ICU Diagnostic Testing - EDUCATA · Noninvasive diagnostic test to determine: • Ventricular size/ventricular hypertrophy • Ejection fraction – EF > 55 – 60 is normal –

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Copyright ©2014 EDUCATA. This presentation is not to be copied in whole or in part without the express permission of EDUCATA.

How to Navigate EDUCATA

From Vent to Rehab: Treatment of the ICU Patient

Part II: Understanding Diagnostic Testing, Including Lab Assessment

and Priorities in Treatment

Ellen Hillegass PT, Ed.D., CCS, FAACVPR, FAPTA


Assessment of Chart Findings

What is important?

What are the implications?

Components of Chart

• Diagnostic testing

– Cardiac diagnostics

– Pulmonary diagnosticsPulmonary diagnostics

• Laboratory information

• Other

Diagnostic Testingcardiac

• Holter monitoring

• Echocardiography

• Chest x‐ray

• Coronary catheterization

• Intravascular lt d i i

• 12 lead ECG

• Exercise testing

• Stress thallium

ultrasound imaging (IVUS)

• Multislice CT imaging


Holter Monitor

Holter Monitor

• Used to assess for arrhythmias, particularly life‐threatening arrhythmias.

• Worn for 24 – 48 hours.

• Used on outpatient basis. Patient may have described symptoms of:

– Palpitations

– Syncope

– Skips in pulse

Echocardiography


Echocardiography

• Valve dysfunction

– Mitral most common, aortic, pulmonic or tricuspid

• Chamber size determined

Noninvasive diagnostic test to determine:

• Ventricular size/ventricular hypertrophy

• Ejection fraction

– EF > 55 – 60 is normal

– 40 – 60 is considered dysfunction

– < 30 – 40 is failure

• Can be used with stress test for diagnosis of perfusion.

Chest X-Ray

Chest X-Ray

• Chest x‐ray looks at heart and lungs to identify:

– Rib fractures– Rib fractures

Ch i l di

– Hyperinflation

Fl id/ i filt t– Chronic lung disease

– Flattened diaphragm

• Limitations of CXR:

– Only 2‐dimensional.

– Cannot see behind structures.

– Chronic lung disease

– Flattened diaphragm

– Fluid/or infiltrates

– Size of heart


12 Lead ECG

Abnormal 12 Lead ECG

Exercise Testing

• Utilized to evaluate chest pain/ischemia.

• Diagnostic for males, requires additional diagnostic procedures for improved

iti it / ifi it f f lsensitivity/specificity for females.

– Thallium or stress echo

• Utilized with metabolic cart to determine true max VO2 or to determine cardiac versus pulmonary impairment.


Exercise Testing With Metabolic Cart

Stress Thallium

Stress Thallium

• Radionucleotide used to assess perfusion defects during stress tests.

• Inject dye at peak exercise, then patient is placed supine under a nuclear scanner toplaced supine under a nuclear scanner to assess for distribution of dye.

• Patient returns 3‐4 hours later and another scan is performed at rest to see if redistribution has occurred.

• Can also do test with pharmacologic stress.


Pharmacologic Stress Test

• Medications used:

– Adenosine

– Dipyridamole

– Dobutamine

• Used when patient cannot perform exercise.

• Adenosine and dipyridamole cause vasodilation, whereas dobutamine increases work on heart.

Coronary Catheterization

Coronary Catheterization

• Performed when coronary blockages are suspected.

– As result of stress test.

Upon ER admission due to chest pain or abnormal– Upon ER admission, due to chest pain or abnormal ECG.

• Dye is injected into orifices of coronary arteries and evaluated for amount of blockage in each artery, as well as injection of dye in ventricle to see pumping of heart (kinesis).


Intravascular Ultrasound Imaging (IVUS)

A

B

Multi-Slice CT multiplanar reconstruction of R coronary

Image from www.medscape.com. Source: Eur Heart J. ©2008, Oxford University Press.

MR Angiography of Brain

Image from www.youtube.com. Source: Philips Healthcare and the Philips Learning Center.


MR Angiography

Image from www.youtube.com. Source: Philips Healthcare and the Philips Learning Center.

Diagnostic Testingpulmonary

• Chest x‐ray

• Bronchography

• CT and spiral CTCT and spiral CT

• Ventilation perfusion scans

• Bronchoscopy/sputum sample

• Pulmonary function testing

Bronchiectasis on Chest X-Ray and Bronchogram

A B


Bronchiectasis on Chest X-Ray and Bronchogram

A B

CT of Normal Mediastinum and Hilum

A B

C D

CT of Normal Mediastinum and Hilum

• CXR simply does not pick up the abnormalities if tumor is small.

• Low dose CT to chest is now the gold standard for assessment of lung cancer but extremelyfor assessment of lung cancer, but extremely expensive.

– American Lung Association: Low dose CT could reduce lung cancer mortality by up to 20%.

– Criteria: Current or former smokers, ages 55 – 74.

– Smoking history of at least 30 pack years.

American Lung Association 2012.


CT of Lung Cancer

Lung cancer revealed by CT lung screening.

Image from www.cedars‐sinai.edu.

Spiral CT of Chest

Image © Nevit Dilmen found at Wikimedia Commons.

PET Scan


Ventilation-Perfusion Scan

RAO Ant LAO Lt Lat

Images from www.med.harvard.edu.

LPO Post RPO Rt Lat

Anterior Posterior

Ventilation-Perfusion Scan

• V/Q scans used to be considered the gold standard for identifying a pulmonary embolus.

• Studies have shown that the sensitivity of V/Q scans is only about 50 – 60%.scans is only about 50 60%.

• Many individuals are undergoing V/Q scans to rule out PE, and the scans may NOT be detecting PE.

• Spiral CT may be the gold standard now for PE, but radiation is disadvantage.

• KEY factor: The individual reading the scans.

Pulmonary Function Testing

Diagnostic Testing


Pulmonary Function Testing

Lung Volumes and Capacities

Static Lung Volumes

• Total lung capacity (TLC)

• Vital capacity (VC)

• Inspiratory reserve

Dynamic Lung Volumes

• Forced expiratory volume in 1 second (FEV 1.0)

• Forced vital capacity (FVC)p yvolume (IRV)

• Expiratory reserve volume (ERV)

• Residual volume

• Dynamic volumes tell you about airway resistance/ obstructive problems

• Patient actively performs spirometry with forced flows.

Interpretation of PFT Results

• Determine if results are...

– Normal or abnormal

i i b i– Restrictive or obstructive

• If obstructive, is this reversible?

• Watch for patient effort….


PFT Interpretation

40

PFT Interpretation

41

PFT Interpretation

42


PFT InterpretationSo what can we learn from this test?

• Individual is most likely an athlete in good physical condition, but

• They most likely have some type of obstructive airway disease, like exercise‐induced asthma.

• Example of how a full workup can pick up something other tests might miss.

PROPERTIES

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Laboratory Information

ABGs

CBC

Cardiac‐Specific

Nutrition


Arterial Blood Gases (ABGs)

• Purpose: acid base regulation

– Acidosis: pH < 7.35

– Alkalosis: pH > 7.45

• Normal values:

– pH: 7.35 – 7.45

– pCO2: 35 – 45

– pO2: > 80

– HCO3: 22 – 26

Arterial Blood Gases (ABGs)primary respiratory conditions: abnormal pCO2

Acidosis

• pH < 7.35, pCO2 > 45

• Example:

pH: 7 32

Alkalosis

• pH > 7.45, pCO2 < 35

• Example:

pH: 7 48– pH: 7.32

– pCO2: 55

• Clinical example: Patient heavily sedated – slow breathing and retaining CO2.

– pH: 7.48

– pCO2: 30

• Clinical example: Patient in pain, rapid shallow respirations.

Arterial Blood Gases (ABGs)primary metabolic conditions: abnormal HCO3

Acidosis

• pH < 7.35, HCO3 < 22

• Example:

pH: 7 32

Alkalosis

• pH > 7.45, HCO3 > 26

• Example:

pH: 7 48– pH: 7.32

– HCO3: 18

• Clinical scenario: Patient with diabetic ketoacidosis.

– pH: 7.48

– HCO3: 29

• Clinical scenario: Patient with flu, frequent vomiting.


Arterial Blood Gases (ABGs)physiologic buffers

Respiratory System

• FAST response to abnormal acid/base balance.

Metabolic System

• Response is slower –24‐48 hours to demonstrate change.

– pH: 7.32 (acidosis)

– HCO3: 19

– pCO2: 30

g

– pH 7.32 (acidosis)

– pCO2: 60

– HCO3: 30

Case Examples

Case #1 Case #2

pH: 7.32 pH: 7.33

pCO2: 68 pCO2: 35

pO2: 60 pO2: 80

HCO3: 28 HCO3: 18

Case Examples

Case #1 Case #2

pH: 7.32 pH: 7.33

pCO2: 68 pCO2: 35

pO2: 60 pO2: 80

HCO3: 28 HCO3: 18

Case #3 Case #4

pH: 7.48 pH: 7.49

pCO2: 42 pCO2: 31

pO2: 70 pO2: 90

HCO3: 30 HCO3: 24


Other Important Lab Valuescomplete blood count

• Normal values:

– Red blood cells

– Hemoglobin

Other Important Lab Valuescomplete blood count

• Normal values:

– Red blood cells

– Hemoglobin

– White blood cells (4,000 – 11,000)

– Platelets (NL: 150,000 – 400,000)

Other Important Lab Valuescardiac‐specific lab values

• Troponin

• CPK (creatinine phosphokinase)

– MB isoenzyme is specific for cardiac injury.

• Lactic dehydrogenase (LDH)

– 5 isoenzymes

• C‐reactive protein (CRP)

• Homocysteine

• Lipoprotein (a)


Other Important Lab Valuesliver enzymes

• AST

• Bilirubin

• Alkaline phosphataseAlkaline phosphatase

Other Important Lab Valuesother heart/kidney values

• Blood urea nitrogen (BUN)

• Creatinine (↑ in kidney disease)

• BNP (> 700 decompensated heart failure)BNP (> 700 decompensated heart failure)

Other Important Lab Valuesblood coagulation

• PT/PTT

– PT NL: 11 – 16 secs

• D dimer to assess for excess clotting.

– Elevated D dimer means increased risk of clotting.

• INR

– NL is 0.8 – 1.2.

– Anticoagulation up to about 2.5 (keep between 2 – 3).


Other Important Lab Valuesnutrition values

• Albumin (↓ with malnourishment)

• Total protein

Other Important Lab Valueselectrolytes

• Na+ (NL = 135 – 145 mEq/L)

• K+ (NL = 3.5 – 5.0 mEq/L)

• Mg+ (1.5 – 2.0 mEq/L):Mg+ (1.5 2.0 mEq/L): ↓ in malabsorption syndrome and pancreatitis, including with frequent antacid use

PROPERTIES







Physical Assessment of the ICU Patient

What is important?


Bedside Assessment

• Cognition/delirium/orientation

• Risk assessment: Are they mobile, or will they be difficult to mobilize and mobility will be an assisted process?– DVT, PE, pneumonia, contracture, integument

• Hemodynamic stability• Hemodynamic stability– Vital signs and vital sign responses to activity

• Pulmonary status

– Ventilator settings?

– Risk for pneumonia?

• Integumentary status

• Musculoskeletal status

• Neuromuscular

Physical Assessment

• Supine

• Sit

Amount of assist and vital sign responses to:

– Optimal for heart and lung auscultation, skin check

• Stand

• ADL

• Ambulation


VS Responses to Activitypatient #1

Activity HR BP SpO2 Symptoms

Supine 72 124/78 96 Tired

Sit 84 110/70 94 TiredSit 84 110/70 94 Tired

ADL sit 96 118/78 94 Tired

Stand 108 94/68 93SOB/light‐headed

Ambulation (6’) 114 110/78 94 Fatigue



Supine 80 irreg 118/72 96 None

Sit 90 irreg 120/70 96 NoneSit 90 irreg 120/70 96 None

ADL sit 100 irreg 126/76 96 Tired

Stand 100 irreg 114/72 96 Tired

Ambulation 110 irreg 92/60 94 SOB, fatigue



Supine 100 120/76 93 SOB

Sit 106 124/74 92 SOBSit 106 124/74 92 SOB

ADL sit 120 134/72 89SOB

increased

Stand 110 120/70 91 SOB

Ambulation (10’) 120 132/80 88 Severe SOB


Developing a Plan of Care and Treatment Priorities/

Interventions Based Upon Assessment Findings

What is important?


Treatment Priorities

• Cognition/alertness

– Reduce deep sedation

• Cardiopulmonary

P t l i f ti– Prevent pulmonary infections

– Maintain adequate SpO2

– Monitor VS with activity

• Integumentary

• Musculoskeletal

• Neuromuscular

ICU Priorities for Mechanically Ventilated Patients

• Sedation and paralysis administration

• Mechanical ventilation d

• Maintenance of skin integrity

• Physical activityorders

• Stress ulceration prophylaxis

• Deep venous thrombosis prophylaxis

• Nutritional support

• Treatment of sleep deprivation

• Prevention or treatment of infectious complications

• Prevention of aspiration

American College of Chest Physicians.


ICU Priorities for Mechanically Ventilated Patients

• Keep in mind the importance of physical activity.

• Once a patient is stable, physical activity should be part of his or her daily routine.

• Look at the protocols from the American College of Chest Physicians for more guidance at www.chestnet.org.

American College of Chest Physicians.

Goals

• Reducing oversedation.

• Increasing early activity.

• Encouraging sleep to reduce delirium and toEncouraging sleep to reduce delirium and to allow for physical conditioning and weaning from mechanical ventilation.

• Airway protection in newly extubatedpatients.

Early Activity Requirements

Neurologic criteria: Patient responds to verbal stimulation.

– Purposeful response.

Respiratory criteria: FiO2 no greater than 0.6 and PEEP ≤ 10 cm H20.

Circulatory criteria: Absence of orthostatic hypotension and catecholamine drips.

ASSESS CRITERIA DAILY.


Pulmonary Problem List

Decreased oxygenation

Decreased ventilation

Decreased airway clearance

Decreased lateral costal expansion

Decreased diaphragmatic excursion

Increased amount of secretions

Increased retention of secretions

Poor mobility

Decreased thoracic mobility

Decreased diaphragmatic mobility

Increased risk for pulmonary dysfunction

Infection/inflammation

Interventions for Pulmonary Issuesimprove oxygenation

• O2

• Positioning

• Breathing exercises

• Mobilization of secretions

Interventions for Pulmonary Issuesimprove ventilation

• Mobilization of secretions

• Positioning



Incentive Spirometry

Breathing Exercises

• Diaphragmatic

• Pursed lip

• Segmental breathing

Breathing Exercises

• Maximal inspiration hold

• Active cycle breathing

• Inspiratory muscle training


Interventionsimproving airway clearance

• Abdominal support

• Abdominal strengthening

• Positioning

• Cough instruction

Interventionsmobilizing secretions

• Postural drainage

• Percussion/vibration

• Mobility• Mobility


• Cough

• Humidity/medications

Airway Clearance Devices


Airway Clearance Devicesthe vest

Cough Assist

Monitoring and Titrating

• O2 is a drug… Always check the order.

• Look at ABGs.

• Check O2 saturation measures.

• Compare the patient report vs. the numbers.

• Review other vital signs.


PROPERTIES






Mobility Aids

Developing a Plan of Care

Dynamic Tilt TableMoveo


Dynamic Tilt TableMoveo

Dynamic Tilt TableHocomo

Overhead Device


Standing Aid Arjo

Standing Aid Arjo Sara Plus for standing/walking

Standing Aid Arjo Sara Plus


Improving Mobility and Posture

• Thoracic mobility techniques

– Pulleys

– Side‐lying stretch

• Thoracic postural exercises

– UE exercises seated on therapy ball

• Paced BREATHING!!!

– Prone extension

Strength

• Anterior neck flexors

• Rhomboids

• Middle and lower trapezii

• Lattisimus

Incorporate Functional Strengthening Into Daily Activities


Flexibility

• Posterior cervical

• Pectoral muscles

• Anterior deltoidsAnterior deltoids

• Sternocleidomastoids

Yoga

Interventions for Cardiac Patients

• Therapeutic exercise

– Aerobic capacity/ endurance conditioning

– Balance coordination and agility training

• Functional training in self‐care and home management

– ADL trainingagility training

– Flexibility exercises

– Gait and locomotion training

– Relaxation

– Strength, power, and endurance training for ventilatory muscles

– Device and equipment use and training

• Airway clearance techniques

• Education


Heart Failure Patients

• Frequent bouts of activity with rest in between.

• Teach patients about:

– Daily weighing to check for changes in fluid.

– Daily checks on activity by instructing in RPE or dyspnea monitoring.

– Watching for dyspnea when laying down.

– Energy conservation.

Modified Dyspnea

Scalebreathing

Scale Severity

0 Nothing at all

12

Very slight

34

Slight

56

Moderate

78

Severe

910

Very severeMaximum

Evidence for Exercise

• Bicycle ergometer training (ET) versus aerobic and strength training (CT) resulted in:

Strength and endurance training vs. endurance training alone.

strength training (CT) resulted in:

– Improved EF in CT group by 18% over 3 months.

– Decreased EF in ET alone group (‐11.4%).

– Delagardelle C, Feiereisen P, Autier P, Shita R, Krecke R, Beissel J. Strength/endurance training versus endurance training in congestive heart failure. Med Sci Sports Exerc. 2002 Dec;34(12):1868‐72.


Case Study #1

• Patient with decompensated heart failure. Admitted with one‐week history of worsening dyspnea and weight gain of 8 lbs.

• Once stabilized, ,– Exercise interventions:

• Multiple bouts of walking with frequent rest.

• Strength training consisting of UE functional strengthening and LE strengthening with chair rises.

– Education: teaching self management with weight monitoring and RPE monitoring of all activities.

Case Study #2COPD

• Patient admitted for acute exacerbation.

• Once ABGs show pH in normal range, begin activity– Breathing exercises

– Mobility out of bed

– Optimize oxygen – maintain SpO2 > 90

– LE strengthening: EOB to stand activities

– Short bouts of walking, coordinating breathing exercises and frequent rests

• Education

PROPERTIES







In Conclusion

• I hope that this helps you understand more about working with ICU patients, including

– Lab tests

Diagnostic tests– Diagnostic tests

– Therapeutic interventions

– Treatment for the pulmonary system

• This should make you more comfortable when working with critical patients and making clinical decisions.

Documents

ICU Diagnostic Testing - EDUCATA · Noninvasive diagnostic test to determine: • Ventricular size/ventricular hypertrophy • Ejection fraction – EF > 55 – 60 is normal –