Ch 9 - Pulmonary Rehabilitation Flashcards
What does exercise cause regarding oxygenation?
Inc arterial venous oxygen (AVO2) difference by increasing oxygen extraction from arterial circulation
What are benefits of pulmonary rehab?
Inc exercise tolerance, work output, mech efficiency
Red dyspnea and RR
Inc ambulation capacity
Dec hosp rates
Which patients benefit the most from pulmonary rehab regarding exercise limitation?
Respiratory limitation of exercise at 75% of predicted maximum O2 consumption
Which patients benefit the most from pulmonary rehab regarding obstructive airway disease?
Forced Expiratory Volume in 1 second (FEV1) <2,000 mL or an FEV1/FVC (Forced Vital Capacity) ratio <60%
Which patients benefit the most from pulmonary rehab regarding restrictive airway disease?
Restrictive lung disease or pulmonary vascular disease with carbon monoxide diffusion capacity <80% of predicted value
What is Moser Classification 1?
Normal at rest
Dyspnea on strenuous exertion
What is Moser Classification 2?
Normal ADL performance
Dyspnea on stairs/inclines
What is Moser Classification 3?
Dyspnea with certain ADLs
Able to walk 1 block at slow pace
What is Moser Classification 4?
Dependent with some ADLs
Dyspnea with minimal exertion
What is Moser Classification 5?
Housebound
Dyspnea at rest
Assistance with most ADLs
What do central chemoreceptors monitor?
Hypercarbia in CSF
What do peripheral chemoreceptors monitor?
Carbon dioxide, oxygen, and pH levels in the blood
What is the primary muscle of inspiration and its innervation?
Diaphragm
Phrenic nerve
What are accessory muscles of inspiration?
SCM Trapezius Pectoralis major External intercostals Scalene muscles
What are active muscles of expiration?
Typically passive
Abdominal
Internal intercostals
What is VO2 max?
Max volume of O2 that can be utilized in 1 minute during maximal or exhaustive exercise
How is VO2 max measured?
Milliliters of oxygen used in 1 min/kg of body weight
How is VO2 max calculated?
VO2 max = (HR × SV) × AVO2 difference
What is COPD characterized by?
Inc airway resistance due to bronchospasm, which may result in air trapping, low maximum mid-expiratory flow rate, and normal to increased compliance
How can hypoxemia result from COPD?
Possible perfusion-ventilation mismatching
How can COPD present clinically?
Inc airway resistance
Impaired expiratory airflow
Respiratory muscle fatigue
Flattening of the diaphragm seen on chest x-ray due to increased total and residual lung volumes
What is the MCC of COPD?
Cigarette smoking
What is chronic bronchitis?
Chronic mucus hypersecretion and respiratory infections as a result of tracheobronchial mucous gland enlargement
Describe mucus production in chronic bronchitis.
> 100 mL of sputum/day for >3 months, for at least 2 consecutive years
What is emphysema?
Distention of air spaces distal to the terminal nonrespiratory bronchioles with destruction of alveolar walls
What therapy improves mortality in hypoxic patients?
Oxygen
What is Cystic Fibrosis?
AR dz involving the chloride ion channels found in exocrine glands
What causes respiratory failure in Cystic Fibrosis?
Failure to adequately remove secretions from the bronchioles, resulting in widespread bronchiolar obstruction and subsequent bronchiectasis, overinflation, and infection
What does exercise cause in Cystic Fibrosis?
Inc sputum expectoration
Inc ciliary beat with improved mucous transport
Describe exercise limitation with FEV1 between 2-3L.
Mild exercise limitation (able to walk significant distances, but not at high speed)
Describe exercise limitation with FEV1 between 1-2L.
Mod degree of exercise impairment (intermittent rest periods are required to walk significant distances or to climb stairs)
Describe exercise limitation with FEV1 <1L.
Severe exercise impairment (very short distance ambulation)
What is Restrictive lung disease?
Impaired lung ventilation due to loss of normal elastic recoil of the lungs or chest wall
What are causes of Restrictive lung disease?
- Intrinsic lung diseases (inc stiffness of lung tissue)
- Extrinsic lung diseases (inc stiffness of chest wall)
- Neuromuscular diseases
- Thoracic deformities
- Pleural disease
- AS
- Cervical SCI
- Obesity
- Surgical removal of lung tissue
What are pulmonary complications of Duchenne muscular dystrophy?
■ Atelectasis secondary to hypoventilation
■ Pneumonia
What is the MC motor neuron disease to cause pulmonary complications?
ALS
What scoliotic angle do patients complain of dyspnea?
> 90 degrees
What scoliotic angle do patients develop overt hypoventilation and cor pulmonale?
> 120 degrees
What is the rate of decrease of FEV1 due to normal aging?
FEV1 decreased at a rate of 30cc /year
What is the rate of decrease of FEV1 in smokers?
FEV1 decreased at a rate of 60-90cc /year
Quitting smoking at what age can increase lung function?
<35 yo
When can pulmonary changes be seen in SCI?
C5 or higher quadraplegia
What causes decreases in diaphragmatic excursion and the vital capacity (VC) in the sitting position in SCI?
ABD contents sag due to the greater strength of the diaphragm relative to the weakness of the abdominal wall muscles
What are potential guidelines to adding ventilator support in DMD patients?
– Dyspnea at rest
– 45% predicted VC
– Maximal inspiratory pressure <30% predicted
– Hypercapnia
When is aspiration risk increased in ALS?
VC falls to 25 mL/kg, the ability to cough is impaired
What is the best indicator for noninvasive ventilation in ALS?
Forced vital capacity
What are medications for dyspnea and to decrease exacerbations of COPD?
– Inhaled anticholinergics: ipratropium (Atrovent®), tiotropium (Spiriva),
– Short-acting inhaled b-2 agonists
Which asthma patients may benefit from theophylline use for exercise induced asthma/bronchospasm?
Young patients w/ moderate asthma, who have tried b-2 agonists during exercise as well as mast cell stabilizers or leukotriene inhibitors
When is supplemental oxygen recommended with exercise?
Patient exhibits an exercise-induced SaO2 below 90%
What are benefits of home oxygen?
– Red polycythemia – Improvement in pulmonary HTN – Red of the perceived effort during exercise – Prolongation of life expectancy – Improvement in cognitive function – Red in hospital needs
What are outcomes of controlled breathing techniques?
Red dyspnea
Red the work of breathing
Improve resp muscle function and pulmonary function parameters
What are the benefits of diaphragmatic breathing?
Increased TV, decreased FRC, and increase in maximum oxygen uptake
What is pursed-lip breathing?
Patient inhales through the nose for a few seconds with the mouth closed, then exhales slowly for 4 to 6 seconds through pursed lips. Expiration lasts 2-3x as long as inspiration.
What are the benefits of pursed-lip breathing?
Prevents air trapping due to small airway collapse during exhalation and promotes greater gas exchange in the alveoli. Increases TV, reduces dyspnea and work of breathing
What is the postural position to drain the upper lobes of the lung?
– Patient is positioned sitting up – Exceptions: ■ Right anterior segment: supine ■ Lingular: lateral decubital Trendelenburg ■ Both posterior segments: prone
What is the postural position to drain the middle and lower lobes of the lung?
– Patient is positioned in the lateral decubital Trendelenburg
– Exceptions:
■ Superior segment of the lower lobe: prone with buttocks elevated
■ Posterior lower segment: prone Trendelenburg position with buttocks elevated
■ Anterior segment: supine Trendelenburg
What degree of Trendelenburg can COPD patients tolerate?
Up to 25° tilt
What should postural lung drainage be avoided in?
– Pulmonary edema – CHF – HTN – Dyspnea – Abd: hiatal hernia, obesity, recent food ingestion, abdominal distention
How do alveoli change from sitting to supine position?
Expand in size, increasing ventilation at the base of the lung
Where is the ventilation/perfusion (V/Q) mismatch most effective in upright sitting?
Middle lung lobes
Which lobes are preferentially perfused in sitting?
Lower lung lobes
Which lobes are preferentially ventilated in sitting?
Upper lung lobes
When changing from a sitting to supine position, how does venous pressure change in relation to arterial pressure?
Venous pressure increases in relation to the arterial pressure in dependent areas of the lung
What are advantages of pre and post op chest therapy program?
– Dec pneumonia risk
– Red postop atelectasis following thoracic and abdominal surgery
What aerobic exercises can be done in CF patients?
– Exercises involving the trunk muscles, such as sit-ups
– Swimming
– Jogging/structured running
What does Continuous positive airway pressure (CPAP) provide?
Splinting of the
pharyngeal airway with positive pressure delivered through a nose mask and prevents desaturation.
What are uses of glossopharyngeal breathing?
– Breathe w/o mech vent (mins up to 4 hrs)
– Improves the volume of the voice and the rhythm of speech
– Prevent microatelectasis
– Deeper breaths for more effective cough
– Improves or maintains pulmonary compliance
What are examples of Intermittent abdominal pressure ventilator (IAPV)?
Pneumobelt
Exsufflation belt
What is a Rocking bed?
Rocks the patient along a vertical axis (15° to 30° from the horizontal) utilizing the force of gravity to assist ventilation
What is the preferred method to treat obstructive sleep apnea?
Continuous positive airway pressure (CPAP)
Which patients are candidates for Fenestrated tracheal tubes?
Able to speak and require only intermittent ventilatory assistance
Which patients are candidates for Non-Fenestrated tracheal tubes?
Require continuous mechanical ventilation or are unable to protect the airway during swallowing
How can patients talk with a Non-Fenestrated tracheal tubes?
One-way talking valve that open on inhalation and close during exhalation to produce phonation
Which patients are candidates for Speaking tracheal tubes?
Alert and motivated patients, who require an inflated cuff for ventilation and who have intact vocal cords and the ability to mouth words
What are indications for one-way speaking valves?
■ Alert, awake
■ Medically stable, able to exhale efficiently
■ Tolerate complete cuff deflation and speaking valve trial
What are contraindications for one-way speaking valves?
■Unconscious/coma ■ Vocal cord paralysis-adducted position ■ Inflated tracheostomy ■ Foam-filled cuffed trach ■ Severe airway obstruction, laryngeal stenosis or tracheal stenosis ■ Thick secretions ■ Severe risk for aspiration ■ COPD
What are complications of trach suctioning?
Bleeding, infection, atelectasis, hypoxemia, CV instability, elevated ICP, cause lesions to the tracheal mucosa
