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Physical Therapy Cardiopulmonary Tests and Measures

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Angina Pain Scale Ankle-Brachial Index Arterial Blood Pressure Auscultation of Heart Sounds Auscultations of Lung Sounds Capillary Refill Time Body Mass Index Dyspnea Scales Electrocardiogram (ECG) Exercise Stress testing Homan's sign for deep vein thrombosis Palpation of Peripheral Arterial pulses Pulmonary Function test Pulse Oximetry Rating of Perceived Exertion Respiratory Rate , Rhythm and pattern Six Minute walk Test

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Angina Pain Scale

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A # of pain scales are used to grade the severity of ANGINA PECTORIS. 1 → MILD, BARLEY NOTICEABLE 2 → MODERATE, BOTHERSOME 3 → MODERATELY SEVERE, VERY UNCONFORTABLE 4 → MOSTE SEVERE OR INTENSE PAIN EVER

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Ankle-Brachial Index

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(ABI) %= ankle systolic pressure divided by arm systolic pressure. ABI of 90% or less indicates presence of PVD. ≥ 1.30 Indicates RIGID arteries → needs US to check for PAD 1.0-1.30 = Normal → NO blockage 0.8-0.99 = MILD BLOCKAGE → Beginning of PAD 0.4-0.79 = MODERATE BLOCKAGE → May be assoc. w/ intermittent claudication during ex. < 0.4 = SEVERE BLOCKAGE → Severe APD → may have claudiation at rest

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Blood Pressure

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Non-invasive measurement of arterial BP w/ a PNEUMATIC CUFF and Sphygomomanometer. **Vital Signs** important indicator of health. Deviations from normal pressure provide info regarding cardiovascular conditions.

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BP procedure

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Use appropriate sphygmomanometer cuff for size of body part. BLADDER INSIDE CUFF SHOULD ENCIRCLE 80% OF ARM IN ADULTS AND 100% OF ARM IN CHILDREN YOUNGER THAN 12 *Occlude Brachial artery w. sphyg. (warpped around arm). *Inflate Sphy to to above anticipated SBP *Deflate cuff at rate of 2-3 mm Hg/sec. As bld flow returns, can be heard w/the Steth.→ Korotkoff sounds *Korotkoff sounds = Turbulent bld flow and oscillations of the arterial wall

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Korotkoff phases

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Phase 1 → SBP →1st appearance of CLEAR TAPPING SOUND corresponding to APPEARANCE OF PALPABLE PULSE Phase 2 → Sound becomes SOFTER and LONGER Phase 3 → Sound becomes CRISPER and LOUDER Phase 4 → Sound becomes MUFFLED and SOFTER Phase 5 → DBP → Last audible sound - Sound DISAPPEARS COMPLETELY

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Adult Normal blood pressure

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Normal - < 120 mm Hg SBP and < 80 DBP Hypotension = lower than 90 SBP/ 60 DBP Pre-HTN = 120-139 mm Hg SBP /80-89 mm Hg DBP Stage I HTN = 140-59 mm Hg SBP/ 90-99 mm Hg DBP (Thiazide diuretic for most patients) Stage II HTN = ≥160 mm Hg SBP/100 mm Hg DPB (two drug combination antihypertensive for most patients)

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BP for Children 3-17

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Normal BP = SBP and DBP <90% Pre-HTN = SBP or DBP ≥ 90% →95% Stage 1 HTN = SBP and/or DBP ≥ 95% → 99% + 5mm HG Stage 2 HTN =

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Placement of Stethoscope

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Directly on Pt.s skin Aortic Area: 2nd intercostal space at R sternal border Pulmonic Area: 2nd intercostal space@ L Sternal border Mitral Area: 5th intercostal space, Medial to L midclavicular line Tricuspid area: 4th intercostal space @ L sternal border

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S1

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the "lub" sound when ventricular pressure rises and closes the mitral and tricuspid valves - (SYSTOLE) This is the first sound heard as the AV valves close & is heard loudest at apex of heart. Heard at the left 5th intercostal space,

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S2

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the "dub" sound when ventricular pressure falls (after emptying) below the pressure in the aorta and pulmonary artery allowing the aortic and pulmonic valves to close - (DIASTOLE), the second heart sound that occurs with closure of the semilunar valves and signals the end of systole. loudest at the base

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S3

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VENTRICULAR GALLOP this heart sound is normal in children but abnormal in adults, an abnormal heart sound detected early in diastole as resistance is met to blood entering either ventricle; most often due to volume overload associated with heart failure

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S4

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ATRIAL GALLOP, the fourth heart sound in the cardiac cycle. It occurs late in diastole on contraction of the atria. Rarely heard in normal subjects, it indicates an abnormally increased resistance to ventricular filling, as in hypertensive cardiovascular disease, coronary artery disease, cardiomyopathy, and aortic stenosis.

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Systolic murmur

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Abnormal heart sound during the first heart sound or "lub". Can be caused by narrowed semi-lunar valve, regurgitation of the bicuspid and tricuspid valves or a VSD or ASD leading to excessive blood being ejected from the right ventricle.

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Diastolic murmur

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Abnormal heart sound during the second heart sound or "dub". Can be caused by narrowed bicuspid or tricuspid valve or regurgitation of the semi-lunar valves.

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Body Mass Index

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Or BMI, is using your height and weight to determine if you are underweight (Below 18.5), Normal (18.5 - 24.9), Overweight (25.0 - 29.9), Obese (30.0 and Above) BMI=Weight(kg) ÷ Height(m squared) BMI=Weight(kg) ÷ Height(in ²) x 703 = 40.0 Extreme Obesity Class 3

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Dyspnea

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Non-painful → uncomfortable awareness of breathing that is inappropriate to the level of exertion, also called shortness of breath. Caused by ↓'d O₂, Hypoventilaiton, hyperventilation, ↑'d work of breathing d/t ∆'s in respiratory mechanics or anxiety

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Dyspnea Scales

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0 No breathlessness .5 VV Slight 1 V Slight = noticeable to participant, but not to observer 2 Slight Breathlessness = some difficulty, participant can continue to exercise 3 Moderate difficulty,= participant can continue to exercise 4 Somewhat Severe = difficulty, participant must stop exercising 5/6 Severe Breathlessness 7/8 Very Severe Breathlessness 9 Very very Severe Breathlessness 10 Maximal

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Capillary Refill Time

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Time it take blood to resume flowing in the base of the nail beds Normal = > 2 seconds after compression and release of the nail bed Abnormal = < 2 Seconds (arterial occlusion, hypovolemic shock, hypothermia)

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Normal Breath Sounds

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BRONCHIAL/TRACHEAL = Big tubes. Loud sounds = heardover the proximal airways such as the trachea. You hear the air. Usually over the sternum and between the scapula. **A PAUSE** occurs between the inspiratory and expiratory phases VESICULAR = High Pitched, breezy sounds → Normal breath sounds made by air moving in and out of the alveoli (Distal airways) INSPIRATION > EXPIRATION PHASE ***NO PAUSE***

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Abnormal Breath Sounds

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Adventitious breath sounds = Abnormal breathing sounds heard during inhalation or expiration CRACKLE (formerly RALES) PLEURAL FRICTION RUB RHONCHI STRIDOR WHEEZE

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Crackle (used to be called Rales)

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Discontinuous, High-Pitched POPPING sound → heard more w/ INSPIRATION. Assoc. w/ Restrictive or Obstructive Respiratory disorders

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PLEURAL FRICTION RUB

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DRY, CRACKLING sound heard during EXP/INSP Inflamed pleura

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RHONCHI

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Continuous LOW PITCHED sound described as having a SNORING or GURGLING quality

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STRIDOR

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Continuous HIGH PITCHED "Wheeze" heard w/ INSP or EXP.

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WHEEZE

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Continous MUSICAL SQUEAK or WHISTLING Various PITCHES occuring on expiration n sometimes on inspiration When air moves thru a narrowed or partially obstrcuted airway.

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ECG

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Graphic representation of the Hearts Electrical activity recorded from electrodes on the surface of the body. Provides insight into the Electrical behavior of the heart and its modificaiton by physiologic, pharmacologic and pathologic events 12 Leads→ provide 12 views of the heart. Used to assess cardiac rhythm, dx location, extent and acutness of MI / ischemia, Eval ∆'s w/ activity.

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Waveforms and Intervals

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...

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P Wave

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Atrial Depolarization

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PR Interval

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From beginning of P wave to the beginning of the QRS complex (the time neccessary for atrial depolarization plus time for the impulse to travel through the AV node to ventricles)

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QRS comples

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- Ventricle depolarization and - Atria repolarization

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QT Interval

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Ventricular depolarization and repolarization, ventricles contract and relax

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ST Segment

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Time during which ventricles are contracting and emptying, Isoelectric, ventricles depolarizaed

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T Wave

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ventricle repolarization

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Sinus Node Rhythms

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...

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Normal Sinus Rhythm

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Atrial Depolarizaion begins in the SA NODE and spreads normally thru out Electrical conduction sys w/ a HR b/w 60-100 Beats/ min Regular rhythm of the heart cycle stimulated by the SA node (average rate of 72 beats per minute) The normal sequence on the ECG

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Bradycardia

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Slow heart rate, usually below 60 beats per minute (Adults)

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Tachycardia

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abnormally rapid heartbeat (over 100 beats per minute) Adults

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Arrhythmia

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Irregular pattern of heartbeats. quickening/slowing of impulse fomation in the SA NODE → beat - beat variations

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Sinus Arrest

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Intermittent failure of either SA node impulse formation or AV node conduction → Results in the occasional complete absense of P or QRS waves

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Exercise Stress Testing

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Exercise stress tests are used to assess the patients ability to tolerate increasing intensity of exercise while ECG, BP, HR and symptoms are monitored for evidence of myocardial ischemia, abnormal electrical conduction, or other normal signs and symptoms of exertion. May be used to evaluate disease severity and prognosis and to determing functional capacity, expecially for exercise prescription and counseling

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Procedure for Exercise Stress Testing

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Pt is required to EX at progressively greater increments of work, by varying the speed / grade of treadmill or speed / resistance to Pedaling an UE or cycle Ergometer *HR, BP, ECG, RPE and S/S are monitored b4, during & after

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ABSOLUTE Indications to TERMINATE Stress Test

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*↓ in SBP > 10mm Hg from baseline despite ↑ in workload w/ other evidence of ISCHEMIA *MODERATELY SEVERE Angina (3/4) *↑ NS Sx (Ataxia, Dizziness) *Signs of POOR PERFUSION (cyanosis, pallor) *SUSTAINED Ventricular TACHYCARDIA *1.0 mm ST ↑ in Leads W/O Diagnostic Q WAVES.

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RELATIVE Indicaitons for TERMINATING Stress Test

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*↓ in SBP > 10mm Hg from baseline despite ↑ in workload WITHOUT other evidence of ISCHEMIA *> 2 MM ST Segment DEPRESSION *ARRHYTHMIAS other than SUSTAINED VENTRICULAR *TACHYCARDIA including mulifocal PVC's, Supraventricular Tachycardia, Heart Block or Bradyarrhythmias *FATIGUE, SOB, Wheezing, Leg cramps and Claudication *Development of Bundle Branch Block or Intraventricular Cunduction Delay *↑'d CHEST PAIN *Hypertensive Response (SBP > 250 mm Hg and/or DBP 115 mm Hg)

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Interpretation of Exercise Stress Test

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(−) Test indicates a ↓ probability of CAD An Aerobic Exercise Perscription can be determined from Performance on the Ex test.

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Homan's sign for DVT

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Test to detect DVT in the LE Passively dorsiflex the foot a the ankle with the knee straight (+) = Pain in the calf or popliteal space. Clinical findings alone are INSENSITIVE and NON-SPECIFIC Cannot be relied on to confirm / exclude Dx of DVT

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Palpation of Peripheral Arterial pulses

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Assessing heart rate and rhythm as well as blood flow in the extremity Normal = Stronge / Regular Irregular = Weak / Difficult to Palpate High Intensity = Present when SV is ↑'d

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Procedure for Peripheral arterial Pulses

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*Assessing HR and RHYTHM Palpate over the artery with the tip of the index and the middle finger with enough pressure to feel the pulse but with out obstructing blood. *Note TIME BETWEEN PULSATIONS *REGULAR = Time B/W Pulsations is ∼ EQUAL → Count the pulses for 15 sec and Multiply by 4 *IRREGULAR = Time B/W pulsations IS NOT EQUAL → Count the Pulses for 60 Sec. *Note VOLUME / QUALITY of pulse and any differences b/w the pulses in the two limbs

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Pulse Points

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*CAROTID = The pulse felt along the large carotid artery on either side of the neck. *BRACHIAL (cubital) = Medial to tendon of biceps brachii *RADIAL = At the Wrist → Lateral to FCR tendon *ULNAR = At Wrist → b/w Flexor Dig. Superficialis, & FCU tendon *FEMORAL = Upper Thigh → 1/3 the distance from Pubis to ASIS *POPLITEAL = Popliteal space → Post Knee *POST. TIB = Space b/w Medial Malleolus and Achilles Tendon → above CALCANEUS *DORSAL PEDIS = Near center of Long Axis of Foot → b/w 1st abd 2nd Metatarsal Bones

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Heart Rate by AGE

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Beats/MIn NEWBORN = 130-140 INFANT → 2 yrs = 110-130 2 → 6 yrs = 96-115 6 → 10 yrs = 70-110 ADULT = 60-80

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Volume / Amplitude of Pulse

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+3 = Large / Bounding pulse + 2 = Normal / Avg Pulse 1 = Small / Reduced Pulse 0= No Pulse felt

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Pulmonary Function Test

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Measures the volume or flow of air during inhalation or exhalation. Typically involves subject exhaling as hard and fast into a mouthpiece which determines the FVC.

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Procedure for PFT

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*Upright Posture→ Pt EXHALES into the spirometer mouthpiece as hard and as fast as possible for 6 SECONDS until no more air can be expelled *Repeat 3 Times *Modern Spirometers Calculate "PREDICTED NORMAL" values (Test value pt. should normally attain based on AGE, SEX, HEIGHT, WEIGHT, RACE)

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Interpretation of PFT

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OBSTRUCTIVE VENTILATORY IMPAIRMENT = ↓'d EXPIRATORY flows NARROWED AIRWAYS → resistance to airflow during breathing. Examples = Asthma, Bronchiectasis, COPD, and Cystic fibrosis. RESTRICTIVE VENTILATORY IMPAIRMENT = Condition where the ability to expand the lungs is ↓'d, 1) Chest wall disorders a)Obesity b)Kyphoscoliosis c) Polio 2) Interstitial/Infiltrative diseases a) ARDS, Pneumoconiosis b) Pulmonary fibrosis

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Pulse Oximetry

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Non-invasive method of estimating the % of O₂ Saturation of HEMOGLOBIN in the bld using an oximeter with a specialized probe attached to the skin at a site of arterial pulsation, commonly the finger SpO₂ → Indication of partial pressure of O₂ in Atrial BLD.

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Interpretation of Pulse Oximtry (SpO₂)

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NORMAL = greater than or equal to 95% CRITICAL = less than 75% SIGNIFICANCE = Elevated-Increased inspired o2; hypervenilation -Decreased-hypovenilation; inadequate 02 is inspired User-contributed If SpO₂ < 90% in Acutely ill pts or < 85% in pts w/ Chronic Lung Disease → ACTIVITY SHOULD BE STOPPED → TALK TO MD → CONSIDER L ADDING SUPPLIMENTAL O₂

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RPE

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Used during EXERCISE EVALUATION 2 scales = LINEAR (6-20) NON-LINEAR/RATIO (0-10) → Used to measure during AEROBIC EX / EXERSION during STRENGTHENING Used for EX TESTING / PERSCRIPTION and determining INTENSITY esp. when max HR IS NOT known; Can rate work to help prevent injury Multiply # × 10 to get HR

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RPE Origional Scale

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6/7 = Very Very Light 8/9 = Very Light 10/11 = Fairly Light 12/13 = Somewhat Hard 14/15 = Hard 16/17/18 = Very Hard 19/20 = V V Hard

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RPE Revised Scale

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0 = Nothing 0.5 = Very Very Weak 1 = Very Weak 2 = Weak 3 = Moderate 4 = Somewhat Strong 5 = Strong 6/7/8 = Very Strong 9/10 = Maximal → Very Very Strong

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Interpretations for RPE

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13-14 represents about 70% of Maximal HR during Ex on a treadmill / Cycle ergometer 11-13 Upper limits of Prescribed Training HR in EARLY CARDIAC REHABILITATION RPE can substitute for HR in Prescribing the INTENSITY of EX when → *Ability to monitor HR is compromised (sensory deficits) *No Exercise Stress Test was performed prior to beginning Rehab program *HR response to EX is altered (transplant) *Physical activities other than Cardiorespiratory Endurance are assessed *Clinical / Medical Therapy status ∆'s

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Respiratory Rate / Rhythm / Pattern

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Complete Assessment of Respiration → Consideres 4 parameters Rate → # of BREATHS /min Rhythm → regularity of Insp/Exp Depth → Volume of air exchanged w/in each breath Character → Effort / Sounds produced during breathing

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Interpretation (RR rates for Normal Adults)

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Newborn →30 55 17 years →12 20 3 years → 20 30 10 years →16 20 6 years →16 22 1 year → 25 40

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Normal Respiratory Rhythm

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Inspiration → ½ as long as Expiration I:E ratio → 1:2 COPD = I:E → 1:3 or 1:4

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Depth of Respiration

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Deep or Shallow

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Character of Respiration

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Normal = Quiet / Effortless Labored Breathing = Use of Accessory mm Wheezes/Crackles = Abnormal → ∆'s in Airways

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Common Breathing Patterns

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...

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Apnea

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Absence of Spontaneous Breathing

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Biot's

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Irregular Breathing → Breaths vary in Depth and RATE. W / periods of APNEA Assoc w/ ICP or Damage to MEDULLA

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Bradypnea

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Slower than Normal RR → < 12 breaths/min in Adults Assoc w/ Neurologic / Electrolyte disturbance / infection / ↑ Level of Cardiorespiratory fitness

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Cheyne-Stokes

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↓ Rate / Depth of Breathing → PERIODS OF APNEA CNS Damage

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Eupnea

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Normal Rate and Depth of Breathing

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Hyperpnea

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↑'d Rate / Depth of Breathing

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Hypopnea

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↓'d Rate / Depth of Breathing

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Tachypnea

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Faster than Normal RR → > 20 breaths / min (Adults)

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6 Min Walk Test

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6MWT → Used to measure FUNCTIONAL STATUS and to DOCUMENT OUTCOMES for Pt.s w/ Heart and Lung Disorders (also for healthy adults) *Pt. walks on Measured "track" at least 100 ft (30 Meters) length *Take Meds b4 if needed *May use O₂ if needed *Can use Assistive Device *Do 3 Walks → Rest 15 min b/w each test *Measure → Bp, HR, RR, RPE and O₂ Saturation b₂4 and immed after test

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Interpretation of 6MWT

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Record Distance walked and # of Rests taken

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