General Medical Rehab Flashcards
Total Lung Capacity Vital Capacity Forced Vital capacity FEV1 Residual volume Minute voume
TLC: Total amount of air in lungs after max inspiration
VC: The amount of air that can be expelled after a deep breath
FVC: same as above but after maximal exhalation
FEV1: amount exhaled in first second (decreases over time, way faster in smoker)
RV: amount of air in lungs at end of large exhalation
MV: Amount of air inhaled/exhaled in 1 min
Pulmonary rehab
increases AVO2 difference
Most common brain tumor
Cerebellar astrocytomas the most common CNS tumor in young adults, over the age of 7.
astrocytoma (glibolastoma)
Most common metastatic
lugng, breast, GI
Most common brain tumor in children
Cerebellar astroyctoma (better prognosis), medulloslbastoma
most common primary osseous tumor
osteosarcoma (knee-sital femur, proximal tibia)
Most common metastatic cancers to bone
lung, breast, prostate, MM (prostate is the oosteoblastic one best seen with bone scan)
Most common pediatric cancer
Leukemia
most common solid pediatric cancer
Brain tumors- pilocytic astrocytoma, medulloblastoma, ependymoma (posterior fossa tumors)
Pediatric burn percents
18% head, 14% each limb, every year after 1 subtract 1% from the head and add 0.5% to each leg
Pts who benefit most from pulm rehab
- resp limitation of exercise 75% of predicted max O2 consumption
- Obstructive airway disease with FEV1 <2,000mL or FEV1/FVC ratio <60%
- Restrictive lung disease with CO diffusion capacity <80% of predictive value
Pulmonary disability Moser Classification (stages 1-4 do not have dyspnea at rest)
1) normal at rest, dyspnea with strenuous exercise
2) Normal ADL performance- dyspnea on stairs/incline
3) Dyspnea with some ADLs; able to walk 1 block slow pace
4) Dependent with some ADLs; dyspnea with minimal exertion
5) Dyspnea at rest, housebound
Vo2 max equation
VO2 max= (HR x SV) x AVO2 difference
VO2 depends on body weight , age, sex, genetics (most important).
Obstructive disease
Air trapping, low max mid-expiratory flow rate, and normal to increased compliance, increased total and residual lung volumes
Chronic bronchitis
Emphysema
Cystic Fibrosis
Asthma
Chronic bronchitis- tracheobronchial mucous gland enlargement
Emphysema- distention of terminal nonrespiratory bronchioles with destruction of alveolar walls (secondary to neutrophil derived elastase); destruction of alveolar wall elasticity results in loss of lung recoil leading to excessive airway collapse on exhalation and chronic air obstruction/trapping.
CF: AR Cl- ion channels, failure to remove secretions from bronchioles, causing obstruction, bronchiectasis, overinflation and infection, aerobic exercise
Asthma- hypertrophy of bronchial muscle, mucosal edema, infiltration of eosinophils and mononuclear cells. Chronic bronchitis can result from asthma
FEV in COPD patients
FEV1 of 4L, no exercise impairment
FEV1 2-3 L, mild exercise limitation
FEV1 1-2 L moderate exercise impairment
FEV1 <1 L severe exercise impairment
Restrictive Lung Disease Intrinsic vs extrinsic
Intrinsic- asbestosis, sarcoidosis, silcosis, idiopathic pulmonary fibrosis
Extrinsic: NM dz, Thoracic deformities (>90 deg of scoliosis then have dyspnea, >120 deg scoliosis hypoventilation/cor pulmonale), Pleural dz, AS, Cervical SCI, obesity, surgical removal of lung tissue
DMD lung
resp muscle weakness -> Hypoventilation-
Chronic alveolar hypoventilation with hypoxemia
Reduced arterial oxygen tension (PaO2) and increased Carbon diooxide tension (PaC02) leading to daytime sleepiness.
ALS lung
Measure FVC at diagnosis and then every 3 months to monitor disease progression (FVC best prognostic indicator)
Earliest changes are decr in max inspir/expir muscle pressures, followed by reduced VC and maximum breathing capacity,
A vital capacity less than 25 ml/kg would have an impaired ability to cough
Active expiration
Abdominal muscles, internal intercostals
Aging PFTs
Restrictive Lung PFTs
Obstructive Lung PFTs
Aging:
Decrease: VC, FEV1 (30 mL/year), PO2, MVV
Increase: RV, FRC
No changes in : TLC, PCO2
Restrictive:
Decrease: VC, TLC, RV, FRC, FVC, MVV
FEV1 IS NORMAL!!!!
Obstructive:
Decrease: VC, FEV1 (45-75 mL/year) , FVC, MVV
Increase: RV, FRC, TLC
Ventilatory support for DMD
No clear guidelines but : dyspnea at rest, 45% of predicted VC, max inspiratory pressure <30% predicted, hypercapnia
Young pts with moderate asthma who have tried B2 agonists during exercise as well as mast cell stabilizers or LT inhibitors may benefit from
Theophylline for exercise induced asthma/bronchospasm
Inheritance pattern of CF
Autosomal Recessive- involving Chloride ion channels found in exocrine glands. Failure to remove secretions- obstruction, bronchiectasis, overinflation and infection
Therapy for CF
Aerobic exercise helps increase sputum production, increase ciliary beat
Asthma
Hypertrophy of bronchial muscle , mucosal edema, infiltration with eosinophils and mononuclear cells which causes changes in the basement membrane.
SCI respiratory dysfunction related to 3 factors
1) Reduced VC
2) Retention of secretions
3) Autonomic dysfunction
Complete lesions above C2 result in loss of function of
Diaphragm and intercostal muscles
What increases in C spine injury
residual volume
PFT of C5 injury
Expiratory muscles paralyzed- retain 60% of inspiratory capacity and ventilate well, but have weak cough and difficulty clearing secretions during respiratory infections; All volumes are greatly reduced because of limited expansion of chest wall; decr TLC and VC, incr RV
Nutrition status COPD
- decr serum albumin levels, supplement with 1.7 g/kg body weight per day
- Pseudomonas colonize poor nutrition ppl
- Affects surfactant synthesis
- Incr fluid intake in COPD
Supplental oxygen
reduce polycythemia, improve pHTN, prolongs life expectancy, improved cognition, decr blood pressure
Controlled breathing techniques
Used to reduce dyspnea, reduce work of breathing, and improve respiratory muscle function and pulm function
Diaphragmatic breathing
Used to reverse altered pattern of resp muscle recruitment; hand under thorax and on abdomen and try too expand abdomen; benefits : increased tV, decr FRC, increase in Max O2 uptake
Techniques to reduce dyspnea and work of breathing
Pursed lips
Airway secretion mgmt techniques
Controlled cough, Huffing pg 660
Electrolyte impairment in acute DMD respiratory exacerbation
Hypokalemia
Uses of glossopharyngeal breathing
Pt can breathe without mechanical ventilation
Intermittent abdominal pressure ventilator
air sac inflates and compresses abdomen causing diaphragm to move up and assist with expiration
Speaking valve for patient who only requires intermittent ventilatory assistance
Fenestrated tubes
Speaking valve for patient who requires continuous mechanical ventilation
Non fenestrated tube, open on inhalation and close on exhalation for phonation
Talking tracheostomy tube
used in alert and motivated patients, when thumb port is occluded, gas passes through larynx via small holes above the inflated cuff allowing patient to speak
Passy-Muir valve
unique in that it is the only valve that is maintained in closed position and opens only on inspiration, other valves are open at all times until they are actively closed during expiration; contraindication vocal cord paralysis, inflated cuff, tracheal stenosis
Cardiac rehab phases
I : during acute hospitalization (1-14 days) intensity should be aimed at 4 mets by the end of phase 1.
II: Closely supervised lasting 3-6 months
III: Extended outpatient period divided into intermediate and maintenance
VO2
represents oxygen consumption of the whole body and corresponds to peripheral skeletal muscles (rather than myocardial)
Maximum oxygen consumption that an individual can achieve during exercise
VO2 max which is = COxAVO2 difference
Myocardial oxygen consumption
actual oxygen consumption of the heart measured via cath
Can be used to estimate MVO2 (MVO2 surrogate)
Rate pressure product: SBPXHR
Can be used to estimate MVO2 (MVO2 surrogate)
Rate pressure product: SBPXHR divided by 100
Absolute contraindications to exercise training
EKG changes, unstable angina, uncontrolled arrythmias, symptomatic aortic stenosis or other valvular disease, decomp HF, Acute PE or Pulm infarction, acute myocarditis or pericarditis, acute thrombophlebitis
Relate contraindications to exercise training
Electrolyte abnormalities, tachyarrhythmias/brady, high degree AV block, A fib with RVR, HOCM, known aortic dissection, SBP >200 Diastolic >110, mental impairment
Mets for: slow walk 2mph regular walk 3 mph brisk walk 4 mph sex shovel snow jog
slow walk- 2-3 mets reg walk 3-4 mets brisk 4-5 sex 3-4 mets shovel snow 7 mets jog 9 mets
Sex after MI
not until after 2 weeks
NYHA classes
I: patients can perform activities equal to/more than 7 mets, no limits physically
II: Slight limitation to physical activity, comfortable at rest, equal to or more than 5 mets, cannot complete the 7 or more mets
(patient who has cardiac disease that limits them to only walking, gardening and performing sexual intercourse without becoming symptomatic.)
III: Comfortable at rest, marked limitation of physical activity, equal to or more than 2 mets but less than 5 mets
IV: dyspnea at rest, cannot perform anything equal to or more than 2 mets.
Max heart rat
220 - Age
Borg scale of perceived exertion
6 to 20.
6 no exertion at all, 9 very light, 11 light, 13 somewhat hard, 15 hard, 17 very hard, 19 extremely hard, 20 maximal exertion
The AHA recommends a rating of 13-15 for low-level graded stress testing.
Orthotopic heart transplant
makes up 99 percent of all cardiac transplants; bicaval technique
Heterotopic heart transplantation
less than 1 percent, recipient heart is left in place to assist the donor heart
Transplanted heart HR
Tachycardia bc denervated from vagal innervation and central regulation (parasympathetic tone) and consequently lack vagal inhibition to the SA node
- lower peak heart rate
- resting HTN (renal effects of calcineurin inhibitors and steroids)
- Slower return to resting HR post exercise
- Work capacity, CO, SBP, and total Vo2 are lower at max effort
- 5 year survival 70%, 20 year survival 20%
- Accelerated atherosclerosis after transplant
Transplanted heart HR
Tachycardia bc denervated from vagal innervation and central regulation (parasympathetic tone) and consequently lack vagal inhibition to the SA node
- lower peak heart rate
- resting HTN (renal effects of calcineurin inhibitors and steroids)
- Slower return to resting HR post exercise
- Work capacity, CO, SBP, and total Vo2 are lower at max effort
- 5 year survival 70%, 20 year survival 20%
- Accelerated atherosclerosis after transplant
Following orthotopic cardiac transplantation, stroke volume may be reduced due to diastolic dysfunction from increased myocardial stiffness in the new heart.
ABI
Ankle SBP ÷ Brachial SBP
Cardiac conditioning causes
Wider AVO2 difference, heart does less work to bring adequate oxygen to tissue bc improved utilization of oxygen by active muscles
Increased Max VO2 consumption
Slower pulse, lower BP and lower rate pressure product (RPP equals myocardial oxygen demand so trained heart has lower myocardial demand)
VO2 max=
(HR X SV) x AVO2 difference
Supplemental O2 use when SaO2 falls below
90%
any activity that uses large muscle groups, can be maintained continuously, and is rhythmic in nature” with the goals of producing physiological adjustments to the cardiovascular system in response to the exercise is considered
aerobic exercise
Stages of edema
Stage 1 (pitting edema) is edema that gets worse throughout the day but is almost normal in size by the morning; it is partly, if not entirely, reversed with elevation of the affected limb. Stage 2 (nonpitting edema) is characterized by fibrosis. This marks the beginning of hardening of the skin and an increase in size. In stage 3, the swelling is irreversible and the affected area is very large. The tissue is fibrotic and unresponsive.
largest volume of air that can be held by a patient against a closed glottis is called
MIC. The MIC is achieved by “air stacking” consecutively delivered volumes of air that are delivered by an external resuscitator or volume ventilator with a nasal piece or mouthpiece interface.
If a patient can maintain an MIC greater than his or her VC through air stacking techniques, may be able to forgo the need for a tracheostomy and be maintained on noninvasive ventilatory support alone.
What is an intermittent abdominal pressure ventilator (IAPV)?
A body ventilator that consists of an elastic air sac, which is worn underneath the clothing by patients who have respiratory muscle weakness. When the elastic bladder inflates with air by an external positive pressure ventilator, it causes the diaphragm to move upward. Once it deflates, the abdominal contents sag and pull the diaphragm down, allowing inspiration to occur passively. This technique can augment tidal volume by at least 300 mL or even higher if the patient has any degree of inspiratory capacity.
Greatest modifiable risk factor for cardiac disease
Smoking cessation
Central chemoreceptors in the medulla are sensitive to:
both, changes in pH and rising CO2 levels within the cerebrospinal fluid of the fourth ventricle.
Peripheral chemoreceptors are sensitive to:
pH, pCO2, and pO2 levels. Such receptors are located in the aortic arch as well as the carotid bodies.
Bisphosphonates MOA
inhibit osteoclastic bone resorption.
hereditary disorder characterized by congenital central hypoventilation- may also develop more normal patterns of breathing during wakefulness with episodes of apnea during sleep.
Ondine’s curse
Fick equation:
VO2 = HR x SV x a-VO2diff
ratio of work to resting metabolic rate
MET
Exercise therapy in CHF ( what happens to Ejection fraction, HR, BP, stroke volume)
impaired contractility would cause an increase in heart rate which would result in decreased ejection fraction, lower stroke volume, and hypotension
What lobe is responsible for : voluntary motor function. interpretation of sensory information and proprioception. Long-term memory storage interprets visual information.
frontal
parietal
temporal
occipital
where is the pharyngeal phase of swallowing triggered?
Faucial pillars.
As the food bolus leaves the oral cavity and moves backward, it must pass the faucial pillars (where tonsils are located). This region contains sensory receptors that detect the presence of the bolus, which sets into motion a chain of events that result in the bolus moving through the pharynx and entering the esophagus.F
Three or more of the following five criteria must be met for the diagnosis of frailty:
The stages of frailty are:
- Weight loss of ≥5% in last year or Body mass index (BMI) less than 18.5 or unintentional weight loss of more than 10 pounds in the past year.
- Exhaustion. The Center for Epidemiologic Studies Depression Scale is used.
- Weakness (decreased grip strength measured by a dynamometer)
- Slow walking speed of greater than6 to 7 seconds for 15 feet, or scoring less than the 20th percentile, stratified for sex and height
- Decreased physical activity (males <383 kilocalories, kcals); females <270 kcals) or complete inactivity.
0 criteria are present: Non-frail stage
1– 2 criteria present: Prefrail stage
3– 5 criteria present: Frail stage
Least neurotoxic: Cyclophosphamide Bortezomib, paclitaxel, and lenolidomide
cyclophosphamide
Why no weakness with platinum chemotherapy
platinum analogues do not usually cross the blood-brain barrier at contemporary doses, the anterior horn motor cells are unaffected
The coasting effect
is a phenomenon often seen following exposure to platinum-based chemotherapeutics such as cisplatin commonly used to treat testicular cancer. Damage to the dorsal root ganglion by platinum-based chemotherapeutics causes progressive dysfunction of the dorsal root ganglion. This leads to the progressive development of sensory neuropathy that can start weeks to months after the discontinuation of chemotherapy and continue for as long as a year. When patients develop signs and symptoms of neuropathy more than a year following exposure to chemotherapy other potential causes should be vigorously sought.
Neuropathy found in platinum chemo
As opposed to neurotoxic chemotherapeutics such as the vinca alkaloids and taxanes which cause a length-dependent axonopathy, platinum analogues exert their putative neurotoxic effect by intercalating in the DNA of the dorsal root ganglion thereby killing or disrupting function of affected sensory nerves. Sensory neuropathy caused by platinum analogues is not length dependent, so it is not unusual to see the sensory amplitudes in the upper extremities more affected than those in the lower extremities. Because platinum analogues do not cross the blood brain barrier to affect the anterior horn cells at contemporary doses, the CMAP amplitudes and needle EMG should be normal.
Nerve conduction studies demonstrate low sensory nerve action potential (SNAP) amplitudes in the median, ulnar, and radial nerves bilaterally but normal SNAP amplitudes in the lower extremities. Compound muscle action potential (CMAP) amplitudes are normal in both the upper and lower extremities. Needle electromyography (EMG) is normal.
DM in elderly
American Geriatric Society guidelines place greater emphasis on reduction of cardiovascular complications and minimizing the risk of hypoglycemia. A fasting plasma glucose below 200mg/dL and a hemoglobin A1c of less than 9% is sought.
Relative contraindications to complete decongestive therapy include
significant congestive heart failure, acute DVT, acute or untreated infection or inflammation of the affected limb, and fracture. Lymphatic drainage massage should be avoided over concurrently irradiated soft tissues
In addition to surgery, impending pathologic fractures of femur can be treated with
Bisphosphonates
radiation therapy
chemotherapy
The most sensitive of the studies listed for detecting osteoporosis.
Dual energy x-ray absorptiometry ( more than bone scan , xr, and CT)
CHF exercise type
avoid isometric, isotonic is better, Supine exercise performance increases myocardial oxygen requirements so do exercise in seated position
AD is characterized by:
(i) Memory impairment noted in learning or recall
(ii) Aphasia, Apraxia, Agnosia or Dysexecutive function (planning, organizing, sequencing, abstracting)
(iii) Cognitive deficits of sufficient severity to affect social or occupational functioning, representing a change from previous level
The Parkland formula =
4ml X kg X BSA % burned = 1/2 total fluid replacement in the first 8 hours. Give the remaining over 16 hours.
majority of brain metastasis in women.
Melanoma, breast, GI and lung cancer accounted for the
Mets
About 4 METs are used casually biking less than 10 mph, slow dancing, easy swimming, lifting <50 lbs, and having sexual intercourse. 2 METs are used for dressing, dusting, walking 2 MPH, playing piano, typing, and lifting <10 lbs. Typically when the patient can w
About 9 METs are used for a 5 mph jog, playing soccer, pushing/pulling, and lifting 100 lbs.alk 2 flight of stairs they are able to return to sex.
one BKA requires how much more energy expenditure from dysvascular disease
bilateral traumatic BKA 40% more energy
40%
one BKA requires how much more energy expenditure from dysvascular disease
bilateral traumatic BKA 40% more energy
One AKA from dysvascular disease requires 100% more energy
Bilateral traumatic AKA It takes >200% more energy to ambulate; These patients will likely be wheelchair bound.
40%
Prone position drains what part of lung
Superior segments of the lower lobes
Contraindication to chest percussion
increased intracranial pressure (flail chest and fx rib are NOT contraindications)
