Cardiovascular & Pulmonary Systems Flashcards

Question

# Obstructive Lung Disease - Clinical Definition **What is obstructive lung disease?**

Answer 1

***Obstructive lung disease*** is a pathological condition of the lungs that is characterized by reduced airflow due to an obstruction. Examples of obstructive lung diseases include: * Chronic obstructive pulmonary disease (COPD) (i.e., chronic bronchitis, emphysema) * Bronchiectasis * Cystic fibrosis * Asthma *_Reference:_* * *See "Specific NPTE Study Topics" Word doc.*

Answer 2

* Increased residual volume (i.e., “too much air in the lungs;” hyper-inflated lungs with loss of elastic recoil) * Increased airway resistance * Increased difficulty expiring air rapidly through the narrowed airways * Characterized by early inspiratory crackles upon auscultation * Digital clubbing due to hypoxemia *_Reference:_* * *See "Specific NPTE Study Topics" Word doc.*

Answer 3

* Patients with obstructive lung diseases tend to work harder to expire air because of the primary issue of increased airway resistance. It is therefore recommended that these patients optimize their breathing pattern by **expiring air slowly and deeply using relaxed pursed-lip breathing**. * _Rationale:_ Relaxed pursed-lip breathing decreases the velocity or flow rate at which the air travels through the airways, thereby decreasing airway resistance as well as increasing the amount of air expired out. Relaxed pursed-lip breathing also creates a back pressure that helps to keep the airways from prematurely collapsing during expiration. * Patients with obstructive lung diseases tend to experience an increase in the work of breathing because of overuse of their accessory inspiratory muscles (e.g., sternocleidomastoid, pectoralis minor) and the associated increase in energy and oxygen utilization to fuel those accessory inspiratory muscles. In conjunction with relaxed pursed-lip breathing, patients with **_mild obstructive lung diseases_** should be instructed to relax their accessory inspiratory muscles and **perform** **diaphragmatic breathing** (aka, *deep breathing*, *belly breathing*) **to reduce the work of breathing through increased use of the diaphragm during inspiration.** * _Note:_ Diaphragmatic breathing is NOT recommended for patients with moderate or severe obstructive lung diseases due to the structural changes in the shape of the diaphragm (i.e., low and flat diaphragm) from significant lung hyperinflation. * Patients with chronic airflow limitations (e.g., COPD) can adapt to baseline hypercapnia and thus can become dependent on their hypoxic drives (i.e., stimulation of ventilation through decreases in PaO2 levels) instead of rising PaCO2 levels to increase ventilation. As a result, **low-flow supplemental oxygen is usually administered to these patients to avoid abolishing their O2-dependent drive to breathe**. * _Note:_ When increasing the amount of supplemental oxygen delivered to these patients, monitor the patient's respiratory rate and breathing pattern. **An increase in PaO2 may reduce the ability of the hypoxic drive to “drive” ventilation for these patients, resulting in hypoventilation that further exacerbates hypercapnia and increases the risk of death.** *_References:_* * *_Pursed-lip breathing_* * *Goodman and Fuller (4th ed.), p.794 ("Pursed-lip breathing helps slow the respiratory rate and prevent airway collapse during exhalation.")* * *Frownfelter and Dean (5th ed.), p.359 ("Pursed-Lips Breathing")* * *_Diaphragmatic breathing_* * *Goodman and Fuller (4th ed.), p.794 ("Diaphragmatic breathing may be helpful to those with mild disease...")* * *Frownfelter and Dean (5th ed.), p.359 ("Considerations in Teaching Breathing Control to Patients with Primary Versus Secondary Pulmonary Dysfunction")* * *DMCC Lecture: Pulmonary Pathophysiology (slide 32)* * *_Hypoxic drive:_* * *Frownfelter and Dean (5th ed.), p.480 ("Patients with chronic airflow limitation can adapt to high PaCO2 levels and thus can become dependent on their hypoxic drives to breathe. Therefore lowflow supplemental oxygen is administered to these patients to avoid abolishing their O2-dependent drive to breathe.")* * *Goodman and Fuller (4th ed.), p.795 ("Some people with COPD retain carbon dioxide and have a depressed hypoxic drive requiring low oxygen levels to stimulate the respiratory drive.")* * *DMCC Lecture: Pulmonary Anatomy and Physiology (slide 65)* * *See "Specific NPTE Study Topics" Word doc.*

Answer 4

***Restrictive lung disease*** is a pathological condition of the lungs that is characterized by a limitation in lung expansion. Examples of restrictive lung disease include: * Pulmonary fibrosis * Atelectasis * Sarcoidosis * Pneumonia In addition to the progression of various lung diseases, restrictive lung disease can develop as a result of: * Structural abnormalities (e.g., kyphosis, scoliosis, chest wall injury or deformity) * Neurologic or neuromuscular disorders (e.g., Guillain-Barré syndrome, muscular dystrophy, traumatic brain injury, spinal cord injury, amyotrophic lateral sclerosis, myasthenia gravis) *_Reference:_* * *See "Specific NPTE Study Topics" Word doc.*

Answer 5

* Decreased residual volume (i.e., “too little air in the lungs;” hypo-inflated lungs) * Decreased lung compliance * Increased difficulty with inspiring air * Impaired respiratory movements because of abnormalities in the lung tissue (e.g., progressive scarring or fibrosis of the lungs), the pleura, the chest wall (e.g., chest wall injury or trauma), or the neuromuscular machinery (e.g., head or spinal cord injury) * Characterized by late inspiratory crackles upon auscultation * Digital clubbing due to hypoxemia *_References:_* * *See "Specific NPTE Study Topics" Word doc.* * *Goodman and Fuller (4th ed.), p.812 ("Clinical Manifestations")*

Answer 6

* Patients with restrictive lung diseases tend to work harder to inspire air because of the primary issue of limited lung expansion. It is therefore recommended that these patients optimize their breathing pattern by **inspiring air quickly using short, shallow breaths.** * ****Breathing in quickly is a compensation strategy for patients with restrictive lung diseases who have limited lung expansion. The strategy allows for patients to inspire an adequate volume of air. * A person with restrictive lung disease will be more adversely affected by the restriction in lung expansion in the supine position due to the additional weight of gravity on the chest wall when breathing. Routine positioning (especially upright positioning) is therefore required. *_References:_* * *See "Specific NPTE Study Topics" Word doc.* * *Goodman and Fuller (4th ed.), p.812 ("Special Implications for the Therapist")*

Answer 7

***Sarcoidosis*** is a systemic disease of unknown cause that is characterized by lumps called granulomas that are formed by groups of immune cells. These granulomas present diffusely throughout the body and can involve any organ in the body but most often involves the lungs and lymph nodes. In sarcoidsosis of the lungs, the granulomas can progress to pulmonary fibrosis and restrictive lung disease. *_References:_* * *Goodman and Fuller (4th ed.), p.840 ("Sarcoidosis")* * *Frownfelter and Dean (5th ed.), p.95 ("Sarcoidosis")*

Answer 8

***Pulmonary fibrosis*** (aka, *interstitial lung disease*) is a general term that refers to a variety of lung disorders in which ongoing epithelial damage leads to progressive scarring (fibrosis) of the lungs. Fibrosis irreversibly distorts and shrinks the lung lobe at the alveolar level and causes a marked loss of lung compliance, resulting in the limitation of lung expansion that is characteristic of restrictive lung diseases. Most cases of pulmonary fibrosis are idiopathic. *_Reference:_* * *Goodman and Fuller (4th ed.), p.812 ("Definition and Overview;" "Etiologic and Risk Factors"), 813 ("Pathogenesis and Clinical Manifestations")*

Answer 9

**_Age:_** 50-70 years **_Past medical history:_** * Recent active lung disease (e.g., cystic fibrosis) * Chest radiation therapy * Pulmonary fibrosis can develop in patients who are undergoing radiation of the chest as part of cancer treatment. As radiation dose increases, the frequency of pulmonary fibrosis increases. *_Reference:_* * *Goodman and Fuller (4th ed.), p.812 ("Eitologic and Risk Factors") 813 ("Special Implications for the Therapist")* * *asd*

Answer 10

* Progressive dyspnea * Nonproductive (dry) cough * _Pulmonary function tests_ * Decreased total lung capacity * Decreased forced vital capacity * Decreased forced expiratory volume in 1 sec (FEV1) * Restrictive lung disease signs and symptoms (\*see flashcard) *_Reference:_* * *Goodman and Fuller (4th ed.), p.812 ("Definition and Overview")*

Answer 11

***Cystic fibrosis (CF)*** is a congenital (inherited) genetic disorder of the exocrine glands that is primarily characterized by dehydrated and increased thickening of mucous gland secretions. In the lungs, the dehydration results in thickened dry and gooey secretions that (1) predispose the lungs to infection and (2) result in the mechanical obstruction of the airways that is characteristic of obstructive lung diseases. \*_Note:_ Cystic fibrosis is strongly associated with bronchiectasis, or the destruction of the bronchial walls. The recurrent bacterial infections combined with mucus hypersecretion in the lungs can lead to bronchiectasis. *_References:_* * *Goodman and Fuller (4th ed.), p.821 ("Definition and Overview"), 822 ("Pathogenesis")* * *Frownfelter and Dean (5th ed.), p.310 ("Cystic Fibrosis")*

Answer 12

* Chronic cough and purulent sputum production * Increased anterior-posterior (A-P) diameter of the chest (i.e., "barrel chest") due to hyperinflation of the lungs * Obstructive lung disease signs and symptoms (\*see flashcard) *_Reference:_* * *Goodman and Fuller (4th ed.), p.824 ("Pulmonary")*

Answer 13

***Pneumonia*** is an acute lung disorder that is characterized by inflammation, damage, and fibrosis of the lung parenchyma in response to offending organisms or agents (e.g., upper respiratory viral infection such as influenza) when the immune system is compromised. Pneumonia results in limitations in lung expansion that is characteristic of restrictive lung diseases. Pneumonia can be caused by: * Aspiration of food, fluids, or vomit (**aspiration pneumonia**) * Inhalation of toxic or caustic chemicals, smoke, dusts, or gases * Bacterial infection (**bacterial pneumonia**) * Viral infection (**viral pneumonia**) * Fungal infection (**fungal pneumonia**) *_Reference:_* * *Goodman and Fuller (4th ed.), p.779 ("Overview and Etiologic Factors"), 780 ("Pathogenesis")*

Answer 14

* Sudden and sharp pleuritic chest pain aggravated by chest movement * Decreased chest excursion on the affected side * Hacking, productive cough with rust-colored or green purulent sputum * Restrictive lung disease signs and symptoms *_References:_* * *Goodman and Fuller (4th ed.), p.780 ("Clinical Manifestations")*

Answer 15

***Asthma*** refers to chronic airway inflammation caused by airway hyperresponsiveness to allergens or irritants. The inflammation process associated with asthma primarily results in (1) intermittent attacks of bronchospasm, (2) mucosal edema, (3) hypertrophy of the mucosal membrane, and (4) production of thick, tenacious mucus. Asthma results in reduced airflow due to obstruction of the airways, which is characteristic of obstructive lung diseases. Asthma can be divided into two main types according to causative factors: * **Extrinsic** (*allergic* or *atopic*) **asthma** is the result of an allergy to specific triggers (e.g., pollen, dust, molds, smoke, automobile exhaust, or animal dander). * **Intrinsic** (*nonallergic*) **asthma** has no known allergic cause or trigger and is most often secondary to chronic or recurrent infections. *_References:_* * *Goodman and Fuller (4th ed.), p.799 ("Definition and Overview"), 800 ("Etiologic Factors")* * *DMCC Lecture: Pulmonary Pathophysiology (slide 40)*

Answer 16

* Sensation of chest constriction described as “chest tightness” or a sense of suffocation * Inspiratory and expiratory wheezing * Coughing may be initially dry but can become more productive of a thick, tenacious sputum. *_Reference:_* * *Goodman and Fuller (4th ed.), pp.801-802 ("Clinical Manifestations")*

Answer 17

* Patients with asthma should use their metered-dose inhaler before exercise in conjunction with a warm-up activity in order to avoid bronchospasm with higher workload exercise. * If a patient experiences an acute asthma attack, place the patient in an upright sitting position, and encourage diaphragmatic and pursed-lip breathing to reduce the work of breathing. If the client has a metered-dose inhaler available, provide whatever assistance is necessary for that person to self-administer the medication. * **Bronchodilators** are medications that stimulate beta (β) 2 receptors on the smooth muscle of the bronchi and bronchioles and subsequently induces relaxation of these structures. Patients usually take two doses (i.e., "puffs") when using the metered-dose inhaler. The first dose induces dilation of the bronchi, and the second dose dilates the bronchioles. *_Reference:_* * *Goodman and Fuller (4th ed.), p.805*

Answer 18

***Chronic obstructive pulmonary disease (COPD)*** refers to a prolonged and progressive airflow limitation and includes chronic bronchitis, emphysema, or a combination of the two. *_References:_* * *Goodmand and Fuller (4th ed.), p.789 ("Definition")* * *See "Specific NPTE Study Topics" Word doc.*

Answer 19

**_Gender:_** Male **_Age:_** 55-60 years **_Past medical history:_** * Current or past *\*\*_**tobacco smoker**\*_\** * Exposure to environmental irritants (e.g., air pollution, chemical and dust exposure, second-hand smoke)

Answer 20

***Chronic bronchitis*** refers to prolonged inflammation of the inner lining of the bronchi and bronchioles that results in swollen mucous membranes and the production of thick sputum secondary to mucus hypersecretion. The inflammation-induced changes obstructs the airways and results in the reduced airflow that is characteristic of obstructive lung diseases. *_Reference:_* * *Goodman and Fuller (4th ed.), p.796 ("Risk Factors and Pathogenesis")*

Answer 21

***Emphysema*** refers to abnormal permanent enlargement of air spaces distal to the terminal bronchiole, accompanied by destruction of their walls as well as airway collapse and trapping of inspired air due to the loss of elasticity in the distal airways. This results in the airflow limitation that is characteristic of obstructive lung diseases. * The most common type of emphysema is called **centrilobular emphysema**, which is characterized by inflammatory destruction of the respiratory bronchioles. *_References:_* * *Goodman and Fuller (4th ed.), p.796 ("Definition and Overview")* * *See "Specific NPTE Study Topics" Word doc.*

Answer 22

**_"Blue Bloater" (\*see image below)_** * ***Wheezing and sputum-producing cough***. Occurs as part of the body’s response to clear the airways of excessive mucus * ***Cyanosis***. Due to hypoxemia * ***Excessive weight gain***. Due to (1) impaired nutrition from neglect, and (2) decreased activity level due to the excessive energy cost needed to complete activities of daily living * ***Hypercapnia.*** Due to obstruction of the airways that results in a decrease in alveolar ventilation and a subsequent increase in PaCO2 levels (i.e., increased CO2 retention) (\*see Goodman and Fuller [4th ed.], p.796 ["Clinical Manifestations"]) * ***Frequent infections***. Due to mucus hypersecretion and impaired ciliary removal of the excess mucus * ***Chronic cor pulmonale***. Due to pulmonary arterial hypertension caused by hypoxemia and the associated vasoconstriction of the pulmonary arterioles * ***Peripheral edema***. Due to chronic cor pulmonale *_Reference:_* * *See "Specific NPTE Study Topics" Word doc.*

Answer 23

_**"Pink Puffer" (\*see image below)**_ * ***Excessive weight loss and muscle wasting***. Due to impaired nutrition, increase in tumor necrosis factor-α production (\*see Goodman and Fuller [4th ed.], p.728), and increased energy cost to complete the work of breathing due to significant reliance on the accessory inspiratory muscles * Patient will often be in the sitting tripod position in order to maximize use of the accessory inspiratory muscles. * ***Pink complexion*** (among white individuals). Due to having normal to near-normal PaCO₂ and PaO₂ levels as compared with a patient with chronic bronchitis. May also be due to the increased effort required to complete the work of breathing * Patients with emphysema have relatively normal arterial blood gas values because of compensatory hyperventilation via the pursed-lip breathing pattern. * ***Pursed-lip breathing pattern and hyperventilation***. Occurs as a way to “blow off excess CO₂” (i.e., the excessive trapping of air within the lungs) and decrease the elevated level of PaCO₂ * ***“Barrel-chest” appearance***. Due to excessive trapping of air within the lungs that eventually cause lung hyperinflation (\*see DMCC lecture on pulmonary pathophysiology [slide 20]) * Can be associated with ***decreased or absent breath sounds*** due to severe hyperinflation of the lungs (\*from Frownfelter and Dean [5th ed.], p.206 ["Abnormal Breath Sounds"]) *_Reference:_* * *See "Specific NPTE Study Topics" Word doc.*

Answer 24

***Atelectasis*** refers to the partial collapse of normally expanded and air-filled lung parenchyma that involves all or part of the lung. Atelectasis results in limtations in lung expansion, which is characteristic of restrictive lung diseases. *_Reference:_* * *See "Specific NPTE Study Topics" Word doc.*

Answer 25

**_Past medical history:_** * Prolonged bed rest in the supine position and immobilization associated with hospitalization or severe illness * Hypoventilation, which decreases the secretion of surfactant as well as ventilation of the gravity-dependent lung parenchyma (e.g., alevoli) * Physical compression of the lung tissues (e.g., obesity—compression of the lungs by excessive abdominal weight when in supine)

Answer 26

* ***Reduced or absent breath sounds*** over the involved area * Due to reduced or absent ventilation of the lung secondary to hypoventilation * ***Whispered pectoriloquy*** over the involved area (i.e., increased resonance when whispering "one, two, three" or "nine, nine, nine") (\*see Goodman and Fuller [4th ed.], p.795; Frownfelter and Dean [5th ed.], p.207) * Due to increase in lung density secondary to significant collapse of the involved lung * ***Chest X-ray: Increased density*** ***over the involved areas*** ***with a*** ***shift of the trachea and mediastinum toward the collapsed lung tissue*** ****** *_Reference:_* * *See "Specific NPTE Study Topics" Word doc.*

Answer 27

***Bronchiectasis*** is a progressive condition characterized by destruction of the bronchial walls and the development of abnormal dilation and distortion of medium-sized bronchi and bronchioles as the result of chronic inflammatory changes associated with infection. Other inflammatory changes such as the increase in mucus production, airway plugging, and bronchospasm cause the reduced airflow that is characterstic of obstructive lung diseases. \*_Note:_ Bronchiectasis is strongly associated with cystic fibrosis (\*see flashcard). Cystic fibrosis causes half of all cases of bronchiectasis. *_Reference:_* * *See "Specific NPTE Study Topics" Word doc.*

Answer 28

* Persistent coughing with large amounts of purulent sputum production (worse in the morning) * The breath and sputum may become foul-smelling with progression of bronchiectasis. *_Reference:_* * *See "Specific NPTE Study Topics" Word doc.*

Answer 29

Patients with neurological, neuromuscular, or musculoskeletal conditions that are associated with respiratory muscle weakness (e.g., GBS, DMD) will have weak, ineffective coughing mechanisms and inadequate control of respiratory secretions. Appropriate interventions to improve airway clearance include manual-assistive cough techniques (e.g., costophrenic assist) and other airway clearance techniques. **Costophrenic assist** is a manual technique that actively assists a patient with forceful expiration and coughing through manual faciliation of the movements of the abdomen and intercostals when these respiratory muscles are weak or paralyzed. (For information about how to perform the costophrenic assist, see Frownfelter and Dean [5th ed.], pp.342-343.) *_References:_* * *See Youtube video, "Costophrenic assist" (https://www.youtube.com/watch?v=qgVHfWS0t7E)* * *Physiopedia: Assisted Coughing (https://www.physio-pedia.com/Assisted\_Coughing)*

Answer 30

***Prophylactic respiratory care*** (aka, *bronchopulmonary hygiene*) refers to a therapeutic regimen that helps to prevent the development of respiratory complications as a result of immobilization. Prophylactic respiratory care in physical therapy can include: * ***Postural drainage.*** Frequent position changes associated with postural drainage helps to promote drainage of secretions (e.g., mucus plugs) in all lung segments. * Postural drainage is one of various airway clearance techniques that can be used to improve clearance of the airways. * ***Upright positioning and mobilization.*** The upright position (i.e., sitting, standing) promotes lung and chest wall expansion by reducing the effects of gravity on chest and lung compliance. As a result, lung volumes and capacities are maximized in the upright position. The upright position also allows for optimal use of the abdominal muscles to assist with forceful expiration as during coughing. Mobilization (especially early ambulation) helps to promote drainage in all lung segments. * _Note:_ The effect of gravity on the body in the supine position forces the patient to work harder to recruit the abdominal muscles when coughing. In the upright position, the abdominal muscles are more easily recruited because the effects of gravity are lessened (i.e., it is easier to perform trunk flexion in sitting or standing as compared with supine). * ***Coughing***. Patients who have increased secretions and fluids that the mucociliary escalator cannot clear on its own should be instructed on coughing as a means to facilitate clearance of the airways. Coughing will help clear the airways down to the segmental bronchi. (\*For more details, see Frownfelter and Dean [5th ed.], pp.337-341). * _Note:_ To minimize postoperative pain during deep-breathing and coughing exercises, teach the patient the pillow splinting technique. The technique involves holding a pillow firmly over the incision. Pain is reduced with the pillow splinting technique because the incision and sensitive skin surrounding the incision are prevented from moving when completing deep-breathing or coughing exercises. * ***Deep breathing***. Deep breathing is beneficial because it promotes the ciliary clearance of secretions, stabilizes the alveoli by redistributing surfactant, and permits collateral ventilation of the alveoli through the Kohn pores that helps re-expand collapsed alveoli. Deep breathing can be accomplished through use of an incentive spirometer or instruction on breath control techniques (e.g., diaphragmatic breathing). * _Note #1:_ Deep breathing helps to loosen pulmonary secretions, making it easier for the secretions to be removed by the mucociliary escalator. * _Note #2:_ Because the surfactant in the alveoli will begin to disappear within 24 to 36 hours, it is very important that patients who are at high-risk for developing atelectasis be educated on deep breathing. * ***Mechanical suctioning*** (e.g., nasotracheal suctioning) can be used as a last resort for clearing the airways when all other options are not effective. *_References:_* * *See "Specific NPTE Study Topics" Word doc.* * *For more about incentive spirometry, see Frownfelter and Dean (5th ed.), p.496; MedlinePlus: Using an incentive spirometer (https://medlineplus.gov/ency/patientinstructions/000451.htm).*

Answer 31

***Respiration*** refers to the exchange of oxygen and carbon dioxide between the organism and the environment via the lungs. In other words, respiration refers to the actual gas exchange that occurs in the alveoli. ***Ventilation*** refers to the mechanical movement of air between the atmosphere and the alveoli. In other words, ventilation refers to the movement of air through the lungs that is basic to respiration. *_Reference:_* * *See "Specific NPTE Study Topics" Word doc.*

Answer 32

***Digital clubbing*** (aka, *clubbing*) refers to thickening and widening of the terminal phalanges of the fingers and toes. Digital clubbing results in a painless, club-like appearance recognized by the loss of the angle between the nail and the nail bed. Lung diseases (e.g., chronic obstructive pulmonary disease [COPD], pulmonary fibrosis) are a major cause of clubbing due to impaired tissue perfusion secondary to hypoxemia. *_Reference:_* * *Goodman and Fuller [4th ed.], pp.775-776 ("Clubbing")*

Answer 33

***Postural drainage*** (aka, *bronchial drainage*) is a passive technique in which the patient is placed in positions that allow gravity to assist with the drainage of secretions from specific bronchopulmonary segments. Postural drainage is accomplished by positioning the patient so that the angle of the lung segment to be drained allows gravity to have its greatest effect. The patient should be encouraged to take deep breaths and cough after each position and, if possible, again after the treatment is completed. *_Reference:_* * *See "Specific NPTE Study Topics" Word doc.*

Answer 34

* ***Post-neurosurgery.*** For patients with recent craniotomies, Trendelenberg (“head-down”) bed positions are contraindicated due to the increase in intracranial pressures in those positions. * ***Potential decrease in SpO2*** * ***Neonates***. Avoid placing neonates in the Trendelenberg (“head-down”) bed position. The position can increase the likelihood of the neonate experiencing gastroesophageal reflux. * ***End-stage lung disease***. Due to risk for hemoptysis, or coughing up of blood *_Reference:_* * *Frownfelter and Dean (5th ed.), p.315 ("General Precautions and Contraindications to Postural Drainage Positioning"), 316 (Box 21-2)*

Answer 35

*\*_Note:_ The Trendelenburg (heads-down) position is the ideal position when completing postural drainage of the inferior lobes. Alternative positions include elevating the pelvis above the level of the thorax using a therapy ball, pillows, and so on.* **_Right inferior lobe (\*acronym for bronchopulmonary segments is "LAMPS")_** * **_L_**ateral: Trendelenburg, left-sidelying * **_A_**nterior: Trendelenburg, supine * **_M_**edial: Trendelenburg, right-sidelying * **_P_**osterior: Trendelenburg, prone * **_S_**uperior: Prone only **_Left inferior lobe (\*acronym for bronchopulmonary segments is "ALPS")_** * **_A_**nterior: Trendelenburg, supine * **_L_**ateral: Trendelenburg, right-sidelying * **_P_**osterior: Trendelenburg, prone * **_S_**uperior: Prone only *_Reference:_* * *See "Specific NPTE Study Topics" Word doc.*

Answer 36

To drain the apical segments of the superior lobes, have the patient positioned in long-sitting. Leaning forward will also facilitate drainage of the apical segments. *_Reference:_* * *See "Specific NPTE Study Topics" Word doc.*

Answer 37

***Percussion*** (aka, *chest clapping*) is a manual technique that involves applying a rhythmical force against the thorax with cupped hands for the purpose of dislodging or loosening bronchial secretions from the airways so they may be removed by suctioning or expectoration. The proposed mechanism of action of percussion is the transmission of a wave of energy through the chest wall into the lung. This wave loosens secretions from the bronchial wall and moves them proximally, where ciliary motion and cough (or suction) can remove them. This technique is performed during both the inspiratory and expiratory phases of breathing and has been shown to be effective in secretion removal when combined with postural drainage. *_Reference:_* * *Frownfelter and Dean (5th ed.), pp.315-316 ("Percussion")*

Answer 38

* ***Post-operative pain***. Percussion is not well tolerated by many patients postoperatively without adequate pain control. * ***Osteoporosis*** ***and coagulopathy***. Percussion is contraindicated because of (1) risk of fracturing the weak, fragile osteoporotic bones; and (2) risk for excessive bleeding due to impaired blood-clotting ability. * ***Potential fall in SpO2*** * Can be eliminated with concurrent thoracic expansion exercises and pauses for breathing control *_Reference:_* * *Frownfelter and Dean (5th ed.), p.313 (Box 21-1)*, *317 ("Advantages and Disadvantages of Percussion")*

Answer 39

Vibration and shaking are manual techniques that are used in conjunction with postural drainage to facilitate removal of secretions from the airways. Vibration and shaking are only performed during the expiratory phase of breathing. ***Vibration*** involves delivering a gentle, high-frequency force and pressure to the chest wall through a sustained co-contraction of the caregiver’s upper extremities. ***Shaking*** is more vigorous than vibration and involves delivering a bouncing maneuver (aka, “rib springing”) through a concurrent, compressive force to the chest wall. *_Reference:_* * *Frownfelter and Dean (5th ed.), p.317 ("Vibration and Shaking")*

Answer 40

* Shaking or vibration may be better tolerated than percussion, especially in the postsurgical patient. * ***Osteoporosis and coagulopathy***. Vibration and shaking are contraindicated because of (1) risk of fracturing the weak, fragile osteoporotic bones; and (2) risk for excessive bleeding due to impaired blood-clotting ability. * ***Potential fall in SpO2*** * Can be eliminated with concurrent thoracic expansion exercises and pauses for breathing control *_Reference:_* * *Frownfelter and Dean (5th ed.), p.313 (Box 21-1), 317 ("Advantages and Disadvantages of Percussion"), 318 ("Advantages and Disadvantages of Vibration and Shaking")*

Answer 41

***Cardiovascular rehabilitation*** (aka, *cardiac rehab*) is a comprehensive interdisciplinary management program that includes physical activity and exercise, education, and behavioral change designed to improve the physical and emotional status of individuals with cardiovascular dysfunction or their risk factors. The goal of cardiac rehab is to maintain or return an individual with cardiovascular and pulmonary dysfunction to full participation in life with a high level of life satisfaction. _Cardiac rehab consists of four phases:_ * **Phase I** refers to inpatient care (medical and surgical) and a predischarge exercise test. * \*\****_Cardiovascular training is not an objective during phase I._***\*\* Examples of phase I objectives include (1) minimizing deconditioning effects of bedrest and relative inactivity; and (2) patient education concerning heart disease, risk factors, exercise and home program, and self-monitoring. * **Phase II** refers to a supervised exercise program lasting 3 to 6 months. Phase II usually takes place in a community center where the patients can be monitored during exercise and education by the rehabilitation professions can be ongoing. * The focus on cardiovascular training begins in Phase II. * **Phase III** refers to the maintenance phase, during which the patient is responsible for exercising mostly at home. This phase lasts from 6 to 12 months. * **Phase IV** refers to an unsupervised community program. The patient is usually ready for this phase within 9 to 12 months. *_References:_* * *Frownfelter and Dean (5th ed.), p.378 (Box 24-1), 393-394 ("Phases")* * *DMCC Lecture: Cardiac Rehabilitation*

Answer 42

* Diastolic blood pressure (DBP) ≥ 110 mm Hg * Decrease in systolic blood pressure (SBP) \> 10 mm Hg during exercise with increasing workload * Significant ventricular or atrial arrhythmias with or without associated signs/symptoms * Second- or third-degree AV block * Signs/symptoms of exercise intolerance including angina, marked dyspnea, and electrocardiogram (ECG) changes suggestive of ischemia *_Reference:_* * *ACSM (10th ed.), p.227 (Box 9.3)*

Answer 43

The ***carotid pulse*** can be palpated on either side of the anterior neck between the trachea and the medial border of the sternocleidomastoid (SCM) muscle. The SCM muscle can be identified by having the patient tilt the head to one side (i.e., cervical lateral flexion) and turn the head to the opposite side (i.e., cervical rotation). The muscle is palpated from its origins at the mastoid process and superior nuchal line to its insertions at the manubrium of the sternum and the medial aspect of the clavicle (i.e., sternal end of the clavicle). *_Reference:_* * *Physical Rehabilitation, p. 49, Box 2.4* * *Folder: Anatomy → "Overview of Muscle OINAs" Word doc*

Answer 44

Repeated palpation of the carotid pulse places excessive manual pressure on the carotid sinus baroreceptors, causing stimulation of the carotid sinus baroreceptors and subsequently a reflexive decrease in pulse rate (i.e., heart rate) and arterial blood pressure. The reflexive decrease is due to activation of the baroreceptor reflex. Physiologically, the baroreceptor reflex is activated as follows: increased blood volume (as during exercise) → increased blood pressure → increased stretch and stimulation of the arterial baroreceptors → decreased pulse rate (i.e., heart rate) and arterial blood pressure. *_References:_* * *Physical Rehabilitation, p. 49, Box 2.4* * *Specific NPTE Study Topics (Word doc): "Review of Concepts" → “Baroreceptor Reflex" section*

Answer 45

During a cool-down period, the skeletal muscle pump is used to facilitate venous return and prevent the venous pooling that precedes post-exercise hypotension. When a cool-down period is not completed, decreased venous return as well as increased venous pooling and increased risk for developing post-exercise hypotension occurs as a result of the absence of the skeletal muscle pump. Individuals are also more likely to complain of experiencing muscle stiffness (i.e., “muscle tightness”), which is caused by the buildup of metabolites in the blood during venous pooling. *_Reference:_* * *See "Specific NPTE Study Topics" Word doc.*

Answer 46

* **_Heart rate (HR):_** 60-100 beats per minute * **_Respiratory rate (RR):_** 12-20 breaths per minute * **_Blood pressure (BP)_** * Systolic BP less than 120 mm Hg * Diastolic BP less than 80 mm Hg * **_Oxygen saturation (SpO2):_** 95-100% * It is clinically acceptable to maintain oxygen saturation at 90% or higher. A drop below 90% is of concern. * _Note:_ Because oxygen consumption increases proportionately with exercise, a patient may desaturate if oxygen transport is compromised to the extent that it is unable to compensate or respond appropriately to increased demand. For example, if a patient is on oxygen at rest and the SpO2 is 90%, he or she may desaturate because the red blood cells need to give up more oxygen to supply the exercising muscle. *_References:_* * *O'Sullivan et al. (7th ed.), p.29 (Table 2.1), 33 ("Observation")* * *Frownfelter and Dean (5th ed.), p.674 ("Special Monitoring Considerations for Patients on Oxygen")*

Answer 47

***Compartment syndrome*** (aka, *myofascial compartment syndrome*) is a condition in which the circulation within a closed fascial compartment is compromised by an increase in interstitial pressure within the compartment. This causes necrosis of muscles and nerves and eventually of the skin because of excessive swelling. ***Acute compartment sydrome*** refers to the abrupt and recent onset of compartment syndrome, usually following a traumatic event such as a bone fracture. Acute compartment syndrome is a ***\*\*_medical emergency_\*\**** because of the potential for permanent loss of function or limb if the condition is left untreated. Patients with acute compartment syndrome require immediate surgical intervention (i.e., emergent fasciotomy that allows for surgical decompression of the involved fascial compartment). *_References:_* * *Paz et al. (5th ed.), p.189 ("Compartment Syndrome")* * *See "Specific NPTE Study Topics" Word doc.*

Answer 48

***Traumatic events*** (e.g., fractures, crush injuries, penetrating injuries) * Fractures of long bones such as the tibia, ulna, and radius are the most common cause. * _Rationale:_ Fractures and other traumatic events can cause excessive bleeding and subsequently increase the interstitial pressure within the fascial compartment. *_Reference:_* * *See "Specific NPTE Study Topics" Word doc.*

Answer 49

***Circumferential burn injuries*** * _Rationale:_ Swelling associated with a burn injury (aka, burn edema) occurs as a result of the leakage of fluid from damaged blood vessels into the surrounding tissues. Burn edema can increase the interstitial pressure within the fascial compartment. ***Excessively constrictive circumferential wraps, dressings, cast, or other unyielding immobilizer*** * _Rationale:_ External compression that is excessive can reduce the volume capacity of the fascial compartment and subsequently increase the interstitial pressure within the compartment. *_Reference:_* * *See "Specific NPTE Study Topics" Word doc.*

Answer 50

**_The five "P's":_** 1. ***Pain*** * Sharp, deep, and throbbing pain that is disproportionate to that expected from the injury * Passive stretching of the muscles within the affected compartment increases the pain. * The involved extremity is tense and tender when palpated. 2. ***Paresthesia*** * Occurs distal to the affected fascial compartment * Can progress to a loss of sensation 3. ***Pulselessness*** of the peripheral pulses 4. ***Pallor***, indicating tissue ischemia * Pallor can be associated with observation of reduced perfusion of the distal extremity during capillary refill test. * The **capillary refill test** involves squeezing the nail bed of the toes and noting the amount of time it takes for the pink color to return to the nail bed. Capillary refill is delayed if the pink color does not return to the nail bed within 2 seconds after release of the pressure (\*from Magee [6th ed.], p.1112). 5. ***Paralysis*** of muscles within the involved fascial compartment * _Anterior (volar) compartment of the forearm_ * _Muscles:_ Pronator teres, flexor carpi radialis, palmaris longus, flexor carpi ulnaris, flexor digitorum superficialis, flexor digitorum profundus, flexor pollicis longus, and pronator quadratus * _Nerve:_ Median nerve * _Exceptions:_ Flexor carpi ulnaris and the medial head of the flexor digitorum profundus are innervated by the ulnar nerve. Flexor pollicis longus and pronator quadratus are innervated by the anterior interosseous nerve, a branch off of the median nerve. * _Arterial supply:_ Radial and ulnar arteries * _Anterior compartment of the lower leg_ * _Muscles:_ Tibialis anterior, fibularis tertius, extensor digitorum longus, and extensor hallucis longus * _Nerve:_ Deep fibular nerve * _Arterial supply:_ Anterior tibial artery * _Deep posterior compartment of the lower leg_ * _Muscles:_ Tibialis posterior, popliteus, flexor digitorum longus, flexor hallucis longus * _Nerve:_ Tibial nerve * _Arterial supply:_ Primarily the posterior tibial artery **_Other signs:_** In severe acute compartment syndromes, other objective signs include a swollen extremity with smooth, shiny, or red skin. If acute compartment syndrome is left untreated or is inadequately treated, the muscles and nerve undergo ischemic necrosis, and a limb contracture usually follows (e.g., Volkmann contracture). * ***Volkmann contracture*** (aka, *Volkmann ischemic contracture*) is associated with anterior (volar) compartment syndrome of the forearm and is the result of the replacement of necrotic muscle and nerve tissue with fibrous tissue. Volkmann contracture is a permanent flexion contracture of the wrist and fingers, resulting in a claw-like appearance of the hand. *_References:_* * *See "Specific NPTE Study Topics" Word doc.* * *Paz et al. (5th ed.), p.189 ("Compartment Syndrome")* * *Moore et al. (8th ed.), p.217 (Table 3.10)*

Answer 51

* Elevation of the affected limb must be discontinued, and the limb should be placed no higher than the heart level. * Excessive elevation of the affected limb will allow gravity to further decrease arterial blood flow and subsequently exacerbate the tissue ischemia. * Circumferential wraps, dressings, cast, or any other unyielding immobilizer must be removed to reduce the excessive compression on the extremity. * Following emergent fasciotomy, be aware of the patient's ROM precautions. *_Reference:_* * *Paz et al. (5th ed.), p.189 ("Physical Therapy Considerations")*

Answer 52

***Heart failure (HF)*** refers to a condition in which the heart is unable to pump enough blood to supply the body’s needs (i.e., “low-output problem”). Failure may occur on both sides of the heart or may predominantly affect the right or left side. * Strictly classified, **left-sided heart failure** is referred to as **congestive heart failure (CHF)**. Congestive heart failure occurs when the left ventricle is unable to adequately pump blood forward to the body (\*think impairment in forward blood flow from the heart). * **Right-sided heart failure** occurs when the right ventricle is unable to adequately pump blood to the lungs (\*think back-up of blood). In contrast to cor pulmonale, right-sided heart failure indicates that the underlying cause of the condition is a cardiac pathology (e.g., left-sided heart failure, vascular dysfunction, congenital heart disease). * **Biventricular heart failure** occurs when both sides of the heart are unable to adequately pump blood. Biventricular heart failure usually occurs as a progression of left-sided heart failure that eventually involves the right side of the heart. Biventricular heart failure can present with signs and symptoms of both left-sided and right-sided heart failure. *_Reference:_* * *See "Specific NPTE Study Topics" Word doc.*

Answer 53

* ***Hypertension, coronary artery disease, diabetes mellitus*** * Hypertension that is either idiopathic (i.e., no known cause) or due to a condition that narrows the lumen of arterial vessels (e.g., atherosclerosis from coronary artery disease or diabetes mellitus) increases the work the ventricles must do to eject blood (i.e., increased afterload). * ***Cardiac ischemia or myocardial infarction*** * Structural damage to the myocardium due to decreased coronary blood flow (e.g., cardiac ischemia) or death of myocardial tissue (e.g., myocardial infarction) causes either an impairment or loss of the ventricle’s ability to contract and eject blood. As a result, more blood remains in the ventricle at the end of each contraction (i.e., increased end-diastolic volume). *_Reference:_* * *See "Specific Study Topics" Word doc.*

Answer 54

* **_General_** * ***Tachycardia***. Due to compensatory activation of the sympathetic nervous system to maintain normal cardiac output * **_Left-sided heart failure (aka, congestive heart failure)_** * ***Pulmonary edema (aka, pulmonary congestion).*** Due to backup of blood from the left ventricle to the pulmonary veins in the lungs * ***Dyspnea***. Due to the stimulation of a reflex response caused by pulmonary edema * ***Coughing up of pink and frothy sputum***. Due to blood and fluid in the lungs as a result of pulmonary edema * ***Fatigue and muscle weakness***. Due to decrease in flow of oxygenated blood to the body, especially skeletal muscle * **_Right-sided heart failure_** * ***Peripheral edema***. Due to backup of blood into the systemic venous vessels --\> venous pooling --\> increased filtration of fluids into the interstitial space. The resultant edema is usually symmetric and occurs in the dependent or peripheral parts of the body (especially the lower extremities—e.g., legs, feet), where venous pressure is the highest. * May present as pitting edema * ***Jugular vein (venous) distension***. Characterized by bulging of the jugular veins * ***Abdominal pain***. Secondary to enlargement of the liver as the liver becomes congested with venous blood (\*note that the liver is most susceptible to venous congestion because the hepatic veins are located most proximally along the inferior vena cava) * May be associated with right-upper quadrant pain. (Note that the right-upper quadrant contains the liver.) * Can progress to ascites * ***Cyanosis*** (especially of the nail beds). Due to venous congestion and subsequent reduction in peripheral blood flow

Answer 55

**_General_** * ***Education on upright positioning*** (e.g., supine with head of bed elevated to 60-90 degrees, upright sitting) ***with legs in a dependent position as much as possible*** * Supine positions can exacerbate the signs and symptoms of heart failure by increasing venous return. The position described above helps to decrease venous return, alleviating signs and symptoms. **_Left-sided heart failure (aka, congestive heart failure)_** * ***Education on tripod positions in sitting or standing*** to facilitate use of accessory inspiratory muscles (especially the pectoralis minor) and decrease severity of dyspnea **_Right-sided heart failure_** * ***Monitor for signs of increasing peripheral edema.*** * Circumferential girth measurements and pitting edema assessments of the lower extremities, especially the legs and feet *_Reference:_* * *See "Specific NPTE Study Topics" Word doc.*

Answer 56

* The ***6-Minute Walk Test (6-MWT)*** or ***2-Minute Walk Test (2-MWT)*** examines walking endurance and exercise (aerobic) capacity as individuals cover as far a distance as possible over 6 minutes or 2 minutes, respectively. * The ***10-Meter Walk Test (10-MWT)*** examines walking speed (aka, gait velocity, gait speed) as individuals walk 10 meters (32.8 feet) without assistance. * The ***Timed-Up-And-Go (TUG)*** test examines fall risk. The test evaluates time (in seconds) required for individuals to rise from chair, walk 3 meters, turn around, walk back to the chair, and sit down. * The ***2-Minutes Step Test*** (aka, *2-Step Exercise Test*) examines endurance and exercise (aerobic) capacity and is the clinical standard for assessing exercise-induced ischemia. In this test, the subject is asked to step in place for 2 minutes. * ***Maximum VO2 assessment*** examines the maximum rate of oxygen consumption as measured during incremental exercise. * ***VO2 max treadmill test*** examines functional cardiovascular capacity*.* * A ***submaximal exercise test on a cycle ergometer*** estimates VO2 max and assesses aerobic power. ** *_References:_* * *O'Sullivan et al. (7th ed.), pp.246-247 (Table 7.9)* * *See "Specific NPTE Study Topics" Word doc.*