Definitions

Tachycardia: Heart Rate > 90 beats/ minute

Tachypnea: Respirations/ minute >20

Dyspnea: Shortness of Breath (SOB)

Orthopnea: SOB when in a supine positionParoxysmalNoctural Dyspnea: SOB upon awakeningNocturia: Frequent nightime urination

CONGESTIVE HEART FAILURE

Congestive heart failure (or heart failure) is a condition in which the heart can't pump enough blood to meet the needs of the body's other organs. This can result from

• narrowed arteries that supply blood to the heart muscle

• past heart attack, or myocardial infarction , with scar tissue that interferes with the heart muscle's normal work.

• high blood pressure. • cardiomyopathy . • congenital heart disease. • infection of the heart valves and/or

heart muscle itself - endocarditis and/or myocarditis.

What does CHF feel like?

Because the "failing" heart is an inefficient pump CHF causessufferers to become SOB and tired.

Blood flow from heart

Blood returning to heart“Backs Up” causing tissue tobecome congested

Congestion causes swelling inlegs/ankles and, possibly, the lungs

Heart failure also affects the ability of the kidneys to dispose of sodium and water. The retained water increases theedema.

Congestive heart failure usually requires a treatment program of

• rest • proper diet • modified daily activities • surgery or drugs such as

A.C.E. or angiotensin converting enzyme inhibitors and vasodilators expand blood vessels and decrease resistance

blood then flows more easily and makes the heart's work easier or more efficient.

Some beta blockers can improve the function of the left ventricle .

Digitalis increases the pumping action of theheart.

Diuretics help the body eliminate excess salt and water.

Nutritional Interventions in CHF include:

• < 3 grams Na; if large dose diuretics taken, reduce <2 g Na.

• Eliminate or limit alcohol intake to 1 drink/day.

• Adequate protein/kcal intake so serum albumin > 3.5 g/dlBMI <25.

• Encourage physical activity

• Consider thiamin supplementation if large dose diureticsgiven.

• Avoid excessive fluid intakes; Quit Smoking!

Chronic Bronchitis (an infectious condition)Emphysema (a non-infectious condition)Bronchitis (Asthmatic, Chronic Obstructive et al.)

Most Common COPD condition=

Emphysema + Bronchitis

Chronic Obstructive Pulmonary Disease

Symptomatology in COPD

Patients often present with:

Fatigue, SOB, productive cough,

wheezing

Caused by: Obstructed of airflow out of the lungs

May be accompanied by:Precipitous weight lossPersistent viral illness (e.g.,

colds)

Treatments for COPD are palliative and focused on QOL.

Stop smoking

Maintain a healthy weightEngage in moderate physical activity

Drink lots of fluids (8-12 cups/ day; low caffeine) Vitamin A intake of 25,000-50,000 units/day

(Vegetables and fruit)Limit simple CHO / replace with fat

Causes Treatment Goals

Physiologic Stress Prevent progression (e.g., surgical, infectious, etc.) of resp. failureAspiration Pneumonia Preserve immunePulmonary Emboli system with highAllergic Rxns protein/kcal

without causingThe Problem? respiratory distress

Insufficient oxygenation of tissueswith excess CO2 retention supports lung fxn &

prevents infections

Weak Muscles Less Forceful Breathing

Poor Respiration Poor Circulation

Poor Nutrition Pulmonary InfectionsEdema

Acute Respiratory Failure

Mechanical Ventilator

Fuel Utilization and Lung FunctionFuel Utilization and Lung Function

Respiratory Quotient (RQ): ratio of CORespiratory Quotient (RQ): ratio of CO22 produced produced to Oto O22 consumed. consumed.

RQ RQ

CO2 produced CO2 produced

Workload for respiratoryWorkload for respiratory systemsystem

RQ

Glucose Oxidation = 1.00

Triglyceride Oxidation = 0.71 0.82

Amino Acid Oxidation = 0.80

High Kcals or Adequate Kcals with excessive glucose

Increased Lung Workload

Difficulty in Weaning from Mechanical Ventilator

Decrease Kcals or Replace glucose with fat to lower RQ

Nutrient Requirements

Kcals: 25 to 35 nonprotein kcal/kg/day (maintenance)45 nonprotein kcal/kg/day (anabolism/severe stress)

Protein: 1.5 g/kg2-2.5 g/kg in severe stress

30-60% of kcal lipids

Fluid and Sodium Restrictions

Ease Pulmonary Edema

Lung Muscle Tissue Maintainedby optimal Ca, Mg, PO4

Acid-Base Balance

Acid Base

pH < 7 pH=7 pH > 7

Normal Physiological pH = 7.35-7.45

Extreme acidosis = <6.8

Extreme alkalosis= >7.8

Regulation of Acid-Base Balance

Body has components that act in Seconds,Minutes, and Hours/Days to combat pH changes.

Seconds… Chemical Buffers:

Inside cells: phosphate buffers(NaH2PO4= acid or hydrogen donor; Na2HPO4= base or hydrogen acceptor)In Bloodstream: serum proteins (Hgb)

Minutes… Respiration Rate Controls plasma CO2 plasma CO2 Respiration Rate plasma pH

plasma CO2 Respiration Rate plasma pH

Hours/ Days… Renal Function Controls PlasmaPlasma Bicarbonate (HCO3) Levels.

How to Measure Acid-Base Status?

ABGs = Arterial Blood Gases

All are expressed “partial pressures” because thereare many dissolved gases in blood.

Normal Values: pO2 = 80-100 mm Hg (NL = 90) pCO2 = 35-45 mm Hg (NL = 40)

pH = 7.35-7.45 (NL = 7.4) HCO3

-= 22-26 mEq/L (NL = 24)