9] NIV, Transplant, Apnea ADD article questions- make sure all the info is on here Flashcards
What is sleep apnea?
Significant daytime sleepiness with other Sx
Hallmark of sleep apnea
Airway narrowing/obstruction at night
3 types of sleep apnea
Central
Obstructive
Mixed
What does obstructive sleep apnea mean? (OSAS)
Periods that last 10 sec or more where you have hypopnea or apnea of breathing
Patho of OSAS
Partial or complete pharyngeal collapse during sleep- relaxed pharynx during sleep obstructs ventilation
What’s dampened during sleep?
Reflex
What else gets dampened during sleep worsening the loss of airway tone?
Chemoreceptors
Results of narrow airway in OSAS
Low oxygen and increased CO2
Healthy breathing
Negative intrathoracic pressures pull air in —> ⦿ Pharyngeal dilator muscles fight the inward pull to keep airways patent ⦿ Slow air movement is laminar and aids in keeping airway dilated ⦿ During sleep, pharyngeal dilator muscles relax increasing airway resistance
Severe sleep apnea
More than 30 episodes per night of loss of breathing
Moderate sleep apnea
15-30 episodes/night
Mild sleep apnea
5-14 episodes/night
Gender risk factor for SA
Mor emen
Race for SA
African America, Hispanic, Pacific Islanders
Elevated BMI as risk factor in sleep apnea
40% obese have it and 70% of people with sleep apnea are obese; neck circumference more than 16 inches for women, more than 17 for men
Anatomy as risk factor for SA
Small airways, cervical extension, FHP
Sleep apnea is seen a lot in kids with?
Down syndrome
Signs and Sx in adults for SA
Wifey complains Sleep disturb Tired and groggy even tho they got 8 hours sleep Morning headaches (b/c of alterations in CO2 and O2 levels) Irritable Memory loss Dry mouth Car accidents (they fall asleep)
Signs and Sx of sleep apnea in kids
Hyperactivity- primary Sx
Can’t concentrate
Bad school performance (detention)
Long term consequences of SA
HTN CAD HF Dysrhytthmias CVA disorders Impairs growth in kids
The death rate for ppl with ? SA is ? Than for those who dont have OSAS
Untreated
3x higher
Define obesity hypoventilation syndrome
BMI more than 30
PaCO2 more than 45
Sleep disordered breathing
CHRONIC HYPOventilation
Altered breathing in obesity HYpovent syndrome results in
Daytime LOW PaO2
Daytime elevation PCO2
(Differentiates OHS from OSA)
Risk factor for OHS
Obesity
What does OHS stand for
Obesity hypoventilation syndrome
Signs and Sx of OHS
Sleepy Depression SOB with activity Irritable Signs of cor pulmonale
Risks of OHS
HTN Cor pulmonale Sexual dysfunction Dysrhytmia Polycythemia CVA
Treatment for SA and OHS
NIV, Masks with CPAP and BiPAP which all aim to increase alveolar ventilation and stent airways
Goal of NIV
Airway stunting
Goal os NIV is to increase
FRC = ERV + RV
What is FRC
Volume in lungs after a normal expiration
Increasing the FRC does what
Limits “de-recruitment” of alveoli
What is CPAP
Pressure during exhale to stent open airways
How does patient breathe on CPAP
Spontaneously
What’s another common intervention for SA
BIPAP- NIV
What’s different of BiPAP
It’s a type of CPAP with two diff pressures during inhale (high pressure) and exhale (low pressure)
High pressure in BiPAP during inhale for
Stenting
Low pressure of BiPAP during exhale for
Helps blow off CO2
PT implications for SA
Take a thorough sleep history, look at ADHD in kids, weight, sleep hygiene, exercise, sleep positioning
Indications for lung transplant
Advanced lung disease- class II or IV Progressive lung disease that needs max intervention Survival chance less than 50 in 2 years without transplant Pt understands risks
Contraindications for lung transplant
Active cancer in last 2-5 years Untreatable or advanced disease of another organ Uncurable infection Chest wall/Spine deformity Not compliant with therapy Psych conditions untreatable No social support Substance addition like smoking
RELATIVE contraindications for lung transplant
More than 75 years old Poor functional status Colonization BMI more than 30 Severe osteoporosis- mechanical vent
What does LAS stand for
Lung allocation score
What does LAS predict
The probability of surviving next year without transplant and length of survival post-transplant
6MWT for LAS
In adults, less than 400 m (1312 feet) is correlated with higher mortality
Determination of eligibility and “place in line” for lung transplant depends on:
LAS
Distance from organ
Lung transplant listing for kids
Priority 1- urgent
Priority 2
Kids under 12 cannot?
Get adult lungs
6MWT for kids
More than 1000 feet is correlated with shorter ICU stay and fewer days of vent
2 types of lung transplants
Single- 5-9 hours
Double- 7-9 hours
Lateral thoracotomy cuts through
Serratus and lats
Which intercostal space with transplants?
5th Intercostal space
Aerobic capacity for pre-txp eval
6MWT
Incremental shuttle walk
GXT
Pulmonary endurance and strength for pre-txp
MIP
MVV
Short physical performance battery
Marker for frailty in pre-lung txp and predicts disability and waitlist mortality
Pre-txp Ex presc
F: 2-5x/week
I: 50-80% HRR or 3-5 on dyspnea scale or 60-80% 6MWT speed
TT: continuous training 15-30 minutes or
Intermittent training 5-10 minutes;
2-3 bouts Interval training: 30 seconds exercise;
30 seconds rest for 12-26 minutes
Main med they use to prevent rejection episodes
CALI nursing inhibitors (tacrolimus and cyclosporine)
Main side effects of calcination inhibitors
HTN
Tremor
Electrolyte abnormalities (low Mg and high K)
Side dish meds
Mycophenelate
Imuran
Salads med examples
Sirolimus and everolimus
Mg and K affect?
Cardiac muscle function
What are side dishes
Things they add onto pts regimen to help prevent rejections
Mycophenelate can cause
N/V, diarrhea, Leuko and sytopenia, anemia
What’s the cutoff for platelets for them to use weights?
Above 50,000 **
How do salads work with meds?
If they are having too many Side effects, salads can replace main dishes
Salads can be used for what?
Also if they have mild or mod rejections that help
Bread and butter for rejection episodes
Steroids
Methyprednosolone and
Prednisone
Side effects of steroids
Muscle atrophy
Bone loss
GI irritability
With steroids, people gain
Weight in weird places- abdomen and buffalo hump
Before txp they have likely had what
COPD or etc
Premorbid disease and muscle changes
COPD:
Atrophy type I fibers
More fatigue
Lower lactic acid threshold
It’s usually what that limits the pt after txp?
Peripheral issues- not lungs
Acute care s/p LTXP
Chest PT Postural drainage every 4-6 hours Early mob Training cough Secretion clearance techniques
What is a a-line
Direct measurement of arterial BP
PT precautions with A-line
Dont pull it out
No wrist ROM
How to interpret A line readings
Transducer has to be at level of right atrium for accurate readings
If a-line alarm goes off, what do you do?
1- observe the patient first!!
2- take manual BP
Signs and Sx of intolerance- lower intensity (7)
HR increases more than 20-30 above resting HR SBP increases more than 20-30 RR more than 30 Increased accessory muscle use DNV- dizzy, nausea, vomit Pain Agitation
Ventilator specific alarms (5)
It alarms for disconnect FiO2 more or equal to 0.6 PEEP more than 10 Mode changed to assist-control Tenuous airway
Aerobic training goal of outpatient PT
30 min most days of the week if not all
Strength training in outpatient PT
UE strength training after MD clearance
6-9 weeks
TERMINATE EXERCISE (10)
RR more than 40 More than 20% increase in resting HR HR less than 40 or more than 130 MAP less than 65 or more than 110 OH Severe agitation (RASS more than 2) Sedation or coma RASS (less or equal to 3) EKG changes, chest pain, diaphoresis SpO2 decreases 4% or less than 88% patient discomfort or refusal
Post transplant rehab Ex Prescription
F: 3-5 x/week I: 50-80% HRR 3-4/10 on dyspnea scale 75-100% 6MWT speed T: continuous 20 min
*Keep sats above 88%
Strength training ex prescription for post txp
F: 2-3x/week
I: 60-80% of 1 RM
1-3 sets of 8-15 reps
(Higher sets, lower reps)
Because of steroids you want to focus on what durign strength
Focus on proximal strength
Mechanical changes in thoracic cage
Increased collagen
Loss of disc height
The mechanical changes in the thoracic cage results in
Greater pressure needed to inflate lungs
Lung parenchyma changes with age
Decreased compliance in small airways
Increased size and production of muscles glands
Decreased elastic recoil of lungs
Alveoli changes
Decreased available surface area for gas exchange
Decreased diffusion capacity (DLCO)
Decreased number of pulmonary capillaries
Respiratory muscle changes
Less type I and type II, less # of motor units, slowing at NMJ, lose optimal L-T
Muscles have to work harder to?
Create negative pressure
Lung volumes and capacities with age
⦿Decreased FVC
⦿Decreased FEV1
⦿Increased RV
⦿No change in TLC
FEV1
Amount of air exhaled during 1st second of FVC
FEV1 indicates
Flow in larger airways
Post bronchodilator FEV1/FVC less than what indicates what
Less than 70% predicted = COPD
GOLD 1
Mild
FEV1 more than 80% or = to 80
Gold 2
Moderate
Between 50-80
Gold 3
Severe
Between 30-less than 50
Gold 4
Very severe
Less than 30%
Goals of medical assessment (3)
Determine level of airflow limitation
Determine impact on health status
Determine risk of future events
(hospitalizations, death, exacerbation)
COPD is a common, preventable and treatable disease characterized by ? Respiratory Sx and ? That is due to ? Usually caused by significant ?
Persistent
Airflow limitation
Airway and alveolar abnormalities
Exposure to noxious particles or gases
Goals of phase III
Independent self-minoring
Exercises as life long approach- prevent relapse
The minimal increase that is clinically meaningful in 6MW distance is?
54-84 m (177 - 275) feet for COPD
St George repsiratory questionnaire is ?
Disease specific
Precontemplation
No intention to take action in next 6 months
Contemplation
Intends to take action in next 6 months
Intention to take action in next 30d and has taken behavioral steps to initiate change
Preparation
Behavior has changed for less than 6 months
Action
Behavior has changed for more than 6 months
Maintenance
