Chapter 12 Cardiopulmonary Procedures Copyright 2015 2012 2008

Chapter 12 Cardiopulmonary Procedures Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc.

Lesson 12. 1 Introduction to Electrocardiography 1. 2. 3. Trace the path of the blood through the heart, starting with the right atrium. Describe the heart’s conduction system. State the purpose of electrocardiography. Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 2

Lesson 12. 1 Introduction to Electrocardiography 4. Identify each of the following components of the ECG cycle: • • P wave QRS complex T wave P-R segment ST segment P-R interval Q-T interval Baseline following the T wave Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 3

Lesson 12. 1 Introduction to Electrocardiography 5. 6. 7. State the purpose of the standardization mark. State the functions of the electrodes, amplifier, and galvanometer. List the 12 leads that are included in an ECG. Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 4

Introduction to Electrocardiography (1 of 8) Electrocardiograph: instrument used to record the electrical activity of the heart Electrocardiogram (ECG): graphic representation of the electrical activity of the heart Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 5

Introduction to Electrocardiography (2 of 8) Cardiovascular disorders: Ø Can cause abnormal changes on an ECG Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 6

Introduction to Electrocardiography (3 of 8) Purpose of electrocardiography: Ø Ø Ø Evaluate the following symptoms: • • Chest pain Shortness of breath Dizziness Heart palpitations Detect abnormality in heart rate or rhythm (dysrhythmia) Detect presence of impaired blood flow to heart muscle (cardiac ischemia) Help diagnose damage to heart caused by myocardial infarction Determine the presence of hypertrophy of the heart Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 7

Introduction to Electrocardiography (4 of 8) Purpose of electrocardiography: Ø Ø Ø Ø Detect myocarditis or pericarditis Assess the effect on the heart of digitalis or other cardiac drugs Determine the presence of electrolyte disturbances Assess the progress of rheumatic fever Detect congenital heart defects Performed before surgery to assess cardiac risk during surgery As part of a complete physical examination Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 8

Introduction to Electrocardiography (5 of 8) ECG cannot detect all cardiovascular disorders Ø Cannot always detect impending heart disease (e. g. , MI) ECG is taken with patient in a resting state Ø Only records 10 seconds of the heart’s activity • Ø If patient has an intermittent dysrhythmia – may not occur during this brief time Patient with angina pectoris • Does not usually have symptoms in a resting state – ECG may appear normal Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 9

Introduction to Electrocardiography (6 of 8) To obtain a complete assessment of cardiac functioning Ø ECG must be used in combination with: • • Patient’s symptoms Health history Physical examination Other diagnostic and laboratory tests Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 10

Introduction to Electrocardiography (7 of 8) MA responsible for running ECG, which includes Ø Ø Preparation of the patient Operation of electrocardiograph Identification and elimination of artifacts Care and maintenance of the electrocardiograph Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 11

Introduction to Electrocardiography (8 of 8) ECG machine formats: Ø Ø Single-channel format: one lead recorded at a time Three-channel format: three leads recorded at one time • Most offices use this Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 12

Structure of the Heart (1 of 4) Heart consists of four chambers Ø Upper chambers • • Ø Right atrium Left atrium Large lower chambers • • Right ventricle Left ventricle Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 13

Structure of the Heart (2 of 4) Pathway of blood through the heart Ø Blood enters right atrium: from superior and inferior vena cava • Ø Ø Brought back to heart after circulating in the body Enters right ventricle Pumped to the lungs • By way of the pulmonary artery Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 14

Structure of the Heart (3 of 4) Pathway of blood through the heart Ø Returns to the left atrium of the heart • Ø Enters left ventricle • Ø Through pulmonary veins Most muscular and powerful chamber of the heart Pumped into the aorta to be distributed to the body • Nourishes tissues with oxygen and nutrients Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 15

Structure of the Heart (4 of 4) Coronary arteries Ø Consist of two small arteries that branch off the aorta • Innervate the heart Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 16

Conduction System of the Heart (1 of 2) Sinoatrial node (SA node) Ø Located in upper portion of right atrium • Ø Consists of a knot of modified myocardial cells • Ø Just below opening of superior vena cava Able to send out an electrical impulse without an external nerve stimulus Initiates and regulates the heartbeat • Known as the “pacemaker” of the heart Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 17

Conduction System of the Heart (2 of 2) Path of impulse from SA node Ø Ø Ø Electrical impulse discharged by SA node Impulse distributed to right and left atria: causes atria to contract Impulse picked up by atrioventricular (AV) node AV node delays impulse momentarily Impulse transmitted to bundle of His Bundle branches: relays impulse to the Purkinje fibers • Distribute impulse evenly to right and left ventricles Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 18

Cardiac Cycle (1 of 3) Represents one complete heartbeat Consists of Ø Ø Ø Contraction of atria Contraction of ventricles Relaxation of entire heart Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 19

Cardiac Cycle (2 of 3) ECG: records electrical activity that causes cardiac cycle to occur ECG cycle: graphic representation of cardiac cycle Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 20

Cardiac Cycle (3 of 3) ECG Cycle Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 21

Waves (1 of 4) P wave Ø Ø Represents electrical activity associated with contraction of the atria Known as: atrial depolarization Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 22

Waves (2 of 4) QRS complex (consists of Q, R, S waves) Ø Represents electrical activity associated with contraction of the ventricles • Ø Known as: ventricular depolarization Ventricles are larger than atria • Requires a stronger electrical stimulus to depolarize ventricles – causes R wave to be taller than P wave Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 23

Waves (3 of 4) T wave Ø Represents electrical recovery of the ventricles • Ø Ø Known as ventricular repolarization Muscle cells are recovering in preparation for another impulse Atrial repolarization (electrical recovery of atria) • • Occurs following P wave Occurs at same time as ventricular depolarization (QRS complex) – causes it to be masked by QRS complex; therefore does not appear as a separate wave on the ECG cycle Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 24

Waves (4 of 4) U wave Ø Ø Ø Occasionally follows T wave Small wave May be associated with repolarization Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 25

Baseline, Segments, and Intervals Baseline Ø Ø Ø Flat, horizontal line that separates various waves Heart is at rest (polarized) No electrical activity is occurring in heart Electrocardiograph doesn’t have anything to record • Waves deflect either upward or downward from baseline • • This is why the baseline is flat Positive deflection: wave deflects upward Negative deflection: wave deflects downward ECG: divided into segments and intervals between P wave and T wave Ø Purpose: Interpretation and analysis of ECG Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 26

Segments (1 of 3) Segment: portion of the ECG between two waves P-R segment: Ø Time interval from the end of atrial depolarization to the beginning of ventricular depolarization • Represents time needed for impulse to be delayed at AV node, then travels through bundle of His and Purkinje fibers to ventricles Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 27

Segments (2 of 3) S-T segment: Ø From the end of ventricular depolarization to the beginning of repolarization of ventricles Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 28

Segments (3 of 3) Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 29

Intervals (1 of 3) Interval: length of a wave or length of wave with a segment P-R interval: Ø Time interval from the beginning of atrial depolarization to the beginning of ventricular depolarization Q-T interval: Ø Time interval from the beginning of ventricular depolarization to the end of repolarization of the ventricles Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 30

Intervals (2 of 3) Baseline (after T wave or U wave): Ø Period when entire heart returns to resting or polarized state Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 31

Intervals (3 of 3) Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 32

Electrocardiograph Paper (1 of 4) Paper divided into two sets of squares Ø Ø Small square: 1 mm high and 1 mm wide Large square: 5 mm high and 5 mm wide • Each large square is made up of 25 small squares Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 33

Electrocardiograph Paper (2 of 4) Physician uses graph to measures waves, intervals, and segments Determines if ECG is within normal limits Heart disease Ø Can trigger abnormal changes on ECG cycle • • • Causes results to fall outside normal limits Example: Cardiac ischemia (due to CAD) can cause depressed S-T segment and inverted T wave Example: Myocardial infarction cause larger than normal Q wave and elevated S-T segment Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 34

Electrocardiograph Paper (3 of 4) Paper contains a thermosensitive coating Ø Black or red graph printed on top of coating Thermal print head Ø Ø Produces ECG tracing Generates heat in a prescribed pattern Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 35

Electrocardiograph Paper (4 of 4) Thermosensitive paper Ø Comes in contact with heated print head • Coating of paper turns black where it is heated: produces ECG tracing Paper is also pressure-sensitive Ø Handle carefully to avoid making impressions • May interfere with proper reading of ECG Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 36

Standardization of the Electrocardiograph (1 of 3) Electrocardiograph must be standardized for every recording Ø Quality control measure • • Ensures an accurate and reliable recording Also means ECG run on one electrocardiograph compares in accuracy with a recording run on another machine Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 37

Standardization of the Electrocardiograph (2 of 3) Normal standardization mark: Ø Ø Height: 10 mm (10 small squares) Width: approximately 2 mm wide (2 small squares) Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 38

Standardization of the Electrocardiograph (3 of 3) Three-channel machine: automatically records standardization marks Ø One mark recorded at beginning and end of each ECG strip If standardization mark is more or less than 10 mm high Ø Ø Machine must be adjusted Consult operating manual for adjustment information Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 39

Electrocardiograph Leads (1 of 3) Consists of 12 leads Ø Lead: A tracing of the electrical activity of the heart between two electrodes Each lead: Ø Ø Provides an electrical "photograph" of heart's activity from a different angle Results in 12 "photographs" of the heart • Facilitates thorough interpretation of heart's activity Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 40

Electrocardiograph Leads (2 of 3) Four limb lead wires Ø Ø Ø Right arm (RA) Left arm (LA) Right leg (RL): ground • • Ø Not used for recording Serves as an electrical reference point Left leg (LL) Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 41

Electrocardiograph Leads (3 of 3) Chest lead wires Ø Ø Abbreviated V Uses six chest electrodes Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 42

Electrodes (1 of 7) Electrode Ø Ø Made of a substance that is a good conductor of electricity Picks up electrical impulses given off by the heart • Conducts impulse into machine by lead wires Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 43

Electrodes (2 of 7) Amplifier: device located in machine that amplifies the electrical impulses Ø Electrical impulses given off by the heart are very small (0. 0001 to 0. 003 volt) Must be made larger (amplified) Galvanometer: changes amplified voltages into mechanical motion Thermal print head Ø Records heart tracing on ECG paper Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 44

Electrodes (3 of 7) Used to record a resting 12 -lead electrocardiogram Contain a thin layer of a metallic substance Ø Good conductor of electricity Square in shape Ø Tab extends from one end • Allows for firm attachment of alligator clip Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 45

Electrodes (4 of 7) Electrolyte gel combined with an adhesive Ø Located on back of electrode • Ø Skin is a poor conductor of electricity • Ø Electrolyte: a substance that facilitates the transmission of the heart’s electrical impulse Electrolyte must be used when recording ECG Adhesive: allows for firm adherence of electrode to skin Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 46

Electrodes (5 of 7) Disposable 12 -lead electrode comes on a card containing 10 electrodes Ø Foil-lined pouch holds 10 cards of electrodes (100 electrodes per pouch) Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 47

Electrodes (6 of 7) Electrolyte gel combined with an adhesive Ø Expiration date • • Stamped on each electrode pouch (and box containing the pouches) Always check expiration date before applying Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 48

Electrodes (7 of 7) Electrolyte gel combined with an adhesive Ø Store properly to prevent electrolyte drying • • Ø Cool area (less than 75º F or 24º C) Away from sources of heat After opening electrode pouch • • Seal by folding over the end of it Place pouch in a zip-lock plastic bag to preserve moisture Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 49

Bipolar Leads (1 of 2) Leads I, III Each bipolar lead: uses two limb electrodes to record electrical activity of the heart Ø Ø Ø Lead I: records electrical current between right arm and left arm Lead II: records electrical current between right arm and left leg Lead III: records electrical current between left arm and left leg Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 50

Bipolar Leads (2 of 2) Lead II: shows heart's rhythm more clearly than other leads Ø Rhythm strip: longer recording (12 inches) of lead II • Often requested by physician Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 51

Augmented Leads (1 of 2) a. VR (augmented voltage—right arm) Ø Records electrical current traveling between • • • Right arm electrode and a central point between left arm and left leg Left arm electrode and a central point between right arm and left leg Left leg electrode and a central point between right arm and left arm Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 52

Augmented Leads (2 of 2) Leads I, III, a. VR, a. VL, and a. VF Ø Provides electrical photograph of heart’s activity • From side to side and from top to bottom of heart Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 53

Chest Leads (1 of 3) V 1, V 2, V 3, V 4, V 5, and V 6 Ø Record heart's voltage from front to back of heart • From a central point "inside" the heart: to a point on the chest wall – where each chest electrode is placed Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 54

Chest Leads (2 of 3) Leads must be properly located Ø To ensure an accurate and reliable recording When first learning to locate electrode sites Ø Helps to mark location of chest • Ø With a felt-tipped pen Normally ECG is recorded with paper moving at a speed of 25 mm/second Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 55

Chest Leads (3 of 3) Recommended positions for ECG chest electrodes: Ø Ø Ø V 1, fourth intercostal space at right margin of sternum V 2, fourth intercostal space at left margin of sternum V 3, midway between positions 2 and 4 V 4, fifth intercostal space at junction of left midclavicular line V 5, at horizontal level of position 4 at left anterior axillary line V 6, at horizontal level of position 4 at left midaxillary line Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 56

Patient Preparation Minimal preparation required for an ECG Instruct patient in the following: Ø Ø Do not apply body lotion, oil, or power on day of test Wear comfortable clothing Wear a shirt or blouse that can easily be removed Women should not wear full-length hosiery (e. g. , panty hose or tights) Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 57

Maintenance of the Electrocardiograph (1 of 3) Casing Ø Clean frequently • • Use a soft cloth slightly dampened with a mild detergent to remove dust and dirt Do not use solvents or abrasives – can damage finish of casing Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 58

Maintenance of the Electrocardiograph (2 of 3) Patient cable, lead wires, and power cord Ø Never immerse cables in cleaning solution Ø Clean periodically with a cloth moistened with a disinfectant Could damage them Inspect cables frequently for cracks or fraying Ø Replace if needed Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 59

Maintenance of the Electrocardiograph (3 of 3) Check metal tip of each lead wire for adhesive/electrolyte gel residue Ø Can interfere with transmission of a good ECG signal • Remove residue with alcohol wipe using pressure and friction Reusable alligator clips Ø Ø Clean thoroughly with alcohol wipe after patient use Should fit snugly on metal tip of each lead wire Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 60

Lesson 12. 2 Taking an Electrocardiogram, Holter Monitor Electrocardiography, and Cardiac Dysrhythmias 8. Describe the function served by each of the following: • • Three-channel recording capability Interpretive electrocardiography Electronic medical record connectivity Teletransmission Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 61

Lesson 12. 2 Taking an Electrocardiogram, Holter Monitor Electrocardiography, and Cardiac Dysrhythmias 9. Identify each of the following types of artifact, and state its causes: • • 10. 11. 12. Muscle Wandering baseline 60 -cycle interference Interrupted baseline List the reasons for applying a Holter monitor. State the guidelines for wearing a Holter monitor. Explain the use of the patient diary in Holter monitor electrocardiography Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 62

Lesson 12. 2 Taking an Electrocardiogram, Holter Monitor Electrocardiography, and Cardiac Dysrhythmias 13. Identify each of the following cardiac dysrhythmias, and explain its causes: • • Premature atrial contraction Paroxysmal atrial tachycardia Atrial flutter Atrial fibrillation Premature ventricular contraction Ventricular tachycardia Ventricular fibrillation Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 63

Three-Channel Recording Capability (1 of 5) Records electrical activity of three leads simultaneously Ø Single-channel: records only one lead at a time Advantage Ø ECG can be run in less time Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 64

Three-Channel Recording Capability (2 of 5) Leads recorded simultaneously Ø Ø I, III a. VR, a. VL, a. VF V 1, V 2, V 3 V 4, V 5, V 6 Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 65

Three-Channel Recording Capability (3 of 5) Three-Channel ECG Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 66

Three-Channel Recording Capability (4 of 5) Electrocardiograph automatically labels each lead Ø With its appropriate abbreviation Requires three-channel recording paper (8½ by 11 inch) Ø Printout: fits easily into a paper-based medical record Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 67

Three-Channel Recording Capability (5 of 5) Most have copy capability Ø Quickly produces duplicate copy of an ECG just recorded Some have memory storage Ø Specific number of ECGs can be stored • Ø For later retrieval Misplaced ECG can be retrieved and printed out again Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 68

Interpretive Electrocardiograph (1 of 4) Built-in computer program Ø Analyzes recording as it is being run Provides immediate information on heart's activity Ø Leads to earlier diagnosis and treatment Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 69

Interpretive Electrocardiograph (2 of 4) Patient data: must be entered into electrocardiograph before running Ø Ø Ø Patient age Sex Height Weight Medications Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 70

Interpretive Electrocardiograph (3 of 4) Patient data and analysis are printed at top of recording Ø Along with reason for interpretation Results reviewed and interpreted further by physician Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 71

Interpretive Electrocardiograph (4 of 4) Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 72

EMR Connectivity (1 of 2) Allows electrocardiograph to be linked with office computer Ø Either wirelessly or through a USB port Digital image of ECG sent to computer Ø Displayed on screen of computer Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 73

EMR Connectivity (2 of 2) Software also analyzes ECG Ø Displays this information on screen • Along with reason for each interpretation Copy of ECG can be printed out (if needed) ECG report is reviewed and interpreted further by the physician ECG stored electronically in patient’s EMR Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 74

Teletransmission Transmits recording electronically over phone line Ø Recording interpreted by cardiologist Ø To ECG data interpretation site Along with computer analysis Interpretation and ECG recording Ø Electronically transmitted to sending office on the same day Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 75

Artifacts (1 of 3) Important to produce a clear and concise ECG Ø Can be easily read and interpreted by computer and physician Occasionally artifacts appear in recording Ø Artifact: additional electrical activity picked up by electrocardiograph • Interferes with normal appearance of ECG cycles Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 76

Artifacts (2 of 3) Affects quality of recording Ø Makes it difficult to manually measure ECG cycles May cause a false-positive on ECGs analyzed by a computer Most common artifacts: Ø Ø Ø Muscle Wandering baseline 60 -cycle interference (AC artifact) Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 77

Artifacts (3 of 3) If unable to correct artifacts: machine may be broken Ø Contact service technician with the following information: • • • What has already been done to locate and correct the problem Leads in which artifact occurs Sample of the artifact Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 78

Muscle Artifact (1 of 6) Characterized by Ø Fuzzy, irregular baseline Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 79

Muscle Artifact (2 of 6) Due to Ø Ø Involuntary muscle movement (somatic tremor) Voluntary muscle movement Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 80

Muscle Artifact (3 of 6) Caused by Ø Apprehensive patient – to correct: • Reduce apprehension: relaxes muscles – explain the procedure; reassure patient that ECG is painless Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 81

Muscle Artifact (4 of 6) Caused by Ø Patient discomfort – to correct: • Make patient more comfortable: ensure table is wide enough to support patient’s arms and legs; place pillow under patient’s head; ensure room temperature is comfortable to patient (patient has removed clothing and may be cold; can cause shivering) Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 82

Muscle Artifact (5 of 6) Caused by Ø Patient movement – to correct: • Instruct patient to lie still and not to talk Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 83

Muscle Artifact (6 of 6) Caused by Ø Physical condition (e. g. , Parkinson's disease) • • Nervous system disorder that may prevent relaxation (e. g. , Parkinson’s disease) – patient trembles continuously Difficult to obtain an ECG free of artifacts Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 84

Wandering Baseline Artifact (1 of 5) Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 85

Wandering Baseline Artifact (2 of 5) Caused by Ø Loose electrodes • • Results in poor transmission of electrical impulse To correct: ensure electrodes are attached firmly to patient's skin Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 86

Wandering Baseline Artifact (3 of 5) Caused by Ø Loose electrodes • • If electrode pulls loose: reattach with tape; replace with a new electrode Ensure clips are firmly attached to electrodes Ensure patient cable is well supported on patient's abdomen or table to prevent pulling of lead wires on electrodes – can cause electrodes to pull away from skin Do not allow cable to dangle Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 87

Wandering Baseline Artifact (4 of 5) Caused by Ø Ø Dried-out electrolyte on electrode Prevents good adhesion of electrodes to skin – to correct: • Ø Replace it with a new electrode Check expiration date stamped on electrode pouch (or box) to make sure within the expiration date Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 88

Wandering Baseline Artifact (5 of 5) Caused by Ø Body creams, oils, or lotions on skin at electrode application site – to correct: • Ø Remove by rubbing with alcohol using friction Excessive movement of the chest wall during respiration Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 89

60 -Cycle Interference Artifact (1 of 6) Also known as AC artifact Due to electrical interference Electric current can leak out Ø From power used by electrical appliances in room • May be picked up by patient and carried into machine – results in a 60 -cycle interference artifact Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 90

60 -Cycle Interference Artifact (2 of 6) Appearance of 60 -cycle interference artifact Ø Small straight spiked lines that are consistent • Causes baseline to be thick and unreadable Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 91

60 -Cycle Interference Artifact (3 of 6) Caused by Ø Lead wires not following body contour • • Dangling lead wires pick up electric current – to correct: Arrange lead wires to follow body contour and to lie flat Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 92

60 -Cycle Interference Artifact (4 of 6) Caused by Ø Other electrical equipment in room: may leak electric current – to correct: • Unplug nearby electrical equipment (lamps, autoclave, electrically powered examining table) Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 93

60 -Cycle Interference Artifact (5 of 6) Caused by Ø Ø Other electrical equipment in room: may leak electric current Wiring in walls, ceiling, floors – to correct: • Move patient table away from walls Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 94

60 -Cycle Interference Artifact (6 of 6) Caused by Ø Improper grounding of the electrocardiograph • • Machine is automatically grounded when plugged in (by three-prong plug) Check plug: to make sure prongs are not loose or damaged Ensure plug is securely in wall outlet RL electrode picks up electric current from patient and carries it into machine – electric current is then carried away by grounding system of machine Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 95

Interrupted Baseline Artifact Caused by Ø Metal tip of lead wire becoming detached from alligator clip – to correct: • Ø Reattach lead to alligator clip Frayed or broken patient cable – to correct: • Replace patient cable Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 96

Holter Monitor Electrocardiography (1 of 3) Portable ambulatory monitoring system Continuously records electrical activity of the heart for 24 hours or more Also known as ambulatory electrocardiographic monitor (AEM) Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 97

Holter Monitor Electrocardiography (2 of 3) Detects cardiac abnormalities Ø That occur while patient is engaged in normal daily routine Holter system designed so that Ø Patient is able to maintain daily activities • With minimal inconveniences Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 98

Holter Monitor Electrocardiography (3 of 3) Similar to a resting 12 -lead ECG Ø Electrical impulses given off by heart are picked up by electrodes • Ø Transmitted through lead wires to a recording device Different than a resting 12 -lead ECG • Only about 10 seconds of heart’s activity are recorded with a 12 -lead ECG Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 99

Purpose (1 of 2) Used to diagnose cardiac rate, rhythm, and conduction abnormalities. Most frequently used to: Ø Ø Assess the rate and rhythm of the heart during daily activities Evaluate patients with unexplained chest pain, dizziness, or syncope (fainting) Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 100

Purpose (2 of 2) Most frequently used to: Ø Discover intermittent cardiac dysrhythmias not picked up on a routine resting 12 -lead ECG • • Ø Ø Detect myocardial ischemia Assess the effectiveness of antidysrhythmic medications • Ø Resting ECG: only records between 40 and 50 heartbeats Holter monitor: records approximately 100, 000 heartbeats in a 24 -hour period Examples: digitalis and antianginal medications Assess the effectiveness of a pacemaker Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 101

Digital Holter Monitor (1 of 3) To document heart’s activity, uses either: Ø Ø External (removable) memory card Internal (nonremovable) memory card Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 102

Digital Holter Monitor (2 of 3) Lightweight and battery-powered Can be: Ø Ø Clipped onto a belt around waist Held in a protective pouch • Hung around patient’s neck with a lanyard Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 103

Digital Holter Monitor (3 of 3) Continuously records electrical activity of heart: Ø For 24 hours, 48 hours, or 72 hours • Ø Most physicians order a 24 -hour recording Stores it on the memory card Automatically stops recording after monitoring period is completed Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 104

Patient Preparation (1 of 2) Take a shower or bath before coming to the medical office Ø Will not be able to shower or bathe again until monitor is removed Do not apply body lotion, oil, or powder to chest before or during the test Ø May make it more difficult to apply electrodes Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 105

Patient Preparation (2 of 2) Take usual medications (unless physician specifies otherwise) Wear loose, comfortable clothing Ø Example: shirt or blouse that buttons down front for easier application of electrodes Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 106

Electrode Placement (1 of 2) Holter monitor electrodes Ø Ø Ø Pick up electrical impulses given off by heart Consist of foam Are round or rectangular in shape Adhesive backing Central sponge pad Disposable Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 107

Electrode Placement (2 of 2) Newer Holter monitors are three-channel recording systems Ø Ø Ø Can record three leads at one time Use between four and seven electrodes (depending on brand of monitor) Check monitor’s effectiveness after hooking up patient Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 108

Patient Diary All activities and emotional states must be documented Ø Physical symptoms experienced during activity Ø Along with time of occurrence Must be indicated next to each activity Dysrhythmia or abnormal ECG change recorded by Holter compared with diary Ø To determine if an activity, emotional state, or symptom triggered the ECG abnormality Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 109

Event Marker Some Holter monitors have an event marker button Ø When event market button is pressed Ø Used along with patient diary for evaluation Beep may sound as audible feedback Patient should be instructed to: Ø Ø Depress the button momentarily when experiencing a symptom Record time and nature of symptom in the diary Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 110

Holter Monitor Patient Guidelines (1 of 2) Participate in normal everyday activities Do not shower, bathe, or swim while wearing monitor Check periodically to make sure monitor indicator light is on and electrode and lead wires are still attached to chest Do not touch or move electrodes or lead wires If a lead wire detaches, snap it back on ASAP and record in patient diary Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 111

Holter Monitor Patient Guidelines (2 of 2) If electrode becomes loose, apply tape to restore contact and record in patient diary Do not handle monitor or take it out of its pouch Do not use certain electric or magnetic appliances or objects Record activities and emotional states Record physical symptoms experienced during each activity Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 112

Evaluating Results (1 of 2) At end of monitoring period Ø Holter monitor removed from patient Memory card information uploaded to computer Specialized ECG software: Ø Ø Performs calculations on the data Prepares an ECG summary report • Displayed on screen of the computer Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 113

Evaluating Results (2 of 2) Computer-generated ECG report Ø Summarizes information about: • • Ø Includes selected samples of patient’s cardiac activity: • • Ø Patient’s heart rate and rhythm Any abnormalities that occurred during the monitoring period Patient event-strips Any abnormal cardiac activity (e. g. , dysrhythmias) Results reviewed and interpreted further by physician Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 114

Maintenance of the Holter Monitor (1 of 2) At end of recording period: Ø Remove battery from monitor and discard Clean casing of monitor frequently Ø Ø Using a soft cloth moistened with a mild disinfectant Avoid use of commercial solvents and abrasives Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 115

Maintenance of the Holter Monitor (2 of 2) Clean patient cable and lead wires periodically Ø Ø Using a cloth moistened with a mild disinfectant Never immerse in cleaning solution Clean snap of each lead wire Store monitor in a dry, dust-free area Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 116

Cardiac Dysrhythmias (1 of 5) Normal ECG: consists of P wave, QRS complex, and T wave Ø Repeats in a regular pattern Normal sinus rhythm: ECG that is within normal limits Ø Waves, intervals, segments, cardiac rate: fall within normal range Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 117

Cardiac Dysrhythmias (2 of 5) Normal heart rate range: 60 to 100 beats/minute Sinus bradycardia: Below 60 beats/minute Sinus tachycardia: Above 100 beats/minute Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 118

Cardiac Dysrhythmias (3 of 5) Cardiac dysrhythmia: Abnormal electrical activity in the heart causing an irregular heartbeat Ø Ø Most are harmless Some can be serious (even life-threatening) Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 119

Cardiac Dysrhythmias (4 of 5) Categories of cardiac dysrhythmias: Ø Ø Ø Extra beats Abnormal rhythm (dysrhythmia) Abnormal heart rate Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 120

Cardiac Dysrhythmias (5 of 5) Cardiac dysrhythmias include: Ø Ø Ø Ø Atrial premature contraction Paroxysmal atrial tachycardia Atrial flutter Atrial fibrillation Premature ventricular contraction Ventricular tachycardia Ventricular fibrillation Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 121

Lesson 12. 3 Pulmonary Function Testing 14. 15. 16. 17. List the different pulmonary function tests. List indications for performing spirometry testing. Describe each of the following: FVC, FEV 1, and FEV 1/FVC ratio. Explain the difference between predicted values and measured values. Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 122

Lesson 12. 3 Pulmonary Function Testing 18. 19. 20. Describe patient preparation for spirometry. Explain how to calibrate a spirometer. Explain the purpose of post-bronchodilator spirometry. Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 123

Pulmonary Function Tests Purpose of PFT: To assess lung functioning Assists in detection of pulmonary disease PFT tests include Ø Ø Ø Spirometry Lung volumes Diffusion capacity Arterial blood gas studies Pulse oximetry Cardiopulmonary exercise tests Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 124

Spirometry (1 of 4) Noninvasive screening test often performed in medical office Spirometer: computerized electronic instrument Ø Measures: • • Ø Amount of air that is expelled from the lungs Rate at which air is expelled Report printed out as a table and graph Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 125

Spirometry (2 of 4) Considered a screening test Ø Abnormal results require: • • Additional PFT tests Possibly a CT scan Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 126

Spirometry (3 of 4) Indications for performing spirometry Ø Ø Patients who exhibit symptoms of lung dysfunction (e. g. , dyspnea) Patients at high risk for lung disease • • Smoking Exposure to environmental pollutants: coal dust; asbestos; exhaust fumes Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 127

Spirometry (4 of 4) Indications for performing spirometry Ø Patients with lung disease • • • Ø Patients who will undergo surgery: • Ø Asthma Chronic bronchitis Emphysema To assess probable lung performance during an operation Patients who need to be evaluated for lung disability or impairment • For a compensation program (e. g. , coal miner) Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 128

Spirometry Test Results (1 of 3) Forced Vital Capacity: Maximal volume of air that can be expired when patient exhales as forcefully and rapidly as possible for as long as possible (measured in liters) Ø FVC breathing maneuver • • • Patient takes a deep breath until lungs are completely full Patient blows all air out of lungs into a mouthpiece Minimum of three acceptable efforts must be obtained Be patient and work with patient to help perform the maneuver If unable to perform the maneuver after eight attempts: discontinue testing Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 129

Spirometry Test Results (2 of 3) Forced Expiratory Volume after 1 Second (FEV 1): Volume of air that is forcefully exhaled during the first second of the FVC breathing maneuver Ø Automatically determined by the spirometer Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 130

Spirometry Test Results (3 of 3) FEV 1/FVC Ratio: comparison of FEV 1 with FVC Ø Patient with healthy lungs: 70% to 75% of air (FVC) is exhaled • Ø Patients with COPD: ratio is less than 70% to 75% • Ø In the first second (FEV 1) of breathing maneuver (expressed as a percentage) Patient unable to move exhaled air out of lungs during first second Categories of airflow obstruction • • • Mild obstruction: 61% to 69% Moderate obstruction: 45% to 60% Severe obstruction: Less than 45% Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 131

Evaluation of Results Demographic factors used to evaluate results entered into the machine: Ø Ø Based on demographic factors: spirometer automatically calculates predicted values. Ø Age Sex Weight Height Predicted value: what the results should be for a patient with healthy lungs When test is run: physician compares measured values with predicted values Ø Ø Values are printed out on the spirometry report Assists physician in detecting pulmonary disease Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 132

Patient Preparation (1 of 2) Do not eat a heavy meal for 8 hours before the test Ø Full stomach: interferes with performing breathing maneuver Stop smoking at least 8 hours before test Do not take bronchodilators 4 hours before test Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 133

Patient Preparation (2 of 2) Do not engage in strenuous activity 4 hours before test Wear loose, nonrestrictive clothing: keeps chest area free Ø Easier to perform breathing maneuver Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 134

Calibration of the Spirometer Perform each day machine is used Known quality of air injected into spirometer 3 -L spirometry syringe: used to inject 3 L of air into machine Output should read 3 L Reading should not vary more than 3% Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 135

Post-Bronchodilator Spirometry (1 of 2) Ordered when results of spirometry indicate an obstruction How performed Ø Ø Patient inhales a bronchodilator Spirometry test is run 10 to 15 minutes later Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 136

Post-Bronchodilator Spirometry (2 of 2) Purpose: informs physician how treatment will work in patients with obstructed airway Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 137

Lesson 12. 4 Peak Flow Measurement and Home Oxygen Therapy 21. 22. 23. 24. Identify the symptoms of an asthma attack. List examples of asthma triggers. Explain the difference between long-term control and quick-relief asthma medications. Describe the purpose of a peak flow meter. Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 138

Lesson 12. 4 Peak Flow Measurement and Home Oxygen Therapy 25. 26. 27. 28. State the purpose of peak flow measurements. Explain why oxygen the body needs oxygen. Describe what occurs when the body cannot maintain an adequate blood oxygen level. Identify the conditions that may require home oxygen therapy. Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 139

Lesson 12. 4 Peak Flow Measurement and Home Oxygen Therapy 29. 30. 31. 32. List and describe the information that is included on a prescription for home oxygen therapy. List and describe three common types of oxygen delivery systems along with the advantages and disadvantages of each. List and describe the two types of devices used to administer home oxygen therapy. State the usage and safety guidelines that should be followed by a patient on home oxygen therapy. Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 140

Asthma (1 of 3) Chronic lung disease Affects smaller bronchi and bronchioles Can occur at any age (but more common in children and young adults) Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 141

Asthma (2 of 3) Characteristics of asthma: Ø Recurrent attacks of: • • Coughing Chest tightness Shortness of breath Wheezing: a continuous, high-pitched, whistling, musical sound heard particularly during exhalation and sometimes during inhalation Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 142

Asthma (3 of 3) Characteristics of asthma: Ø Ø Asthma attack usually followed by a symptom-free period Can be controlled by: • • Recognizing warning signs and symptoms of an attack Treating symptoms when they first occur Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 143

Asthma Attack (1 of 6) Varies in frequency and severity May come on suddenly or gradually May last for only 10 to 15 minutes Ø Or for hours or even days Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 144

Asthma Attack (2 of 6) Normal individual Ø Airways to lungs are fully open • Allows air to move easily in and out of lungs Patient with asthma Ø Ø Airways are always inflamed Airways are hypersensitive to certain stimuli known as asthma triggers • Can “trigger” an asthma attack Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 145

Asthma Attack (3 of 6) Asthma triggers Ø Ø Ø Vary from one patient to another May vary from one season to the next Common allergens that may trigger an asthma attack • • House dust Pollens Molds Animal dander and cockroaches Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 146

Asthma Attack (4 of 6) Asthma triggers Ø Environmental irritants, activities, or events: • • Air pollutants Tobacco smoke Chemical fumes (e. g. , perfume, paint, gasoline) Vigorous physical exercise Upper respiratory viral infections Exposure to cold Emotional stress Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 147

Asthma Attack (5 of 6) Asthma triggers Ø Sometimes difficult to determine what specific triggers cause a patient’s asthma attack Reaction that occurs when airways of patient are stimulated by a trigger Ø Bronchial tubes begin to constrict and swell • Ø Causes patient to experience asthma symptoms Symptoms may be mild and go away • On their own, or with minimal treatment with medication Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 148

Asthma Attack (6 of 6) Reaction that occurs when airways of patient are stimulated by a trigger Ø Ø Symptoms may lead to a full-blown asthma attack During a severe asthma attack: • • Bronchial tubes continue to constrict and swell Become clogged with mucus Results in less air moving in and out of lungs – leads to a decrease in oxygen available to body Causes patient to experience: coughing; chest tightness; shortness of breath; wheezing Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 149

Diagnosis and Treatment (1 of 5) Diagnosed through a careful and detailed medical history Physician also performs a thorough physical examination Ø To detect symptoms resulting from asthma (e. g. , wheezing) Laboratory and diagnostic tests usually ordered: Ø May include: • • • Pulmonary function tests (e. g. , spirometry) Allergy testing Arterial blood gas studies Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 150

Diagnosis and Treatment (2 of 5) General treatment of asthma Ø Ø Identifying and avoiding asthma triggers (if possible) Preventing and alleviating symptoms through drug therapy Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 151

Diagnosis and Treatment (3 of 5) Long-term control medication Ø Ø Helps relieve bronchial inflammation Prevents symptoms from occurring Helps the patient have fewer and milder asthma attacks Typically taken every day Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 152

Diagnosis and Treatment (4 of 5) Quick-relief medication (also called rescue medication) Ø Opens the airways quickly • Ø By dilating the bronchial tubes Taken when patient is experiencing symptoms • To prevent or control an asthma attack Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 153

Diagnosis and Treatment (5 of 5) Many asthma medications delivered through an inhaler Ø Nebulizer: Breathing machine used to treat an asthma attack at home Ø Allows medication to go directly to lungs May be used with quick-relief medications Some asthma medications: administered orally Ø Take longer to work • Must first travel through digestive and circulatory systems before reaching lungs Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 154

Peak Flow Meter (1 of 5) Portable, handheld manual or digital device Used to measure a breathing maneuver Manual peak flow meter Ø Ø Consists of a plastic tube with a sliding indicator Indicator manually moves along a scale of numbers when patient performs the breathing maneuver Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 155

Peak Flow Meter (2 of 5) Digital peak flow meter Ø Ø Automatically measures breathing maneuver Displays measurement digitally on a screen Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 156

Peak Flow Meter (3 of 5) Measures how quickly air flows out of the lungs Ø Frequently used by patients with asthma Ø When patient exhales forcefully Recommended for patients with moderate to severe asthma Measurements obtained from peak flow meter Ø Not as accurate as those obtained by spirometry Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 157

Peak Flow Meter (4 of 5) Peak flow meter: can be used easily by a patient at home Peak flow measurements Ø Provide patient with important information • • When to take medication Severity of asthma attack Different brands of peak flow meters are available Ø Ø Peak flow measurements between brands may vary If more than one meter is purchased • Always buy the same brand Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 158

Peak Flow Meter (5 of 5) Available in two ranges: Ø Low Range • • Ø Ranges from 0 to 300 Used by young children and some older patients Full range • • • Ranges from 0 to 800 Used by older children, teenagers, and adults Adult has much larger bronchial tubes than a child – needs the wider range Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 159

Peak Flow Rate (1 of 2) Patient performs a breathing maneuver Ø Ø Takes a deep breath until the lungs are completely full Blows all the air out of the lungs and into the mouthpiece as hard and as fast as possible • Ø Causes sliding indicator to move up scale of meter Indicator stops and remains at patient’s peak flow rate Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 160

Peak Flow Rate (2 of 2) To obtain most accurate PFR Ø Ø Patient should perform three acceptable breathing maneuvers Record the highest of three measurements • The three measurements should be about the same Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 161

Schedule of Use Most physicians recommend use of peak flow meter: Ø At least once a day • • Preferably in the morning Before taking asthma medication When patient is having symptoms Twice a day for patient with more severe form of asthma • Morning and evening Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 162

Purpose of Peak Flow Measurements Monitor how well asthma is being controlled Change or adjust medication Recognize early changes before symptoms occur Determine the severity of an asthma attack Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 163

Care and Maintenance (1 of 2) MA should instruct patient in proper care of (manual) peak flow meter To clean meter: Ø Ø Wash weekly with warm soapy water Rinse thoroughly with warm water Remove excess water by gently shaking meter Air dry completely before use Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 164

Care and Maintenance (2 of 2) Many peak flow meters can be cleaned Ø By placing them in the dishwasher (on top shelf) • Check manufacturer’s instructions for this information Inspect peak flow meter periodically for damage Ø Cracks: could cause air to leak out of the meter • Leads to inaccurate readings Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 165

Home Oxygen Therapy (1 of 5) Oxygen Ø Ø Ø Colorless, odorless, and tasteless gas Vital to human body Transported to blood by tissues • Oxygen taken into cells, combines with glucose to produce energy Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 166

Home Oxygen Therapy (2 of 5) When lungs cannot deliver enough oxygen to body Ø Reduction in amount of oxygen in blood • Results in hypoxemia: a decrease in the oxygen saturation of the blood – leads to hypoxia: reduction in the oxygen supply to the tissues of the body Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 167

Home Oxygen Therapy (3 of 5) Failure to maintain adequate blood oxygen level Ø Can result in progressive deterioration of patient • • Death of cells Organ failure Body system failure Death Prescription for home oxygen therapy may be written for: Ø Conditions that reduce amount of oxygen in body (hypoxemia) Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 168

Home Oxygen Therapy (4 of 5) Increases oxygen supply to lungs Ø Raises blood oxygen to normal levels • Increases availability of oxygen to the tissues Helps to alleviate effects of low oxygen levels: Ø Shortness of breath and fatigue Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 169

Home Oxygen Therapy (5 of 5) Most commonly prescribed for Ø Patients with severe COPD • Caused by smoking Also prescribed for: Ø Ø Ø Asthma Occupational lung disease Lung cancer Cystic fibrosis Congestive heart failure Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 170

Oxygen Prescription (1 of 4) Need for oxygen therapy determined through: Ø Ø Clinical observation of patient Measuring oxygen level of patient’s blood Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 171

Oxygen Prescription (2 of 4) Oxygen level of the blood measured by: Ø Arterial blood gas (ABG) analysis • • Ø Normal individual: 75 to 100 mm Hg Warrants use of oxygen therapy: less than or equal to 55 mg Hg Pulse oximetry • • Normal individual: above 94% Warrants use of oxygen therapy: less than or equal to 88% Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 172

Oxygen Prescription (3 of 4) Prescription for oxygen therapy Ø Ø Filled by a home medical supply company Prescription includes: • • • Amount and duration of oxygen needed Recommended oxygen delivery system Administration device (e. g. , nasal cannula) Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 173

Oxygen Prescription (4 of 4) Flow rate: Ø Ø Number of liters of oxygen per minute (L/min) Most people with COPD: • • Start with flows rate of 1 to 2 L/min As COPD worsens over time, flow rate might increase to 3 to 6 L/min Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 174

Oxygen Delivery Systems Flow rate: Amount of supplemental oxygen prescribed for a patient Ø Measured in liters per minute (L/min) Type prescribed based on: Ø Ø Patient’s condition Patient’s personal preference Ease of equipment use Cost Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 175

Compressed Oxygen Gas (1 of 2) Oxygen gas compressed under high pressure Ø Then stored in a container (cylinder or tank) • • Large stationary cylinder – used at home by patient Small portable cylinder – placed in a carrying device (e. g. , shoulder bag) when the patient goes outside the home Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 176

Compressed Oxygen Gas (2 of 2) Regulator and flow meter Ø Ø Control flow rate of oxygen Flow of oxygen out of the cylinder is constant Oxygen-conserving device may be attached to system Ø Conserves oxygen and avoids waste • Releases oxygen gas only when patient inhales – cuts off release of oxygen when patient exhales Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 177

Liquid Oxygen (1 of 2) Oxygen gas subjected to extremely cold temperature Ø Stored in insulated tank Ø Changes from gas to very cold liquid Lining similar to a thermos Takes up less space than compressed oxygen gas Ø Container of liquid oxygen lasts four times longer than compressed oxygen gas of same weight Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 178

Liquid Oxygen (2 of 2) Liquid oxygen system consists of: Ø Ø Large stationary tank: primary oxygen reservoir of oxygen Small portable tank used outside the home • • Filled from large primary tank for use outside the home Hung over shoulder or pulled on roller cart Liquid oxygen released from its tank Ø Changes into a gas and patient breathes it in Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 179

Oxygen Concentrator (1 of 2) Electrically powered device Ø Ø Works by Ø Ø Ø Weighs about 35 pounds Size of a large suitcase Separating oxygen out of air Concentrating it Storing it for use by patient Equipped with a built-in flow meter Ø Allows the prescribed flow rate to be set Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 180

Oxygen Concentrator (2 of 2) Portable battery-powered systems have recently been developed Ø Ø Weigh about 10 pounds Can provide patient with oxygen for 8 hours • Ø At a flow rate of 2 L/min Have replaced liquid oxygen or compressed gas cylinders for mobility Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 181

Nasal Cannula (1 of 2) Most frequently used Consists of soft plastic tubing Ø With a two-pronged device • Inserted into patient’s nose Tubing loops over patient’s ears and is secured under chin Ø Connects to oxygen delivery system Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 182

Nasal Cannula (2 of 2) Advantage of nasal cannula Ø Does not interfere with ability to talk, eat, or drink Wash cannula once or twice a week using liquid soap and water Ø Ø Rinse thoroughly Allow to air dry Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 183

Face Mask (1 of 3) Consists of plastic Fits over patient’s nose and mouth Face mask strap Ø Tightened around head to ensure secure fit Oxygen tubing Ø Used to connect face mask to oxygen delivery system Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 184

Face Mask (2 of 3) Not used as frequently as nasal cannula because: Ø Ø Often used for patients who need a high flow of oxygen Ø It is bulky Must be removed to eat, drink, or communicate effectively Can deliver oxygen at a flow rate between 5 and 15 L/min Wearing nasal cannula for extended period: Ø Can cause irritation of nose • To reduce irritation – wear nasal cannula during day and face mask at night Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 185

Face Mask (3 of 3) Face mask may also be preferred Ø When patient has nasal congestion (e. g. , cold) Care Ø Ø Ø Wash once or twice a week using liquid soap and water Rinse thoroughly Dry Replace with new one every 2 to 4 weeks Sooner if it becomes cracked or discolored Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 186

Oxygen Guidelines (1 of 4) Usage Ø Ø Ø Contact physician for symptoms of low blood oxygen level Keep oxygen delivery system clean and free from dust Do not change oxygen flow rate Do not use alcohol or other sedating drugs Order more oxygen in a timely manner Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 187

Oxygen Guidelines (2 of 4) Usage Ø Ø Tuck gauze under tubing to prevent skin irritation Use water-based lubricants on lips or nostrils to relieve drying effect Do not use more than 40 or 50 feet of tubing Compressed oxygen cylinders or liquid oxygen are not permitted on board an airplane Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 188

Oxygen Guidelines (3 of 4) Safety Ø Ø Ø Store oxygen in clean, dry, well-ventilated room Oxygen cylinders and liquid oxygen tanks must remain upright at all times Never smoke while using oxygen Keep oxygen supply at least 6 to 8 feet away from open flames Keep oxygen supply at least 6 to 8 feet away from intense heat Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 189

Oxygen Guidelines (4 of 4) Safety Ø Ø Keep oxygen supply away from flammable products Do not lubricate oxygen equipment with oil or grease Be sure to have functioning smoke detectors in the home Buy a fire extinguisher Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 190

Questions? Copyright © 2015, 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc. 191