Definitions Tachycardia: Heart Rate > 90 beats/ minute Tachypnea: Respirations/ minute >20 Dyspnea: Shortness of Breath (SOB) Orthopnea: SOB when in a supine position Paroxysmal Noctural Dyspnea: SOB upon awakening Nocturia: 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.

Because the "failing" heart is an inefficient pump CHF causes What does CHF feel like? Because the "failing" heart is an inefficient pump CHF causes sufferers to become SOB and tired. Blood flow from heart Blood returning to heart “Backs Up” causing tissue to become congested Congestion causes swelling in legs/ankles and, possibly, the lungs Heart failure also affects the ability of the kidneys to dispose of sodium and water. The retained water increases the edema.

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 the heart. 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/dl BMI <25. • Encourage physical activity • Consider thiamin supplementation if large dose diuretics given. • Avoid excessive fluid intakes; Quit Smoking!

Smoking Causes COPD Most Common COPD condition= Emphysema + Bronchitis Chronic Obstructive Pulmonary Disease Chronic Bronchitis (an infectious condition) Emphysema (a non-infectious condition) Bronchitis (Asthmatic, Chronic Obstructive et al.) Most Common COPD condition= Emphysema + Bronchitis Smoking Causes COPD

Patients often present with: Fatigue, SOB, productive cough, wheezing 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 loss Persistent viral illness (e.g., colds)

Stop smoking Drink lots of fluids (8-12 cups/ day; low caffeine) Treatments for COPD are palliative and focused on QOL. 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 Maintain a healthy weight Engage in moderate physical activity Stop smoking

Acute Respiratory Failure Causes Treatment Goals Physiologic Stress Prevent progression (e.g., surgical, infectious, etc.) of resp. failure Aspiration Pneumonia Preserve immune Pulmonary Emboli system with high Allergic Rxns protein/kcal without causing The Problem? respiratory distress Insufficient oxygenation of tissues with excess CO2 retention supports lung fxn & prevents infections

Building Pulmonary Infections Weak Muscles Less Forceful Breathing Poor Respiration Poor Circulation Poor Nutrition Pulmonary Infections Edema Acute Respiratory Failure Mechanical Ventilator

Fuel Utilization and Lung Function Respiratory Quotient (RQ): ratio of CO2 produced to O2 consumed. RQ CO2 produced Workload for respiratory system Glucose Oxidation = 1.00 Triglyceride Oxidation = 0.71 0.82 Amino Acid Oxidation = 0.80 RQ

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/kg 2-2.5 g/kg in severe stress 30-60% of kcal lipids

Fluid and Sodium Restrictions Ease Pulmonary Edema Lung Muscle Tissue Maintained by optimal Ca, Mg, PO4

Death! 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 Death!

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

Hours/ Days… Renal Function Controls Plasma Plasma Bicarbonate (HCO3) Levels. How to Measure Acid-Base Status? ABGs = Arterial Blood Gases All are expressed “partial pressures” because there are 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)