Obstructive

Question 1

Obstructive Disease

Answer 1

• An expiratory impairment
  
  • Expiratory volumes increase
    
    • May progress to decreased inspiratory volumes (only so much space in lungs)
  • difficulty getting rid of air
  • retained secretionw
  • inflammation of musosal lining of airway walls
  • bronchi constriction
  • weakening of support structure of airway walls
  • low flattended diaphragm
  • horizontal ribs
  • elevated shoulder girdle
  • barrel shaped thorax

Question 2

Causes

Answer 2

Increased resistance to airflow (i.e. lumen obstruction from various causes)

Question 3

S/S

Answer 3

Tachypnea, dyspnea, decreased and/or adventitious breath sounds, chronic (potentially productive) cough, and characteristic musculoskeletal changes

Question 4

Chronic Alveolar hypoxemia

Answer 4

Chronic alveolar hypoxemia → pulmonary vasoconstriction → pulmonary hypertension

•Manifested as cor pulmonale

Question 5

Common pathologies

Answer 5

• Asthma, chronic bronchitis, emphysema, chronic obstructive pulmonary disease (COPD), bronchiectasis, and cystic fibrosis (CF)

Question 6

Why might breath sounds be reduced in obstructive diseases given the pathology typically affects expiration?

Answer 6

• air becomes trapped in lungs
• inc residual and ERV
• some portions may have to mcuh air in them at rest
• so when inspire normal breath, might not be able to move air into lungs because might already be inflated with trapped air
• would then hear “decreased” breath sounds

Question 7

Obstructive Disease- CXR:

Answer 7

• Hyperinflation (with flattened diaphragm)
• Radiopacities(appear white) reveal regions with retained secretions

—Benefit of cough instruction?

Question 8

Obstructive disease- PFTs:

Answer 8

• Increased lung expiratory volumes
• Decreased lung inspiratory volumes with worsening obstructive disease
• Decreased (ratio < 75‐80%) FEV1 / FVC ratio

Question 9

Asthma:

Answer 9

• Hyperirritability of the tracheobronchial tree (can trap air from inc resistance)
  
  • Results in bronchospasm, inflammation of the bronchioles, and excess mucous secretion
  • Causes increased resistance to air flow

Question 10

Asthma- Precipitating factors

Answer 10

• Respiratory infection
• Irritants
• Allergens
• Stress and / or exercise

Question 11

Asthma- Diagnostic findings

Answer 11

• CXR consistent with hyperinflation with acute exacerbation; otherwise normal
• PFTs consistent with obstructive disease

Question 12

Asthma- Hallmark S/S

Answer 12

• Wheezing or diminished / absent breath sounds
• Hyper‐resonant with mediate percussion (air trapping)
• Prolonged expiratory phase
• Increased use of accessory muscles
• Dyspnea
• Cough (with or without sputum)
• Cyanosis
• Retractions (intercostal spaces pulling in rather than out with chest wall)

Question 13

Asthma- PT

Answer 13

• Airway clearance
  
  • Bronchospasm considerations: cough versus huff
• Breathing exercises
  
  • Primarily PLB and diaphragmatic
• Activity / exercise
  
  • Tolerance
  • Ensure availability of rescue inhalers

Question 14

Benefits of Exercise in Patients with Asthma

Answer 14

• Aerobic training at moderate to high intensity
  
  • 20 minutes, 2 times/week, minimum of 4 weeks
  • Contraindicated during acute exacerbation
  • Include warm‐up to reduce risk of exercise induced bronchospasm
• In the asthma population, exercise improves:
  
  • Quality of life
  • Cardiopulmonary fitness, but does not improve lung function
• In the asthma population, exercise reduces:
  
  • Incidence of exacerbations
  • Reports of dyspnea and anxiety during activity

Question 15

Chronic Bronchitis

Answer 15

• Chronic inflammation and swelling of bronchial mucosa (scarring of mucus membrane)
  
  • Leads to hypersecretion of bronchial mucous given hyperplasia of mucous glands
  • Creates irreversible lung damage given scarring of mucous membranes
  • Results in dilation of alveoli

***Associated with recurrent productive cough for at least 3 consecutive months for 2 consecutive years

Question 16

Chronic Bronchitis- Primary causes

Answer 16

• Smoking
• Repeat airway infections
• Environmental and/or chemical irritants

***blue bloatter

Question 17

Chronic Bronchitis- Diagnostic findings

Answer 17

• CXR consistent with mucous secretion; CXR not used diagnostically but rather to rule out other pathologies
• PFTs consistent with obstructive disease
  
  • FEV1 < 65% of predicted value
  • FEV1 / FVC ratio < 70%
• ABGs consistent with hypoxemia and hypercapnia

Question 18

Chronic Bronchitis: Hallmark Signs and Symptoms

Answer 18

• Cyanosis and barrel chest deformity (“blue bloater”)
• SOB
• DOE
• Orthopnea and PND
• Crackles and wheezes
• Tachypnea
• Chronic productive cough
• Peripheral edema (if progressed to R‐sided heart failure)

Question 19

Chronic Bronchitis- PT

Answer 19

• Airway clearance
• Breathing exercises– Primarily PLB and diaphragmatic
• Activity / exercise– Tolerance and Determine parameters of safety (HR & O2 sat)

Question 20

Hypoxic Drive- Obstructive disease Consideration

Answer 20

• Consequence of retained CO2
• Chronic hypercapnia blunts sensitivity of central chemoreceptors to detect changes in CO2
  
  • Body fails to naturally increase respiratory rate to eliminate CO2 excess central chemorecepors on overload)
  • Drive to increase respiratory rate therefore stimulated by peripheral chemoreceptor detection of hypoxemia
• Impact of supplemental oxygen administration in setting of hronic hypercapnia
  
  • May improve hypoxemia
    
    • Without ongoing hypoxemia, body fails to increase respiratory rate to address hypercapnia (negative feedback loop: peripheral chemoreceptors detect sufficient oxygen and fail to stimulate spontaneous increase in respiratory rate or depth)
  • Often results in difficulty with supplemental oxygen weans
• Common for SpO2goal to be ≥ 88%

Question 21

Emphysema

Answer 21

• Destruction of elastic fibers surrounding the alveoli given deficiency of alpha 1‐antritrypsin
  
  • Decreased number of alveoli
  • Increased size of alveolar sac and ducts, thereby reducing elastic recoil
  • Overall reduced surface area for gas exchange

***dec elastic strength, lost structure and recoil

• air trying to get out and pushes walls with it
• over inflated (ribs and tissue change shape)

Question 22

Emphysema- Primary Causes

Answer 22

• Genetic predisposition (hereditary alpha 1-antitrypsin deficiency)
• Smoking
• Environmental (occupational) exposures

Question 23

Emphysema- Diagnostic Findings

Answer 23

• CXR consistent with hyperinflation (mucous not common)
• PFTs consistent with decreased FEV1 and FEV1 / FVC ratio
• ABGs consistent with slight hypoxemia

Question 24

Emphysema- Hallmark S/S

Answer 24

• “Normal” coloration (“pink puffer”)
  
  • dont lack O2. Cant exhale. Pursed lips keeps airway open a little longer to get more air out
• Tachypnea
• Increased WOB with pronounced accessory muscle use
• SOB
• Significant DOE
• Thin (no barrel chest deformity
• Wheezes
• Typically without a cough

Question 25

Emphysema- PT

Answer 25

• Breathing exercises
  
  • Primarily PLB and diaphragmatic
• Activity / exercise
  
  • Tolerance
  • Determine parameters of safety

***inc O2 might dec drive to breath

Question 26

COPD

Answer 26

• Pathologic alveolar and airway changes resulting from inflammatory responses to noxious particles or gases
  
  • Partially reversible (treatable); preventable
• Typically reflects components of both chronic bronchitis, emphysema, and asthma
  
  • Most commonly a manifestation of chronic bronchitis
• Mucous production causes chronic and productive cough
• Additional findings consistent with right‐sided heart failure

Question 27

Benefits of Pulmonary Rehabilitation in Individuals with COPD

Answer 27

• In the COPD population, pulmonary rehabilitation improves:
  
  • Quality of life
  • Activity and maximal exercise tolerance –how?
    
    • Not through improved lung function but instead through improved skeletal muscle and heart function
• In the COPD population, pulmonary rehabilitation reduces:
  
  • Frequency of hospitalizations
  • Reports of dyspnea

Question 28

Bronchiectasis

Answer 28

• Results from a necrotizing infection that destroys the muscular wall and elastic components of the bronchus
  
  • Destroyed regions become fibrotic
  • Changes predispose individual to repeat infections
• Results in irreversible dilation of the bronchi
  
  • Dilated bronchi accumulate mucous (mucopurulent sputum)
  • Mucous leads to bronchospasm
• Antibiotic management has lessened incidence in general population
  
  • Most typically seen in individuals with CF
• Airway clearance and exercise represent primary PT interventions

Question 29

Cystic Fibrosis

Answer 29

• Genetic, autosomal recessive trait
  
  • Caucasian > non‐white
  • Equal gender distribution
  • Noncurable, but now with expanded treatment options and earlier detection
    
    • Diagnosed by sweat test, genetic testing, and stool sample
• Impaired transport of chloride ion across membranes leading to hypersecretion of abnormally thick mucous
  
  • Creates mucous plugging and chronic respiratory infections
  • Greatest impact on small conducting airways which causes air trapping

Question 30

Cystic Fibrosis- Diagnostic findings

Answer 30

• CXR consistent with hyperinflation and secretion retention
• PFTs consistent with decreased VC, increased FRC, and decreased FEV1

Question 31

CF PT

Answer 31

• Airway clearance
• Breathing exercises
  
  • Primarily PLB and diaphragmatic
• Activity / exercise
  
  • Tolerance
  • Posture education