OPP Lymphatic

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					                                                                       OPP #3
                                              The Heart and the Cardiac Patient
                                                      January 19, 2004 1100A
                                                                Dr. Sandhouse
                                                                 Brian Schmidt

                       1. Explain the effects of SNS on CV and respir system
             2. Explain the effects of the PNS on the CV and respir systems
3. Explain the effects of the lympathic system on the CV and Respir systems
                          4. List somatovisceral (SV) effect on the CV system
                         5. Describe the body‟s response to pulmon infection
      6. Formaulate basic Tx approaches for Pt‟s with common cardiac and
                                                          pulmonary diseases

                       Sympathetic Innervation

                                              Heart T1-T6
                                                  o Some preganglionic
                                                      fibers run to cervical
                                                      chain ganglia
                                                  o Fibers from the R-side
                                                      innervate SA node via
                                                      right deep cardiac plexus
                                                  o Fibers from the L-side
                                                      innervate the AV node via
                                                      the LEFT deep cardiac
                                              Peripheral blood vessels: T1-L2
                                              Peripheral Vascularity has NO
                                               parasympathetics – resting
                                               tone done thru SNS
                                              Kidneys and Adrenals: T10-L2
                                              Maintains vascular tone; causes
                                               vasoconstriction with ↑ tone
                                              ↑ sympathetic tone → ↑ HR
                                               ↑ contractility ↑cardiac output

                               Page 1 of 10
                    Parasympathetic Innervation
   Vagus Nerve (CN X)
      o R-vagus → SA

       o L-vagus → AV

   ↑ tone → ↓ HR ↓

                                            Lymphatic drainage from the heart
                                             from R-lymphatic duct
                                         Impaired Lymphatic drainage results
                                                 o ↓ collateral circulation
                                    - need good lymph function to maintain;
                                    helps in post-MI Tx
                                                 o ↑ morbidity and mortality
                                                     from ischemia and infection
                                                 o Congestion of cardiac
                                                     tissues resulting in
                                    -HTN, CAD, „lytes imbalance
                                                 o Linked to pathogenesis of
                                                 o Linked to HTN
                                                 o signif role in pulmonary
                                                     edema, ascites,
                                                     hepatomegaly, and
                                                     peripheral edema
                                                     associated with CHF
                                                 o Electrolyte imbalances that
                                                     can ↑ morbidity in Pt‟s with

                            Page 2 of 10
                          Somatovisceral Changes
SVTs                                  Hypersympathetic on R-side (T1-T6)
Ectopic foci                          Hypersympathetic on L-side
Coronary vasospasm                         ↑ sympathetic tone
Essential HTN                              Vascular & cardiac hyperactivity to
                                           sympathetic stimulus
Elevated BP                                Prolonged sympathetic activity to
                                           kidneys creastes a functional secretion
                                           of H2O and Na+
Sinus bradyarrhythmias                     hyperPARAsympathetic on R-side
AV Blocks                                  hyperPARAsympathetic on L-side
Scoliosis                                  >75‟ seriously compromises cardiac
SVT                                        Trigger Point (TrP) in R-pectoralis
                                           Remember postural SD

                           Specific Applications
Myocardial Infarction (MI)
   Majority of Pt‟s seen within 30 min of AMI have autonomic disturbances

          Anterior Infarction                     Inferior Wall Infarction
Sympathicotonia in T1-T6                   Vagal hyperactivity
- Esp. T2-T3 on Left                       - C2 and cranial base

          o Role of OMT
                  ↓ morbidity and mortality in Pt‟s with AMI
                  Tx Goal: ↓ sympathetic hyperactivity to upper thoracics
                          ↓ incidences of ectopic foci and VFib
                          Remove factors that restrict collateral flow
          o Tx approach
Generalized paraspinal inhibition        ↓ peripheral resistance
                                         ↓ Cardiac Workload
Thoracic inlet dysfunction               Indirect techniques

If CPR performed                           Indirect techniques
                                           Ribs and sternum

                                           Pectoral traction
Enhance lymphatic / venous return          Re-doming the diaphragm

Restore Vagal tone                         Tx of cranial base
                                           Upper cervicals

                                    Page 3 of 10
   Role of OMT
       o ↓ stress
       o ↓ TPR
              Generalized sympathetic inhibition
       o ↓ renal output (renin)
              Sympathetic inhibition of T10-L2
       o Lower BP + ↓ Aldosterone
              Tx of POSTERIOR Chapman‟s reflex points for ADRENALS
       o ↓ med req‟s

Congestive Heart Failure
   In CHF, there is a boat-load (3-40x) the resting amount of lympathic return
   Goals:
         o address sympathetics at T1-T6
         o optimize respir function
                ↑ venous and lympathic return
         o Lymph movement
                Lymphathic pump
                Effleurage

                                  Page 4 of 10
    Goals:
         o ↓ segmental facilitation to modulate sympathic input
         o Tx of cranial base and upper cervical
               Normalize vagal tone
         o Tx of postural factors
               Remember that pectoralis TrP
                      How do we fix a TrP?
                             o Small circular motions over the point 

   The Respiratory System and the Pulmonary Patient
Functional Anatomy
    Autonomic Supply
         o Sympathetics T1-T6
                 ↑ sympathetics = bronchodilator
                 Same as inhalers
         o Parasympathetics from Vagus (X)
    Lymphatics
         o From lungs to R-lymphatic duct
    Somatic Stuff
         o Thoracic vertebrae
         o Ribs
         o Respiratory diaphargm
         o Repsiratory Muscles
                 Primary
                 Secondary

                     Autonomic Effects on Pulmonary Function
          ↑ Sympathetic Tone                   ↑ Parasympathetic Tone
       Bronchodilation                            Bronchoconstriction
       Vasoconstriction with local                 Profuse secretions
       hypOperfusion                             Thinning of secretions
       Epithelial hyperplasia with
       thickening secretions

      What happens when an infection occurs?
         o Pathogenesis
                Viral/bacterial infections → local irritation of bronchial
                       Sympathetic thickens / Parasympathetic
                ↓ Alveolar surfactant
                (+) exudate

                                   Page 5 of 10
                    Congestion / edema of lung tissue
                         Compromises lung function
                    VS reflexes inchronic disease (COPD / Bronchitis)
                         Chronic TART ∆‟s
                         ↑ risk of infection
                         Our Goal: balance the ANS

           o Sympathetics / Parasympathetics
Sympathetics                           Parasympathetic
 ↑ Visceral afferents                  Hering-Breur reflex cannot distinguish
C2-C3 + T1-T6                          between air sacs filled with air v. those
(leads to facilitated segments)        filled with fluids
                                           Hering-Breur Reflex is defined as the reflex that
                                           limits excessive expansion and contraction of the
                                           chest during respiration prior to sending impluses to
                                           the brain via the vagus nerve
VS reflexes occur producing palpable       Lung tissue congestion → respir center
joint and musculoskeletal ∆‟s              receives information from vagus to limit
                                           excursion of the diaphragm
Prolonged sympathetic stimulation          At the same time, carotid body signals
results in vasoconstriction and local      the respir center that more O2 is
hypOperfusion                              needed → ↑ respir rate (rapid shallow
                                           End result → rapid shallow breath

                                    Page 6 of 10
   Diaphragm stressed by
         o Ribs and spine
                 d/t VS reflexes
         o tissue resistance
                 d/t congestion
         o Both of these combine to cause strain:
                 Lower 6 ribs
                 Thoracolumbar junction
                 This results in
                       ↑ LUMBAR lordosis
                       Flattening of the diaphragm
                             o Seen on XRays of COPD Pt‟s
   T1-T6 paraspinal tissue with increased tone
         o Ropiness / bogginess

    Flattening of diaphragm
         o ↓ pressure gradient between thoracic and abdominal cavities
         o ↓ lymphatic flow
         o ↑ tissue congestion
         o GOAL: Optimize the pressure gradient

                                Page 7 of 10
   Typical SSx
         o High fever
         o Tachyapnea
         o Hypoxia
         o Chest pain (deep inhalation)
         o Non-productive cough (initially)
                  ↑ sympathetic activity
                  ↑↑ thickness of mucus
   OMT Techniques
         o Sympathetic VS reflexes
                  Rib raising
                  Paraspinal inhibition (thoracic)
                  Chapman‟s reflexes
                  Lower cervical
         o Lympathic Techniques
                  Pump techniques are CONTRAINDICTATED in acute phase
                        When Pt is febrile
                  Will help improve immunity and drug delivery to tissues
                  Remember, open the thoracic duct 1st!
         o Doming the thoracoabdominal diaphragm
         o Tx of C3-C5 to improve diaphragmatic function
                  Remember, C3-4-5 keeps the diaphragm alive!
                        Thanks John and Lisa for all the help in anatomy last
                  Tx of upper cervicals and cranial base
                        Goal: normalize parasympathetic tone
                  Tx SD‟s as tolerated by the Pt
   Use of OMT in COPD has been documented to signif benefit PCO2, O2
     sat, total lung capacity, and residual volume
   Tx goals
         o Improve chest cage motion
         o Thoracic drainage
         o Diaphramatic function

                                 Page 8 of 10
    Acute attack
         o Goal: ↑ sympathetic stimulation → bronchodilation
    Between attacks
         o Goal: promote maximum thoracic, sternal, and costal motion
         o Reduces the frequency and severity of future attacks
         o ↓ need for meds
         o Tradeoff:
                 ↑ SNS is not always good as this will have affects on heart
                   (arrhythmias) and lungs
    Stiles (he a doctor BTW)
         o 14% reduction in hospital stay with OMT added to medical
             management of asthmatic patients

Prevention of postoperative pulmonary complications
Atelectasis is a common post-op complication
    The usual post-op method to prevent is Incentive Spirometry (IS)
          o I wonder what the incentive really is?
          o Respiratory exercise
          o GOAL: maintain (+) pressure
    Study of IS v. Thoracic lymphatics Pump (TLP)
          o Post-cholecystectomy
          o Atelectasis occurred similarly in both groups
          o TLP Pt‟s
                   Earlier recovery
                   Quicker return to pre-op FVC and FEV1

                                  Page 9 of 10
Osteopathic Approach Incorporates
   Tx of Visceral Component
   Tx of Somatic Component
   Stress Reduction
   Lifestyle ∆‟s
   Psychological components
   Spiritual aspects of Dz and Tx
   “∆” means “changes” (remember calculus?)

                              Page 10 of 10

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