Emphysema Flashcards
what is emphysema?
what does it cause an increase in? Decrease?
- pathologic accumulation of air in the lungs
- disease of exhalation → pts have difficulty w/exhalation
- characterized by air trapping in the lungs
- causes an increase in residual volume, total lung capacity (TLC) and a _decrease in FVC1/FVC rati_o
what causes the increased TLC in pts with emphysema?
flattened diaphragm (length-tension relationship)
describe the changes to lung anatomy in emphysema
creates hyperinflated lungs with enlarged alveoli (super alveoli)
forced expiration causes smaller airways to collapse during expiration which “traps air” in the alveoli
what is considered a bad FEV1/FEV ratio?
less than 0.5 = bad news
list volume changes that may occur in obstructive lung diseases like emphysema (3 things increase)
- increase in RV
- increase in TLC
- increase in FRC
compare FEV1 in COPD to normal pts
the volume of air exhaled in the first second (FEV1) is less in COPD compared to a normal individual
summary: emphysema causes __________, __________, and _________________________________
- reduced lung elastic recoil
- increased lung-compliance
- increased lung volumes with reduced maximal expiratory flow rates
T/F: there is inflammation associated with emphysema at the level of the lung
TRUE
corticosteroids may help manage this which can cause osteoporosis, immune suppression, proximal muscle weakness, weight gain (moon face) and diabetes
list clinical manifestations of emphysema
what is the first complaint of emphysema usually?
- first complaint = SOB at rest
- apprehensive, anxious, addicted to O2
- thin, cachectic
- deformed chest with prolonged expiration
- absent or non-productive cough
- accompanying cardiac problems, cor-pulmonale
- mild COPD → mild hypoxemia
- with progression → hypoxemia worsens CO2 retained (hypercapnia)
- chronic pulmonary metabolic acidosis
- deconditioning
prognosis for emphysema
Poor
is a chronic, progressive, and debilitating diseases
may present with lung cancer
Emphysema implications for PT treatment (6)
- reducing airway edema secondary to inflammation and bronchospasm
- facilitating the elimination of bronchial secretions
- preventing and treating respiratory infection
- increasing exercise tolerance
- avoiding airway irritants and allergens
- relieving anxiety and treating depression
long term oxygen therapy implications for PT
ie. what PaO2 and O2 sat make a pt eligible for long term O2 treatment?
- pts with PaO2 of 55 or less, or a resting oxygen saturation of 88% or less, measured at 2 time periods 3 weeks apart are eligible (under Medicare rules) for long term O2 treatment
how does an oxygen concentrator work?
- N2 scrubber
- increases the PO2 in the air breathed in
- replaces other gases in atmospheric air with O2, increasing the PO2 of the inhaled air
monitoring vitals in emphysema pts
- use pulse ox
- monitor HR and BP
- the first heart sound is best heard under the distal sternal area
- hyper inflated lungs causes the heart to elongate, displacing the left ventricle downward and medially
what is hypoxic drive?
a form of respiratory drive in which the body uses oxygen chemoreceptors instead of CO2 receptors to regulate the respiratory cycle
describe how normal respiration differs from hypoxic drive
- Normal
- driven mostly by the levels of CO2 in blood
- those levels are detected by peripheral chemoreceptors
- an increase in arterial CO2 leads to an increase in respiration
- dissolved O2 typically only plays a minor role in regulating respiration
- pts on emphysema are more reliant on PaO2 to drive O2
how does hypoxic drive influence pts on oxygen?
be careful with bumping up their O2 delivery when you exercise them, this could interfere with hypoxic drive
if you turn up O2 do it incrementally and observe RR and pulse oximeter readings
emphysema: implications for the PT
metered-dose inhaler (MDI)
used to deliver drugs to the lungs
- users must take in a slow deep breath over the course of 10 seconds while maintaining a good seal on the device and pressing on the device
- some devices use spacers
- get a new MDI when the appropriate number of doses has been delivered
- evaluate the ability of the child or adult to correctly use the MDI
List Emphysema meds
- Bronchodilators
- Beta-2 adrenergic agonists
- SABAs
- LABAs
- anticholinergic agents
- steroids/glucocorticoids
- Beta-2 adrenergic agonists
- mucolytic/expectorants
- mast cell stabilizers
- antibiotics
describe SABAs
short acting beta-agonists
- first line med for exacerbations
- used in conjunction with LABAs
- delivered via MDI
- increased therapeutic action (delivered nasally), decreased systemic effects
- onset of action 5 min
- salbutamol (albuterol)
describe LABAs
long-acting beta-agonists
- duration of up to 12 hours
- second line med
- often given in conjunction with glucocorticoids
- dual therapy
what are ultra-long-acting beta-agonists?
once a day treatment dosage
administered via nebulizers generally
issues of concern with beta-2 adrenergic agonists
- receptor downregulation (tolerance)
- “off target” stimulation of other adrenergic receptors
- reduce morbidity and mortality is debated
describe anticholinergic agents
- the vagus nerve helps to regulate respiration rates
- inhibition of this nerve allows airway dilation to occur
- inhibit reflex cholinergic bronchoconstriction
- ipratropium and oxitropium
- often given in combination with B2-agonist
describe mucolytic/expectorants
- modulate mucus production and reduce mucus viscosity
- useful for reducing flare-ups, days of disability, and hospital admissions in ppl with COPD
- taken orally or via nebulizer
- are not considered part of the current standard of care for COPD treatment
- but are considered useful in ppl who cannot take inhaled corticosteroids
describe mast cell stabilizers
- mast cells are a type of resident inflammatory cell
- may contribute to the inflammation associated with COPD
- antihistamines and leukotriene antagonists
- cromolyn and nedocromil
why are antibiotics included in the medical management of emphysema?
- most exacerbations of COPD are caused by respiratory tract infections
- are used empirically - based on experience and observation
T/F: pulmonary rehab is reimbursable?
TRUE
what are the goals of pulmonary rehab?
- Primary goal → restore the chronic lung disease pt to the highest possible level of independent function
- DOES NOT reverse the disease process, simply allows pt to better live with the disease
- improve QOL and dyspnea issues
what does pulmonary rehab involve?
- integrates multidisciplinary services with the goal of helping the pt achieve a max level of independent function
pulmonary rehab indications
- indicated for pts with chronic pulmonary impairment who are dyspneic, have reduced exercise tolerance, and/or experience a restriction in activities
- currently no specific functional criteria to meet to enter a pulmonary rehab program
- referral is often offered only to the more advanced pt
- often a referral earlier in the disease progression would be of more benefit
pulmonary rehab exclusion criteria
- conditions that place pt at undue risk
- unstable angina
- uncontrolled pulmonary HTN
- recent MI
- conditions that make participation impossible
- severe arthritis or other joint problems
- continued cigarette smoking
- lack of motivation
- progression of disease
pt populations for pulmonary rehab
- COPD
- asthma
- interstitial diseases
- CF
- bronchiectasis
- thoracic cage abnormalities
- neuromuscular disorders
- S/P lung transplant
- surgeries for lung cancer
- lung volume reduction surgery
nature of the emphysema pt
- said to live in an “emotional straightjacket”
- express a pattern of:
- low self-esteem, sense of worthlessness, feeling of hopelessness, depression/anxiety, unable to vent their emotions for fear of not being able to breath
- sleep deprivation
- constant need for O2 supplementation
- many use CPAP device
- cachexic
List several pulmonary function tests
- Spirometry
- Spirometry after bronchodilator → tests effectiveness of pt’s drug regime
- single breath diffusion capacity
what does single breath diffusion capacity do?
- DLCO → diffusing capacity of Lung for CO
- assesses the transfer of gas (CO) from air in the alveoli, the the RBCs in lung vasculature
- compares the difference in the amount of CO in the inhaled and exhaled air
- results speak to the quality of the diffusion surfaces in the lungs
single breath diffusion capacity DLCO is reduced in 8 conditions, what are they?
- Emphysema
- Interstitial fibrosis
- Pulmonary embolism
- Pulmonary HTN
- Sarcoidosis
- Lung Hemorrhage
- Asthma
- CF
PFT and severity of disease
- normal PFT outcomes → 85% of predicted values
- mild disease → >65% and <85% of predicted values
- moderate disease → >50% but <65% of predicted values
- severe disease → <50% of predicted values
T/F: exercise is the centerpiece of pulmonary rehab?
what should the intensity be on the BORG and the modified BORG?
TRUE
- aerobic training consisting of walking/cycling with a goal to reach 20-30 min of continuous work (may require intermittent bouts of activity)
- intensity = dyspnea scale of 3-4 BORG 1-10 scale OR 11-13 on BORG 6-20 scale
- limit use of HR to define intensity
describe the incremental shuttle walking test
- the pt is required to walk between 2 cones (10 m) in time to a set of auditory beeps played on a CD
- initially, the walking speed is very slow, but each minute the required walking speed progressively increases
- the pt walks for as long as they can until they are either too breathless or can no longer keep up with the beeps
Exercise prescription in pulmonary rehab: aerobic training parameters
what percentage of Vo2 max and what RPE?
- work at 50% of VO2 max test
- RPE → 12-14
- HR → may be of limited use
- monitor O2 sat with pulse oximetry
- remember pt may quickly surpass their AT
- perceived as LE training
- may have limited central effects\
strength training/UE activities in pulmonary rehab
- arm ergometry
- true resistance exercises
- active ROM
- light weights
- cane exercises
- theraband
strength training/UE activities parameters in pulmonary rehab
what should be duration, frequency, and intensity?
- duration = 5-15 min
- frequency = 3x/week
- intensity = 1 set of 8-12 reps
strength training/UE activities usually lead to ________
- increased ventilatory demand
- early fatigue
- dyssynchronous breathing pattern and increased dyspnea
- adaptation tends to reduce these problems
T/F: flexibility exercises should be included in pulmonary rehab?
what are standard reps and holds?
TRUE
especially upper body/accessory muscles
standard flexibility activities → 5 reps and hold for 30 seconds
T/F: an inspiratory muscle trainer is the same thing as an incentive spirometer
FALSE
inspiratory muscle trainer is used to strengthen the diaphragm
T/F: dyspnea is the most common symptom in COPD
TRUE
which is why dyspnea scales are very important to include
list general tools aimed at QOL issues
- SF-36 (general health status questionnaire)
- disease specific tools
- St. George respiratory questionnaire
- UCSD shortness of breath questionnaire
- chronic respiratory disease quesionnaire
