Obstructive Disease Flashcards
What is an expiratory impairment?
Expiratory volumes increase
Inspiratory volumes decrease with diesease progression.
Obstructive Disease Causes…
Increased resistance to airflow
Signs and Symptoms of Obstructive Disease…
Tachypnea, dyspnea, decreased and/or adventitious breath sounds, chronic cough, and characteristic musculoskeletal changes.
What is the chain of events that lead to cor pulmonale?
Chronic alveoloar hypoxemia…..pulmonary vasoconstriction…..pulmonary hypertension
What are some common obstructive pathologies?
Asthma Chronic Bronchitis Emphysema COPD Bronchiectasis Cystic Fibrosis
What are some diagnostic assessments for obstructive disease?
Chest x-ray
Pulmonary Function Tests
Chest X-ray findings with obstructive disease…
Hyperinflation (flattened diaphragm)
Radiopacities (appear white) reveal regions with retained secretions
PFT findings with obstructive disease
Increased expiratory volumes
Decreased inspiratory volumes with worsening obstructive disease
Decreased FEV1/FVC ratio to (<75-80%)
What is Asthma?
Hyperirritability of the tracheobronchial tree
Results in bronchospasm, inflammation of the bronchioles, and excess mucous
Causes increased resistance to air flow.
What are the precipitating factors to Asthma?
Respiratory infection
Irritants
Allergens
Stress and /or exercise
Diagnostic Findings with Asthma
CXR consistent with hyperinflation with acute exacerbation; otherwise normal.
PFTs consistent with obstructive disease.
Hallmark Signs and Symptoms of Asthma
- 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
Medical Management of Asthma
Pharmacologic bronchodilators corticosteroids beta adrenergic agonists anticholinergics methylxanthines leukotriene inhibitors
Pulmonary Toilet:
secretion clearance
supplemental O2
PT management of Asthma
Airway clearance
bronchospasm considerations, cough vs. huff
Breathing Exercises
pursed lip breathing and diaphragmatic
Activity/exercise
tolerance
ensure availability of rescue inhalers
Exercise benefits in patients with asthma.
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
Given a diagnosis of asthma, what
assessments must be performed to guide the
selection of the most optimal physical
therapy intervention(s)?
?
Chronic Bronchitis Characteristics
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
Chronic Bronchitis Causes
Smoking
• Repeat airway infections
• Environmental and/or chemical irritants
What is chronic bronchitis associated with?
Associated with recurrent productive cough for at least 3
consecutive months for 2 consecutive years
Diagnostic findings with chronic bronchitis?
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
Hallmark Signs and Symptoms of Chronic Bronchitis
- 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)
Medical Management of Chronic Bronchitis
Pharmacological • Bronchodilators • Corticosteroids • Beta adrenergic agonists • Anti‐cholinergics • Cough suppressants • Antibiotics in setting of respiratory infection • Vaccines to reduce risk of influenza and pneumonia
Pulmonary Toilet
secretion clearance
supplemental oxygen as indicated
Smoking cessation
Physical Therapy Management of Chronic Bronchitis
Airway clearance
Breathing exercises
pursed lip breathing and diaphragmatic
Activity / Exercise
tolerance
safety parameters.
What is Hypoxic Drive?
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
• Drive to increase respiratory rate therefore stimulated by peripheral
chemoreceptor detection of hypoxemia
• Impact of supplemental oxygen administration in setting of
chronic 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 SpO2 goal to be ≥ 88%
Emphysema Characteristics
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
Emphysema Causes
Genetic predisposition (hereditary alpha 1‐antitrypsin deficiency)
• Smoking
• Environmental (occupational) exposures
Emphysema Diagnostic Findings
- CXR consistent with hyperinflation (mucous not common)
- PFTs consistent with decreased FEV1 and FEV1 / FVC ratio
- ABGs consistent with slight hypoxemia
Emphysema Hallmark Signs and Symptoms
- “Normal” coloration (“pink puffer”)
- Tachypnea
- Increased WOB with pronounced accessory muscle use
- SOB
- Significant DOE
- Thin (no barrel chest deformity)
- Wheezes
- Typically without a cough
Emphysema Hallmark Signs and Symptoms
- “Normal” coloration (“pink puffer”)
- Tachypnea
- Increased WOB with pronounced accessory muscle use
- SOB
- Significant DOE
- Thin (no barrel chest deformity)
- Wheezes
- Typically without a cough
Medical Management Emphysema
Pharmacologic • Bronchodilators • Corticosteroids • Beta adrenergic agonists • Anti‐cholinergics • Supplemental oxygen as indicated • Smoking cessation • Lung volume reduction surgery to reduce hyperinflation
PT Management Emphysema
• Breathing exercises • Primarily PLB and diaphragmatic • Activity / exercise • Tolerance • Determine parameters of safety
COPD Characteristics
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
Pulmonary Rehab benefits with COPD
Improves:
quality of life
activity and max exercise tolerance due to improved skeletal muscle and heart function
What does pulmonary rehab reduce in COPD patients?
Hospitalization frequency
Reports of dyspnea
What does pulmonary rehab reduce in COPD patients?
Hospitalization frequency
Reports of dyspnea
Bronchiectasis Characteristics
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
Cystic Fibrosis Characteristics
• Genetic, autosomal recessive trait
• Caucasian > non‐white
• Equal gender distribution
• Non‐curable, 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
Diagnostic Findings with Cystic Fibrosis
CXR consistent with hyperinflation and secretion retention.
PFTs consistent with decreased VC, increased FRC, and decreased FEV1
Cystic Fibrosis Hallmark Signs and Symptoms
PULMONARY SEQUELAE • Crackles and wheezes • Tachypnea • Chronic productive cough • Hemoptysis may be present during peak of respiratory infection • Increased WOB and DOE • Increased use of accessory musculature • Increased respiratory rate • Cyanosis • Digital clubbing • May progress to barrel chest deformity • Findings consistent with rightsided heart failure
OTHER SYSTEM SEQUELAE Underweight • Salty skin and sweat • Large, greasy, malodorous stools • Sterility in men • Findings consistent with chronic pancreatitis
Medical Management of Cystic Fibrosis
• Pharmacologic • Aggressive antibiotics during infections • Bronchodilators • Mucolytics • Pulmonary toilet • Secretion clearance • Supplemental oxygen as indicated • Transplantation if candidate • Interdisciplinary coordination • RT, RD, MD, RN, PT
PT Management Cystic Fibrosis
PHYSICAL THERAPY • Airway clearance • Breathing exercises • Primarily PLB and diaphragmatic • Activity / exercise • Tolerance • Posture education
Exercise Benefits with Cystic Fibrosis
Exercise tolerance is an independent predictor of mortality
and morbidity
• In the CF population, exercise improves:
• Mucociliary transport
• Mobility of chest wall
• Activity tolerance
• Quality of life
• In the CF population, exercise reduces:
• Incidence of osteoporosis
• Decline in lung function
• Frequency of lung infections
