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Enhanced Specialty Training for Physiotherapists
on Cardiopulmonary Specialty –
Interpretation of lab results
in patients with
cardiopulmonary disorders
Hosea Cheng (PT I - SH)
Dora Fung (PT II – OLMH)
Gloria Lau (PT II – TMH)
Oliver Luk (PT II – RH)
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Content
•
•
•
•
•
•
•
•
•
Arterial blood gas
Microbiology
Electrolytes
Coagulation profile
Cardiac enzymes
Lung function tests
Renal function tests
Liver function tests
Exercise stress tests
Purposes of investigation
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Arterial Blood Gas
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Arterial blood gas
• Normal body metabolism
• Consumption of nutrients
• Excretion of acid metabolites
• Kept from accumulating in high
amounts
• Cardiovascular & nervous systems
operate in a relatively narrow free H+ ion
range
• Maintenance of body systems requires an
appropriate acid / base balance (Shapiro,
1994)
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Arterial blood gas
• Approximately 98% of normal
metabolites – carbon dioxide
• CO2 readily reacts with water to form
carbonic acid
• Carbonic acid exists as a liquid and a gas
• Much acid content excreted through the
lungs
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Arterial blood gas
• Kidneys – main excretion for normal
metabolic acid
• pH ↑: excrete HCO3• pH ↓: reabsorb HCO3• Acid - base buffering - HendersonHasselbach equation:
2H2O + 2CO2 <-> H2CO3H+ + HCO3-
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Arterial blood gas
• Normal blood pH range
7.35
< 6.8 acidic
lethal
7.45
7.40
alkalotic > 7.8
lethal
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Arterial blood gas
• Acid- base normal range:
• pH: 7.35 – 7.45
• Partial pressure of carbon dioxide (PCO2)
normal range:
• 35mmHg - 45mmHg
• < 35mmHg (Hypocapnea)–
hyperventilating, blowing off more CO2
• > 45mmHg (Hypercapnea) –
hypoventilating, more CO2 retaining
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Arterial blood gas
• Partial pressure of arterial oxygen (PO2)
normal range:
• 80mmHg - 100mmHg
• < 80mmHg in patient less than 60 years
of age – hypoxemic
• 60 to 80 mmHg – mild hypoxemic
• 40 to 60mmHg – moderate hypoxemic
• < 40mmHg – severe hypoxemic
(Cherniak, 1992)
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Arterial blood gas
• To interpret the ABG:
• Is the pH value normal?
7.35 – 7.45 (7.40 +/- 0.05)
• Is it a respiratory problem (PaCO2)?
4.70 – 6.00 (35 – 45 mmHg) (40 +/- 5
mmHg)
• Is it a metabolic problem (Bicarbonate)?
22.0 – 26.0 mEq/L (24.0 +/- 2.0 mEq/L)
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Arterial blood gas
Respiratory acidosis
• pH = 7.31
• PaCO2 = 7.0
more acidic
more acidic
• Bicarbonate = 24
normal
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Arterial blood gas
Respiratory alkalosis
• pH = 7.50
• PaCO2 = 4.0
more alkaline
more alkaline
• Bicarbonate = 24
normal
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Arterial blood gas
Metabolic acidosis
• pH = 7.2
more acidic
• PaCO2 = 5
normal
• Bicarbonate = 18
more acidic
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Arterial blood gas
Metabolic alkalosis
• pH = 7.49
more alkaline
• PaCO2 = 5.0
• Bicarbonate = 29
normal
more alkaline
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Arterial blood gas
• To determine whether acute or chronic
• Uncompensated, partially compensated or
completely compensated
• pH is the key
• pH not in normal range = acute
• pH progressing towards normal range =
partially compensated
• pH within normal range = chronic
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Arterial blood gas
Not within pH (7.35 –
7.45)
Progressing to pH (7.35 –
7.45)
Within pH (7.35 –
7.45)
acute
subacute? transitional?
chronic
uncompensated
partially compensated
compensated
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Arterial blood gas
Respiratory failure
•
• PaO2 < 8kPa (60mmHg) +/• PaCO2 > 6.6kPa (50mmHg)
Clinical presentation:
• Altered mental state – agitation, drowsiness
• Laborious breathing – nasal flaring, use of
accessory muscles, retraction of supraclavicular
fossa or intercostal spaces, tachypnoea,
paradoxical breathing pattern
• Diaphoresis, tachycardia and hypertension
• Central cyanosis
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Arterial blood gas
• Type 1 respiratory failure – hypoxemic
• Failed oxygenation
• ↑ pH, ↓ PO2 and ↓PCO2
• Causes:
• Airway: severe asthma
• Alveolus: pneumonia, pulmonary
oedema, ARDS, atelectasis
• Pulmonary vasculature: pulmonary
thromboembolism, fat embolism
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Arterial blood gas
• Type 2 respiratory failure – hypercapnic
•
• Failed pump
• ↓pH ↓PO2 ↑PCO2
Causes:
• Respiratory center: brainstem infarct, opioidinduced respiratory suppression
• Cervical cord lesion, motor neuron diseases,
neuropathy, muscular dystrophy
• Ribcage (severe kyphoscoliosis), upper airway
obstruction (epiglottitis), extrapulmonary with
diaphragmatic splinting (ascites)
Arterial blood gas
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Normal Values for ABGs and Abnormal Values in Uncompensated Acid-Base Disturbances
Acid-Base Disturbance
PH
PCO2 mmHg
HCO3 mEq/L
Common cause
None (normal values)
7.35-7.45
35-45
22-26
Respiratory acidosis
↓
↑
normal
Respiratory depression (drug,
CNS, trauma), pulmonary
disease (pneumonia,COPD,
respiratory hypoventilation)
Respiratory alkalosis
↑
↓
normal
Hyperventilation (emotions,
pain, respiratory
hyperventilation)
Metabolic acidosis
↓
normal
↓
DM, shock, renal failure,
intestinal fistula
Metabolic alkalosis
↑
normal
↑
Sodium bicarbonate
overdose, prolonged vomiting,
nasogastric drainage
Microbiology
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Microbiology
Pneumonia
Sputum smear and culture
Microorganisms
Bacteria
Streptococcus pneumoniae
Staphylococcus aureus (MRSA)
Klebsiella pneumoniae
Enterobacter
Escherichia coli
Viruses
Influenza
RSV
Pneumonia
+
+
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Microbiology
SARS/ Influenza
Nasopharygeal aspirates
Test
Polymerse chain reaction
(PCR)
→ DNA
Seroconversion by Enzymelinked immosorbent assay
(ELSA) or
Immunofluorescence antibody
analysis (IFA)
→ antibody
Cell culture (Virus isolation)
SARSCoronavirus
(H5N1)
H1N1
+
+
+
+
+
+
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Microbiology
Pulmonary tuberculosis
Sputum for acid-fast bacilli (AFB) culture
Test
Mycobacterium tuberculosis
complex
Culture & identification tests
+
Nuclei acid amplification test
(PCR & species-specific probe)
+
Histological examination
+
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Microbiology
Implication – Infection control
Precaution
Pneumonia/Influenza
SARS/H1N1
Pulmonary TB
√
√
Contact
isolation
Droplet
isolation
Viral droplet
nuclei
(airborne)
transmission
√
Blood Chemistry
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Blood Chemistry
• Electrolytes
• Sodium
• Potassium
• Calcium
• Blood urea nitrogen
• creatinine
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Sodium (Na+)
• Predominant extracellular electrolyte in
body
• Maintain total body fluid homeostasis
• Important in neuron function
• Influencing osmotic balance between
cell and interstitial fluid (Na+ /K+ ATPase Pump)
• Normal Value: 134-149 mmol/L
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HypoNatremia
•
Causes
• Impaired renal
water excretion
• Use of thiazide
diuretics
• Severe cardiac
failure
• Hepatic cirrhosis
with ascites
• Salt-wasting
nephropathy
• hypothyroidism
•
Symptom
• Nausea
• Difficulty
concentrating
• Confusion
• Agitation
• Headache
• Seizures
• Coma
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HypoNatremia
•
Management
• Require hospital
care
• IV hypertonic
saline infusion
• Water restriction
• +/- anticonvulsant
therapy (seizure)
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Hypernatremia
•
Causes
• Dehydration
• Diarrhea
• Vomiting
• Renal loss diuretics
• Diabetes insipidus
• Extreme sweating
•
Symptoms
• Weakness
• Irritability
• Edema
• Seizure
• coma
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Hypernatremia
•
Management
• Attentive to ABC
• Tachycardia
• hypotension
• Require hospital
care
• Adminstration of
free water
• Hypotonic fluid
• Dextrose 5% or
0.45% isotonic
sodium
chloride
solution
• Stop Na
supplement
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Potassium (K+)
• Primary intracellular electrolyte
• Important in neuron function
• Influencing osmotic balance between
cell and interstitial fluid (Na+ /K+ ATPase Pump)
• Generates electrical impulse
• Hyper / hypokalaemia → cardiac arrythmia
• Normal Value: 3.2-5.2 mmol/L
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HypoKaleamia
•
Causes
• Renal losses
• GI losses
• Diarrhoea
• Vomiting
• Medication effects
• Diuretics
• Steriods
• Theophylline
• Inadequate diet
• Alkalosis
• Shift from
extracellular to
intracellular
•
Symptoms
• Palpitations
• Muscle cramp /
weakness
• Paralysis
• paresthesias
• Nausea
• Delirium
• Polyuria
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HypoKaleamia
•
ECG
• T-wave flattening
• Inverted T wave
• ST-depression
• Ventricular
arrhythmias
• Atrial arrhythmias
•
Management
• Contraindicated
to Exercise
training
• Close ECG
monitoring
• Attentive to ABC
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Hyperkalaemia
•
Causes
•
• Impaired K+ secretion
• CRF/ARF
• Urinary obstruction
• Addition of Potassium
• Ingestion of K
supplement
• IV potassium
• Blood transfusion
• Transmembrane shift
• From intra- to extracellular
• acidosis (e.g. DKA) /
medication (e.g.
beta-blocker)
• Hemolysis (e.g.
burns)
Symptoms
• Generalized fatigue
• Weakness
• Paresthesias
• Paralysis
• Palpitations
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Hyperkalaemia
•
ECG
• Peaked T waves
• Widened QRS
complex
• Reduction P-wave
• VF or systole if no
intervention
•
Management
• Life-threatening
• Contraindicated
to Exercise
training
• Close ECG
monitoring
• Attentive to ABC
• Discontinue K+
supplement
• IV bicarbonate
• Insulin
Haematology and
Coagulation Profile
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Haematology and Coagulation Profile
•
•
•
•
•
•
Haemoglobin Conc.
White Blood Cell
Platelet Count
Prothrombin Time (PT)
Internation Normalized Ratio (INR)
Activated Partial Thromboplastin Time
(APTT)
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Haemoglobin Conc.
To determine oxygen-carrying capacity
•
•
Increased by
Severe Dehydration
•
•
•
Decreased by
Anaemia
Blood loss
Normal:
Male: 13.5-18 g/dL
Female: 11.5-16.5 g/dL
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White Blood Cell
• First line of defence against
infectious organisms
Increased by
• Prone to presence of
infection or sepsis
• TB
Decreased by
• HIV
• SLE
Normal: 4-11 x 109/L
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Platelet Count
Coagulating factor
(Normal: 150-450x109/L)
Increased by
• Inflammatory disorder
• leukaemia
Decreased by
• Production defects
• Liver failure
• Bone marrow
failure
• Consumption defect
• Haemorrhage
If Platelet count <10x109 /L:
Spontaneous bleeding may occur ->
Suction is contraindicated
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Prothrombin Time (PT)
• Extrinsic pathway of coagulation
• Increased by
• Liver disease
• Oral anticoagulation therapy
(e.g. warfarin)
• Normal: 12-16 sec
• Elevation of prothrombin time
• Abnormal low clotting ability
• Risk of bleeding
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International Normalized Ratio (INR)
• Ratio of measured PT / Standardized PT
• Normal: 1
• Prevent deep vein thrombosis (DVT): 2
• Prevent pulmonary embolism: 2-4
• After heart valve replacement: 1.5
• INR> 4 -> suction / vigorous exercise is
contraindicated
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Activated Partial Thromboplastin Time
(APTT)
Intrinsic pathway of coagulation
Increased by
Decreased by
• Heparin therapy
• Hypercoagulable
states
• Deficiency in coagulation
factors
• Risk of bleeding
Normal: 32-42 sec
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Clinical implication
•
Cardiac Rehab.
•
•
General Mobilization exercise
•
limbs ex &walking ex
•
Depends on patients’
Physical status
•
psychological status
↑APPT/PT or ↓Platelet count -> risk of
bleeding
•
•
•
Vigorous chest physio should be adjusted
To adjust the intensity of treatment
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Precaution and Contraindication for
exercise training
•
Highest Risk
• Presence of
congestive heart
failure
• S&S of post-event
/ post-procedure
ischemia
•
Contraindication
• Metabolic
Condition
• Hypokalemia
• Hyperkalemia
• Hypovolemia
• Active
pericarditis or
myocarditis
ACSM (2010). ACSMs Guideline for Exercise testing and prescription. LippincottWilliam and Wilkins.
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PT intervention:
7-Step Exercise Protocol
Step 1
Deep breathing
AROM/PROM in bed (supine)
Step 2
Deep breathing
AROM/PROM in sitting
Step 3
Warm up &
Cool down
Calisthenics in sitting / standing
Stepping ex
Step 4
Warm up &
Cool down
Calisthenics in standing +
walking 150 ft
Stepping ex
Step 5
Warm up &
Cool down
Walking 300 ft
Few steps of stair
Step 6
Warm up &
Cool down
Walking 500 ft
Up & down ½ FOS
Step 7
Warm up &
Cool down
Walking 500 ft
Up & down 1 FOS
Cardiac Monitor
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Cardiac Monitors
•
•
•
•
•
•
Creatine Kinase (CK)
Lactate Dehydrogenase (LDH)
Serum Myoglobin
Aspartate Aminotransferase (AST)
Troponins (cTn)
Others
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Creatine Kinase (CK)
• Enzyme that Found predominantly in
heart mm, skeletal mm & brain
• Catalyzes the conversion of creatine to
phosphocreatine degrading ATP to ADP
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CK (cont’d)
• Normal Value:
Male
55-170 U/L
Female 35-135 U/L
• Indications:
• Myocardial mm injury
• neurologic / skeletal mm disease
Starts to Rise
Peaks
Returns to Normal
4-6 hrs
24 hrs
3-4 days
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CK (cont’d)
• Interfering factors:
• IM injections
• Skeletal mm injury & CNS damage
• Strenuous ex & recent surgery
• Muscle mass
• 2 subunits: B (brain type); M (muscle type)
• 3 isoenzymes:
• CK-MM, CK-BB, CK-MB
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CK-MB
• Specific for myocardial cells
• Indications:
• Early marker for MI
• Quantifying the degree
• Timing the onset
• Evaluate the effect of thrombolytic
therapy
• interval measure of CK-MB,
cTn, myoglobin can
document failed reperfusion
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CK-MB & %MB
• Normal Value: <5ng/mL
Starts to Rise
Peaks
Returns to Normal
4 hrs
18 hrs
2 days
• Interfering Factors:
• Severe skeletal mm injury
• Relative Index: CK-MB/ total CK
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Lactate Dehydrogenase (LDH)
• Enzymes that catalyzes the
interconversion of pyruvate & lactate
• 5 isoenzymes:
Tissue
Heart
RBCs
Skeletal mm
Lungs
Kidneys
Liver
LDH Isoenzyme
1, 2
1
5
3, 2
4
5
• Normal Value: 100-190 units/L
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LDH (cont’d)
•
Indications: Tissue Breakdown
• MI
Starts to Rise
Peaks
Returns to Normal
24 hrs
72 hrs
8-9 days
• Hemolysis, Cancer, meningitis, encephalitis,
acute pancreatitis, HIV
•
Interfering Factors:
• Hemolysis
• Strenuous exercise
• Alcohol & Drugs, e.g.: aspirin
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Serum Myoglobin
•
•
•
•
Oxygen-carrying respiratory protein found in
skeletal & cardiac mm
Earliest marker for AMI
Normal Value: <90 mcg/L
Starts to Rise
Peaks
Returns to Normal
1-3 hrs
8-12 hrs
1-2 days
Interfering Factors:
• Recent administration of radioactive substances
• IM injections
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Aspartate Aminotransferase (AST)
• Found in highly metabolic tissue: heart,
liver, skeletal muscle
• Indications:
• Coronary artery occlusive disease
• Hepatocellular disease
• Normal Value: 0-35 units/L
Starts to Rise
Peaks
Returns to Normal
8 hrs
24-48 hrs
4 days
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AST (cont’d)
• Interfering Factors:
• Exercise
• Trauma
• Acute pancreatitis, renal disease
• Drugs, e.g.: antihypertensives, oral
contraceptives, etc.
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Troponins (cTn)
• Found in skeletal & cardiac mm
• Protein that regulate calcium-dependent
interaction of myosin with actin
• 2 cardiac-specific cTn
• Normal Value: cTnI
<0.2 ng/mL
cTnT
cTnT
cTn I
<0..03ng/mL
Starts to Rise
Peaks
Returns to Normal
3-6 hrs
3-6 hrs
10-24 hrs
10-24 hrs
10-14 days
7-10 days
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cTnT & cTnI
•
Indication:
• Cardiac mm injury
• Differentiating cardiac from non-cardiac chest
pain
• Risk stratification in patient with unstable
angina
• Detection of reperfusion associated with
coronary recanalization
• Estimation of MI size
• Detection of perioperative MI
• Predicting future cardiac events
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cTnT & cTnI (cont’d)
• More specific & sensitive
• 13 times more abundant in myocardium
than CK-MB
• Not increased by skeletal muscle injury
• Elevated sooner
• provides longer diagnostic window
• Interfering Factors
• Falsely elevated in dialysis patient
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Others
•
•
•
•
C-Reactive Protein (CRP)
• Rise within 24-48 hrs, peaks at 72 hrs,
becomes normal by 7 days
Ischemia-Modified Albumin (IMA)
• Rise within 6-10min of ischemia, peaks at 2-4
hrs, becomes normal by 6 hours
Glycogen Phosphorylase BB (GPBB)
• Rise within 4 hrs, becomes normal by 24-36
hours
Alanine Aminotransferase (ALT)
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Each cardiac monitor has its
specific use depending on
the stage of event !
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Laboratory markers indicating
stages of ACS:
Proinflammatory cytokines
(e.g.,interleukin 6)
Plaque destabilization (e.g., MPO)
Plaque rupture (e.g., PAPP-A)
Acute phase reactant (e.g., CRP)
Ischemia (e.g., IMA)
Necrosis (e.g., cTn)
Myocardial dysfunction (e.g., BNP)
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ECG
cTn
CK Total
CK-MB
Myoglobin Interpretation
+
+
+
+
+
+
+/-
+/-
+/-
+/-
-
+
-
-
-
AMI or unstable angina with
increased risk of subsequent
coronary event.
-
-
-
+
-
AMI or unstable angina. Confirm
with serial CK-MB, ECG, and cTn.
-
+
+/-
+/-
+/-
-
-
-
-
+
Follow up cTn or CK-MB to rule
out early MI.
-
-
+
-
-
Not AMI
AMI.
AMI. Confirm with cTn for risk
stratification and to monitor
angioplastic/ thrombolytic therapy.
AMI or unstable angina.
Thank you!
End
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Reference
• Service Manual for Physiotherapy in Adult
ICU, Adult ICQ QA working group,
PTQASC(PTCOC), Hospital Authority.
• Pagana, K D & Pagana, TJ (2010).
Mosby’s Manual of Diagnostic and
Laboratory Test. 4th edition. Mosby Inc.,
an affliated of Elsevier Inc.
• Wallach, J B (2007). Interpretation of
diagnostic tests. 8th edition. Lippincott
Williams & Wilkins, USA.