Cardiopulm Unit 8 Obstructive Lung Diseases Flashcards
1
Q
Using Spirogram, a person with normal lungs, how long does it take them to reach 4 L (in volume) and what is the FEV1/FVC?
A
- Takes about 4 seconds
- FEV1/FVC = 75%
2
Q
Using Spirogram, a person with obstructive lungs, how long does it take them to reach 4 L (in volume) and what is the FEV1/FVC?
A
- Takes about 7 seconds
- FEV1/FVC = 25%
3
Q
What is the difference between normal and obstructive lungs in terms of Total Lung Capacity and Residual Volume?
A
Both are higher with the obstructive lungs
- Residual Volume is a key characteristic finding with obstructive lung disease
4
Q
What is COPD?
A
A progressive disease which features chronic airflow limitations that are typically caused by a mixture of parenchymal alveolar disease (emphysema) and small-airway disease (obstructive bronchiolitis) which commonly occur in combination, with proportions varying from individual to individual. However, in some cases, either emphysema or chronic bronchitis is clearly dominant
Parenchymal: functional tissue of an organ (e.g. lung alveoli) as distinguished from the connective and supporting tissue
5
Q
What are the 2 Primary Causes of COPD?
A
- Inhalation Factors
- Genetics
6
Q
The Pathophysiology of COPD includes what? What do these 4, all do?
A
- Hyperplasia of the mucus-secreting cells
- Reactive airways
- Terminal bronchiole destruction
- Alveolar sac destruction
All of which reduce airflow out of the air sacs and the airways and result in hyperinflation and poor gas exchange resulting in ventilation/perfusion (V/Q) mismatch, hypoxemia, and oftentimes hypercapnia
7
Q
With COPD, what is Inhalation Exposure?
How can smoking impair the lungs?
A
Inhalation exposure is often the primary contributing factor to the cascade of airway and alveoli inflammatory responses that lead to disease, especially in genetically susceptible individuals.
Cigarette smoke impairs cilia function, and alveolar macrophages within the lung parenchyma can be permanently destroyed, increasing the risk of infection
8
Q
With Inhalation Exposure, what else may result from its inflammatory response? How long will the inflammatory response take?
A
May result in Infection, which increases the progression of lung destruction
- Inflammatory response will continue as long as the inhalation exposure occurs, and if long-term exposure has occurred, the inflammatory damage may not be reversible despite smoking cessation or removal of the inhalation exposure.
9
Q
With Obstructive lung disease, what is the Vicious Cycle Hypothesis?
A
- This starts off with an initiating factor (e.g., smoking, childhood repsiratory disease)
- Leads to impaired innate lung defense, which exposes the lungs to infection, microbial colonization
- If the Microbial Colonization becomes large enough and the immune system responds, the body creates Microbial Antigens
- This then leads to Airway Epithelial injury, which will further damage the innate lung defense
And the cycle will continue to worsen
10
Q
With the Vicious Cycle Hypothesis, what happens in the cycle if the person with COPD has an Acute Exacerbation?
A
- This will lead to an inflammatory response
- Leading to increased proteolytic activity
- Leading to Altered proteinase anti-proteinase balance
- Which will lead to the progression of COPD, and cause airway epithelial injury and further impair the innate lung defense
11
Q
With the GOLD Staging of COPD, what is stage 1?
COPD Severity, FEV1/FVC ratio, FEV range
A
- COPD Severity: Mild
- FEV1/FVC Ratio: < 0.70
- FEV Range: ≥ 80% of normal
12
Q
With the GOLD Staging of COPD, what is stage 2?
COPD Severity, FEV1/FVC ratio, FEV range
A
- COPD Severity: Moderate
- FEV1/FVC Ratio: < 0.70
- FEV Range: 50 - 79% of normal
13
Q
With the GOLD Staging of COPD, what is stage 3?
COPD Severity, FEV1/FVC ratio, FEV range
A
- COPD Severity: Severe
- FEV1/FVC Ratio: < 0.70
- FEV Range: 30 - 49% of normal
14
Q
With the GOLD Staging of COPD, what is stage 4?
COPD Severity, FEV1/FVC ratio, FEV range
A
- COPD Severity: Very Severe
- FEV1/FVC Ratio: < 0.70
- FEV Range: ≤ 30% of normal OR < 50% of normal with chronic respiratory failure present
15
Q
What are the Characteristics Emphysema-Dominant Phenotype of COPD (“Pink Puffer”)?
A
- Typically characterized by a thin appearance due to weight loss, which is a result of the increased energy expenditure from the effort of breathing.
- May appear to be taking more effort to breathe, Using accessory muscles to compensate for impaired diaphragmatic function secondary to lung hyperinflation.
- Lips and nail beds may not show signs of cyanosis hence the term “pink”, which indicates relatively well- oxygenated blood despite the difficulty in breathing.
- The “puffer” part of the term comes from the pursed-lip breathing that alters respiratory mechanics by increasing airway pressure, which helps to prevent airway collapse during expiration
16
Q
What are the Characteristics Bronchitis-Dominant Phenotype of COPD (“Blue Bloater”)?
A
- Exhibit persistent coughing and produce large amounts of sputum
- Typically presents with an overweight body type due to a combination of factors including a reduction in exercise capacity and the body’s attempt to increase its oxygen reserve capacity.
- Often exhibit signs of cyanosis, which gives rise to the term “blue”.
- The term “bloater” refers to the bloating seen in the body, including potential fluid retention and swelling, particularly in the lower extremities, due to right-sided heart failure that can complicate chronic bronchitis.
17
Q
What do Mucous Plugs and Unstable Airways cause?
A
- Air trapping and hyperinflation on expiration
- During Inspiration, the airways are pulled open, allowing gas to flow past the obstruction
18
Q
Emphysema
During Expiration, what does decreased elastic recoil of the bronchial walls result in?
A
Results in collapse of the airways and prevents normal expiratory flow
19
Q
Emphysema
What is Flattened Hemi-Diaphragmatic contours considered?
- When is this best seen?
A
Its considered on of the most sensitive indicators of Hyperinflation
- Best seen on the lateral chest radiograph and consist of a loss of height of the convexity of the hemidiaphragm
- Draw a line connecting the sternophrenic angle and this arch height should be ≥2.5 cm
- It is considered clearly pathological when measured less than 1.5 cm
20
Q
How is Muscle Composition affected with COPD?
A
- There is a shift from Type 1 to Type 2 Skeletal muscle fibers.
- There is a reduction in aeroic metabolism and poor muscle endurance
21
Q
Those with COPD that have decreases in strength of both skeletal and respiratory musculature are associated with what?
A
Independently associated with poorer exercise capacity and lower extremity functioning across the spectrum of COPD severity
22
Q
Emphysema
With the Diaphragam, what happens as the diaphragm flattens?
A
Its ability to contract and relax affects the individuals ability to perform a normal passive exhalation
23
Q
Emphysema
As COPD progresses, how can it affect the diaphragam and Pelvic Floor?
A
As the disease progresses, exhalation can become forced instead of passive, increasing intraabdominal pressure and putting more stress on the pelvic floor. This can lead to pelvic floor dysfunction that can manifest as urinary incontinence in both males and female
24
Q
What are the Clinical Manifestations for Emphysema?
A
- Use of Accessory Muscles to breath
- Pursed-Lip breathing
- Minimal or absent cough
- Leaning forward to breath
- Dyspnea on exertion (late sign)
25
What is Chronic Bronchitis Defined as?
The presence of a **chronic productive cough for 3 months in each of 2 successive years,** provided that other causes of chronic mucus production (CF, bronchiectasis, and tuberculosis [TB]) have been ruled out
26
With Chronic Bronchitis, what does Airway Remodeling involve?
Tissue repair and malfunctionof the mucociliary clearance system, resulting in the accumulation of inflammatory mucous exudates in the airway lumen
## Footnote
This is the process that damages the airways over time
27
What are the Clinical Manifestations for Chronic Bronchitis?
- Excessive Body Fluids
- Chronic cough
- Shortness of breath on exertion
- Increased sputum
- Cyanosis (late sign)
28
What is the Pathophysiology of Emphysema "Pink Puffer"?
- There is **decreased Elastic recoil, which increases lung compliance and decreases ventilation** -> increases work of breathing
- There is destruction of capillary bed which decreases perfusion
*The **decrease** in perfusion **and** ventilation causes a Matched V:Q Defect (relatively well-oxygenated blood unit late stages)*
- There is **Alveolar detachment which causes air trapping on expiration** (we will see Pursed-lip breathing) -> we will see an increase in End-respiratory volume and an increase in RV and TLC and a decrease in VC -> **then causes barrel chest**
*Also with Emphysema, the people will breath in normally and then they will have an issue getting the air out. Air trapping happens.*
29
What is the Pathophysiology of Chronic Bronchitis "Blue Bloaters"?
- There is Airway obstruction, leads to Alveolar hypoxia. This then leads to V:Q Mismatch and/or Pulmonary Vasoconstriction
-With **V: Q Mismatch** we will see **Hypoexamia** (may also cause cyanosis) -> Polycythemia. Also we will see **Hypercarbia** leading to respiratory acidosis
-With **Pulmonary Vasoconstriction** we'll see Pulmonary Hypertension and this **leads to Decreased Left Ventricle output** leading to decreased circulating volume and Activation of RAAS, also we will see **Right Heart failure** leading to Cor pulmonale
- There is Mucus Hypersecretion, leads to productive cough with copious sputum
30
During the Physical Exam, what breath sounds may we hear with those patients with Chronic Bronchitis?
Vesicular, but likely diminished, prolonged expiration
31
During the Physical Exam, what Adventitous sounds may we hear with those patients with Chronic Bronchitis?
likely wheezing or rhonchi, possible crackles
32
During the Physical Exam, what Transmitted Voice sounds may we hear with those patients with Chronic Bronchitis?
None
33
During the Physical Exam, what Percussion Note may we hear with those with Chronic Bronchitis?
Resonant (Normal)
34
During the Physical Exam, where may we find the trachea when observing those patients with Chronic Bronchitis?
In midline
35
During the Physical Exam, what breath sounds may we hear with those patients with Emphysema?
Vesicular, but likely diminished, prolonged expiration
36
During the Physical Exam, what Adventitous sounds may we hear with those patients with Emphysema?
None, maybe wheezes during exacerbations (less than chronic Bronchitis)
37
During the Physical Exam, what Transmitted Voice sounds may we hear with those patients with Emphysema?
None
38
During the Physical Exam, what Percussion Note may we hear with those with Emphysema?
Diffusely Hyperresonant
39
During the Physical Exam, where may we find the trachea when observing those patients with Emphysema?
In Midline
40
What are Acute COPD Exacerbations?
An acute change in patient's baseline dyspnea, cough or sputum that is beyond normal variability and sufficient to warrent a change in therapy (ATS/ERS definition)
- Presentation may vary from a transient decline in functional to a fatal event
- Exacerbations contribute to high mortality rate associated with the disease
41
Those patients with COPD, what happens if they have an exacerbation?
- They rarely return fully to their baseline functional status; this results in a gradual progressive downhill course
42
What is the COPD Assessment Test used for?
This is used in patients diagnosed with COPD, to assess **progression of lung disease**, **decline in functional status** and **gauge effectiveness of pulmonary rehabilitation**
43
Those with Lung Disease, what are other Examination Domains that we should assess?
- **Walking ability** (Endurance and speed): 2 or 6 MWT, ISWT, Incremental treadmill test, Seated or standing step test, 10 MWT, etc
- **Balanc/Fall Risk**: BBS, FGA, DGI, TUG, 5xSTS / 30 sec chair rise
- **Strength and Power**: Dynamometry, MMT, OMs like 5xSTS / 30 sec chair rise
- **QOL**: Chronic Respiratory Questionnaire (CRQ), COPD Assessment Test (CAT), Saint George Respiratory Questionnaire
(SGRQ), and Living with COPD questionnaire (LCOPD)
## Footnote
The exercise prescription for individuals with lung disease, particularly those with moderate to severe disease, should be based on exercise testing
44
# Considerations for Exercise Testing for Obstructive Lung Disease
Those with Obstructive Lung Disease, what is the purpose of Exercise Testing?
- Purposes of ET include **quantifying exercise capacity, establishing a baseline** for outcome documentation, **evaluating drug treatment efficacy**, assisting in the **development of the Ex Rx, evaluating unexplained dyspnea and exercise intolerance, and prognostic evaluation for individual risk stratification**.
45
# Considerations for Exercise Testing for Obstructive Lung Disease
Those with Obstructive Lung Disease should do Incremental Exercise Test to assess function. What is the difference in duration based on the severity of COPD? (Mild to Moderate compared to severe disease)
**A test duration of 8– 12 min is optimal in those with mild-to-moderate COPD, whereas a test duration of 5– 9 min is recommended for individuals with severe and very severe disease**.
46
# Considerations for Exercise Testing for Obstructive Lung Disease
For those with Moderate to Severe Obstructive Lung Disease (COPD), what may they experience with exercise?
**Individuals with moderate-to-severe COPD may exhibit oxyhemoglobin desaturation with exercise**
47
What is the **Aerobic** FITT Principle for Individuals with COPD?
**F**: Minimally 3 days/wk ; perferably up to 5 days/wk
**I**: Moderate to Vigorous Intensity (50-80% peak work rate or 4-6 on the Borg CR10 scale)
**T**: 20-60 min per day at moderate to high intensities as tolerated. *If the 20 to 60 min durations are not achievable accumulate ≥ 20 min of exercise rest periods of lower intensity work or rest*
**T**: Common Aerobic modes including walking (free or treadmill), stationary cycling and upper body ergometry
## Footnote
UE activity is associated with high metabolic and ventilatory demand, and activities involving the arms can lead to irregular or dyssynchronous breathing. This is because some arm muscles are also accessory muscles of inspiration.
48
What is the **Resistance** FITT Principle for Individuals with COPD?
**F**: At least 2 days/wk performed on non-consecutive days
**I**:
- **Strength**: 60-70% of 1RM for beginners; ≥80% for experienced weight trainers
- **Endurance**: < 50% of 1RM
**T**:
- **Strength**: 2-4 sets, 8-12 reps
- **Endurance**: ≤ 2 sets, 15-20 reps
**T**: Weight machines, free weights, or body weight exercise
49
From the ACSM, what are the Considerations for Exercis training (1) for those with Obstructive Lung Disease?
- **Interval training** may be an alternative to standard continuous endurance training **for those who have difficulty in achieving their target exercise intensity/volume due to dyspnea, fatigue, or other symptoms**. Several randomized, controlled trials and systematic reviews have found **no clinically important differences between interval or continuous training** protocols in exercise capacity, HRQOL, and skeletal muscle adaptations following training.
- **Intensity targets based on percentage of estimated HRmax may be inappropriate**, particularly in individuals with **severe** COPD where resting heart rate is often elevated and ventilatory limitations, as well as the effects of some medications, prohibit attainment of the predicted HRmax and thus its use in exercise intensity calculations. **Most individuals with COPD can accurately and reliably produce a dyspnea rating obtained from an incremental exercise test as a target to regulate/monitor exercise intensity**.
- The use of oximetry is recommended for the initial exercise training sessions to evaluate possible exercise-induced oxyhemoglobin desaturation and to identify the workload a which desaturation occurred
50
From the ACSM, what are the Considerations for Exercis training (2) for those with Obstructive Lung Disease?
- Maximizing pulmonary function using **bronchodilators** before exercise training in those with airflow limitation can reduce dyspnea and improve exercise tolerance.
- Inspiratory muscle weakness is a contributor to exercise intolerance and dyspnea in those with COPD. **Inspiratory muscle training (IMT) may prove useful in those unable to participate in exercise training** or can be used as an **adjunct** for those who participate in an exercise program. IMT improves inspiratory muscle strength and endurance, functional capacity, dyspnea, and QOL, which may lead to improvements in exercise tolerance in those with COPD and asthma.
- Individuals suffering from acute exacerbations of their pulmonary disease **should limit exercise until symptoms have subsided and rather focus on functional mobility**
51
From the ACSM, what are the Considerations for Exercis training (3) for those with Obstructive Lung Disease?
- Exercise for individuals with associated **Pulmonary Arterial Hypertension** should consider:
–Using ECG monitoring if there significant right ventricular dysfunction
–Using supplemental oxygen to avoid hypoxemia which can worsen pulmonary artery pressures due to vasoconstrictive processes
–Caution with higher-intensity exercise – particularly those involving the UE - that may increase intrathoracic pressures (e.g. through Valsalva maneuvers)
- Flexibility exercises may help overcome the effects of postural impairments that limit thoracic mobility and therefor lung function during activity
52
With COPD what is the FITT for Inspiratory Muscle Training? What should PTs consider with this principle?
– **F**: 3 day/week build to 6-7 days/week
– **I**: 30-40% of Maximal Inspiratory Pressure (1 RM), build toward 60-70%
– **T**: 15-30 min/day
– **T**: Threshold, *x*, etc.
Considerations:
* Reduce load back 30-40% in context of exacerbation
* Consider interval training if better tolerated
53
With Heart Failure, what takes place with Action Statement 7 with Inspriatory Muscle Training?
*For Patients with Class 2 and 3 HFrEF*
- Time: 30 min/day or less if using higher training intensity
(> 60% madximal inspriatory prssure)
- Intensity: > 30% MIP
- Frequency: 5 to 7 days/wk
- Duration: At least 8 to 12 weeks
54
# COPD Zones
What do Green Zones Indicate?
*All Clear*
- Able to do usual activities
- No new symptoms
- No chest pain
- Your usual meds are controlling your sympotms
55
# COPD Zones
What do Green Zones Mean?
- Your sx are under control
- Continue taking your meds as ordered
- Continue activity as tolerated
- Use pursed lip breathing as instructed
- Keep all doctor appointments
56
# COPD Zones
What do Yellow Zones Indicate?
*Caution*
- Increased cough and/or discolored sputum production
- Increased SOB with usual activity level
- Change in usual energy level: increase in either fatigue or restlessness
57
# COPD Zones
What do Yellow Zones Mean?
This is a **Warning**
- Sx may indicate that you need an adjustment of meds
- Should consult or see doctor within 24-48hrs
58
# COPD Zones
What do Red Zones Indicate?
*Medical Alert*
- Severe or unusual SOB (@ rest)
- Unrelieved chest pain
- Wheezing of chest tightness at rest
- Need to sit in chair to sleep if you don't normally
- New or increased confusion
59
# COPD Zones
What do Red Zones Mean?
**Emergency**
- You need to be evaluated by a doctor right away - NOW
- Go to nearest emergency room or call 911
60
What is the Hallmark of Asthma?
The Reversibility of airway obstruction following the use of bronchodilator medications
61
What is Asthma?
A Chronic inflammatory disorder of the airways where
**hyperresponsiveness and inflammation** are key
components and acute exacerbations due to **viral** or
**allergen** exposures can accumulate over time to induce
**airway remodeling**
62
What are the Characteristics of Asthma?
An “episodic” obstructive lung condition with periods of relatively normal lung function between episodes of **wheezing, dyspnea, chest tightness, and coughing**
63
During the Physical Exam, what breath sounds may we hear with those patients with Asthma?
Depends on severity, maybe diminished or absent during asthma attack, prolonged expiration
64
During the Physical Exam, what Adventitous sounds may we hear with those patients with Asthma?
likely wheeze, particularly during asthma attack, may also have rhonchi in the presence of mucus
65
During the Physical Exam, what Transmitted Voice sounds may we hear with those patients with Asthma?
None
66
During the Physical Exam, what Percussion Note may we hear with those with Asthma?
Resonant (Normal) to hyperresonant during severe asthma attack
67
During the Physical Exam, where may we find the trachea when observing those patients with Asthma?
In midline
68
What is the most important treatment for asthma management?
It involves the use of appropriate medications to educe inflammation, stabilize airways and relieve bronchospasm
69
# Exercis Testing and Prescription
Asthma Sx are often precipitated by what?
Exercise (i.e., exercise-induced bronchioconstriction {EIB}), Inhalation of cold air, and exposure to allergens or viral respiration infections
*Differentiation of EIB from exertional angina is performed by assessing the individual’s degree of difficulty in breathing (i.e. EIB would likely produce greater work of breathing compared to exertional angina)*
70
With Asthma, what should we consider with Exercise Test and Prescriptions?
- Consider HR effects of asthma control medications (e.g., when using HR zones for exercise prescription)
- Use of short-acting bronchodilators may be necessary before or after exercise to precent or treat EIB
- Peak-flow meters can be used as a guide for medication management and medical care
71
What is Bronchiectasis characterized by?
Irreversible dilation of one or more bronchi with chronic inflammation and infection
## Footnote
Associated with Cystic Fibrosis
72
What is the Etiology of Bronchiectasis?
Mostly idiopathic but is also found to occur as a complication of a prior lung infection or injury to the bronchial wall or it may be related to an underlying anatomic or systemic disease
73
What are 3 common mechanisms of Bronchiectasis that can lead to development of the permanent, pathological dilation and damage of the airways?
- Bronchial wall injury/structural weakness of bronchial walls
- Traction from adjacent lung fibrosis
- Bronchial lumen obstruction
74
With Bronchiectasis Physical Examination, what may we find with Auscultations?
| (Breathing sounds, Adventitious soudns, Mediate percussion)
**Breathing Sounds**:
- Bronchial (with episodes of pneumonia) ; Diminished or absent (with mucus plugging)
**Adventitious Sounds**: Crackles over involved lobes ; Rhonchi during mucus retention
**Mediate Percussion**
- Dullness
## Footnote
- It’s common for individuals with bronchiectasis to breathe very shallowly when their lungs are being auscultated to avoid triggering coughing episodes. As a result of shallow breathing, diminished breath sounds are detected in all lung fields
75
With Bronchiectasis Physical Examination, what MSK findings may we see?
Accessory muscle use and hypertrophy of accessory muscles, increased chest wall size, and kyphosis, as well as skeletal muscle weakness and endurance impairments
76
With Bronchiectasis Physical Examination, what may we find with Pulmonary Function Testing?
- Localized bronchiectasis show few or no abnormalities.
- In more widespread disease demonstrates abnormalities including a reduction in the FEV1, maximal voluntary ventilation, and an increase in the residual volume
77
What is the Goal of Bronctiechasis Management?
To reduce the number of exacerbations and improve QOL
78
With Bronchiectasis, what takes place during Interventions?
- Airway Clearance Techniques as needed
- Controlled breathing techniques coordinated with activity
- Strength training, especially quadriceps muscle strength and endurance
- Aerobic conditioning exercise
- Inspiratory muscle training to improve strength and endurance of accessory muscles
79
What does Cystic Fibrosis affect?
Affects every organ that has epithelial tissue
80
What is the Clinical Presentation with Cystic Fibrosis when its affecting the Pulmonary System?
Chronic airway obstruction and inflammation, thick tenacious
mucus, and recurrent bacterial infections
81
What is the Clinical Presentation with Cystic Fibrosis when its affecting the Intestines?
Thick mucus that interferes with nutrient absorption and results in malnourishment and low weight
82
What is the Clinical Presentation with Cystic Fibrosis when its affecting the Pancreas?
Exocrine pancreatic insufficiency, which affects both gastrointestinal function (fat maldigestion) and the growth and development of individuals with CF
83
What is the Clinical Presentation with Cystic Fibrosis when its affecting the Upper Airway?
Sinus Infection
84
What is the Clinical Presentation with Cystic Fibrosis when its affecting the Male Reproductive Tract?
Obstructive Azoospermia
85
What is the Clinical Presentation with Cystic Fibrosis when its affecting the Sweat Glands?
Elevated sodium chloride levels in sweat
86
How does Cystic Fibrosis present?
The **presentation** of the disease **differs among the different genetic mutations**, with some individuals presenting with severe involvment of the lungs, intestines and pancreas early on and therefore a more rapid deterioration over time, whereas other individuals may have a mild genetic strain and have less multiple organ involvement
87
What is the Primary Pathophysiologic event in CF?
Failure of the airways to clear mucus normally
88
With CF, what is mucus stasis, adhesions and obstructions responsible for?
For severe and unrelenting chronic bacterial infections
89
With CF, what happens as lung disease (chronic bacterial infection) progresses?
Submucosal glands hypertrophy, goblet cells become more numerous, and small airways often become completely obstructed by secretions. **Bronchiolectasis and finally bronchiectasis are the outcome of repeated obstructive infection cycles**
90
What are the Sx of CF?
1. Salty-tasting skin
2. Frequent lung infections
3. Wheezing and/or shortness of breath
4. Poor growth and slow weight gain despite a healthy appetite
5. Frequent greasy, bulky stools and/or difficult bowel movement
91
What will we find in the Physical Exam with those with CF?
- **Lung sounds** are often unremarkable, except for diminution in the intensity of the breath sounds, which correlates with the degree of hyperinflation present.
- **Adventitious breath sounds (e.g., crackles, wheezing)** are usually heard first over the upper lobes
- **Increased respiratory rate**
- **Digital clubbing** occurs in virtually all patients with CF, and its severity generally correlates with the severity of lung disease
92
What should be included in the PT for those with CF?
- Secretion clearance Techniques
-Postural drainage with percussion, shaking and vibration
-Acapella or Aerobike for airway clearence
-Positive expiratory pressure
-High frequency chest wall oscillations (the vest)
-Autogenic drainage
-Active cycle breathing
-Forced expiratory technique
- Controlled breathing Techniques
- Exercise, including endurance and strength training
- Thoracic stretching exercise
- Postural reeducation to avoid round-shouldered postures
93
What are the Exercise Considerations for **Mild** Lung Disease?
- > 80% FEV1, normal ventilatory responses, possible slight reductions in arterial O2 levels
- Recommend using same testing and training principles that would be used for a normal population
94
What are the Exercise Considerations for **Moderate** Lung Disease?
- FEV1 between 50-80%, exercise tolerance is limited by ventilation, possible SOB with ADLs or activities ~3-4 METs, mild-to-moderate hypoxemia at rest that worsens with exercise, may be restricting/modifying activity levels to prevent exacerbation of symptoms
- Exercise tolerance should be assessed with exercise test to assess for vitals and ventilatory responses
- Supplemental oxygen should be considered if there is exercise-induced hypoxemia
95
What are the Exercise Considerations for **Severe** Lung Disease?
- FEV1 < 50%, dyspneic with most daily activities, may require intermittent or continuous supplemental oxygen at rest or with activity, may have elevated CO2 levels and/or right ventricular dysfunction
- Exercise tolerance should be assessed with exercise test to assess for vitals and ventilatory responses
- Interval training should be considered to build toward more continuous forms of exercise that may translate into daily activates that require sustained effort
