/min. This is referred to as? 2 METS, a normal sedentary pt can increase 02 consumption to 7 METS
During exercise 02 consumption increases, but dead space (VD/VT)? Decreases with exercise, C02 production will increase since more 02 is being consumed
Normal C02 production is 200ml/min, this will increase with exercise. It can increase to as much as? 20 times the normal resting value.
There is a point during exercise where there is not enough 02 available to the muscles? the muscle reaches the anaerobic threshold and begins anaerobic metabolism
The anaerobic threshold begins when? at the point that when anaerobic metabolism joins aerobic metabolism in producing ATP, the greatest 02 consumption level reached without the production of lactic acid
When the anaerobic threshold is reached there is an increase in C02 production because? the body attempts to ventilate more to compensate for the lactic acid entering the blood stream
In normal adults when does the anaerobic threshold occur? at 50%-70% of their max work level (V02max), in trained athletes it may not occur until 90% of their V02max
Once a patient reaches their anaerobic threshold the lower 02 consumed and the more C02 produced causes the RQ to? increase to greater than 1
MET's directly relate to? 02 uptake, one MET is the amount of 02 produced at rest, level of 02 used
Exercise testing and oxyhemoglobin desaturation can be used to determine if supplemental 02 is needed during exertion, it can often? help pt get reimbursement for home 02, Sp02 is used to evaluate pt's oxygenation level, make sure Sp02 is accurate before walking, pt can normally walk at a comfortable pace (with general fitness test)
What are the four types of results from a stress test? normal, pulmonary disorder, poor conditioning, cardiovascular problems
A normal test? V02 in predicted range-VEmax 70% of MVV from Pre PFT or estimated MVV(Fev1 x 35)- No significant changes in Sp02 and P02- VD/VT will decrease or stay the same- HR max will come close to predicted
Pulmonary disease? Low V02 max (lower than predicted)- Vemax and MVV very close (no reserve)- Sp02 and P02 drop during test- Normal or increased VD/VT- Normal HR max
Poor Conditioning? Pt will become fatigued before reaching the exercise level that creates the need for increased ventilation HR max lower than predicted- V02 is low because they hit HR max early- VEmax and MVV low
Cardiovascular disorders? Same as poor condition but with added EKG changes and Blood pressure changes. The history, EKG, echo, and other lab values will help to determine if poor condition or cardio problem
If arrhythmias and ST segment changes are seen they strongly suggest a cardio problem, cardio and poor conditioning resemble each other because? exercise tolerance is limited by cardiac function
A stress test can be done to see if a patient has exercise induced asthma, the test is given the same except? FVC's are measured before and after to determine if a bronchospasm has been induced
What directions would you give someone prior to a metabolic study? 1. Avoid substances or drugs that would affect metabolism 2. Fast 2-4 hours before testing 3. Make no ventilator adjustments 1-2 hours before testing
What are the values or calculations required for a metabolic study? exhaled minute ventilation, urea nitrogen, VO2, VCO2
The three main nutritional substates that generate energy are: lipids, proteins, carbs
What can result from under feeding ventilator patients? Muscle wasting Prolonged weaning longer healing times
Your ventilated patient is having problems maintaining a low enough CO2 level. You want a diet that is? high in fats and lipids, low in carbs. Carbs=C02
Normal resting value for DLCO? 25mlCO/min/mmhg
What pulmonary problems can cause a decreased DLCO? emphysema, cystic fibrosis, pulm resection, pulm/fat emboli, anemia, interstitial lung disease(asbestosis, sarcoidosis, fibrosis, pneumonitis) pulm hypertension/edema, lung cancer
What can cause an increased DLCO? supine position, increased pulm blood flow, exercise, pulm hemorrhage, polycythemia with increased Hb, left heart failure, left to right cardiac shunt, high altitudes that increase Hb
Pulmonary disease will affect DLCO results? any disease that decreases AC membrane surface area will decrease DLCO, anything that increases blood flow to the AC membrane will increase DLCO (exercise or disease) asthma will be normal or increased DLCO
Predicted DLCO values? 80-120% normal 60-80% mild defect 40-60% moderate defect 20-40% severe <20% very severe
Short & Fat Loops indicate obstruction
Tall & skinny loops indicate restriction
Scoop in the loop on the expiratory side? obstruction, early is larger airways, later is smaller airways
What is impulse oscillometry? method for detecting obstructions in pt's that cannot do normal spirometry ( infants, pt's with disabilities)
Impulse oscillometry uses sound waves too? determine FEV1, peak flows, and resistance
FeNO is the measurement of exhaled nitric oxide, it is used to determine? asthma severity and the success of treatment, it measures the amount of airway inflammation, the higher the FeNO the more inflammation
Bronchoprovacation studies (methacholine) are used to determine if a pt has hyper reactive airways, they work by? attempting to cause a temporary airway obstruction by administering methacholine or histamine
What study is indicated for subjects who have normal spirometry but periodic wheezing or SOB? Bronchoprovacation
What type of study is indicated when the patient has a history of wheezing, is a known asthmatic, has a cough of unknown etiology, or to see if bronchodilater therapy will benefit pt? pre and post bronchodilater study, an increase in FEV1 > 12% indicates positive response, used to determine if obstructive disease is reversibe, some asthmatics can improve > 50%
Created by: juialynn92
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