OSPE Flashcards
1
Q
What are the symptoms of COPD
A
Dyspnoea [breathlessness]
a chronic cough
chronic sputum production
barrel chest- hyperinflated
2
Q
Why is COPD referred to as an “Umbrella term”?
A
Because COPD patients suffer from both chronic bronchitis and emphysema
3
Q
What causes COPD?
A
the most common risk factor is tobacco smoking but occupational exposure [factories, mining, mills] can also contribute. Leads to changes in the structure and function of the lungs.
4
Q
What is the general pathophysiology of COPD?
A
Irritation of the airway or alveolar walls leads to release of inflammatory mediators [Neurophil Granulocytes, Macrophages and CD8 T-Lymphocytes] and the release of protease and inactivation of anti-protease enzymes
Development of oxidative stress leading to over-activity and uncontrolled, regular and chronic neutrophil and macrophage activity in lung tissue
~Damage to airway/alveolar walls
~Excessive mucus production
~Lack of opportunity for rest and repair (consider
smoking habit – no rest)
5
Q
What is the pathophysiology of chronic bronchitis
A
~Hypertrophy of mucous gland tissue in trachea, bronchi and bronchioles
Thickening of the mucous membrane
~Increased levels of sputum production
~Increase in airways obstruction due to sputum and changes in airway wall structure.
~Increased bronchospasm as a result of intra-airway turbulence
6
Q
What is the pathophysiology of emphysema
A
~Destruction of alveolar walls leads to loss of elasticity and support – become “floppy” and prone to collapse during expiration.
~Affects alveoli and terminal bronchioles
Further obstruction to airflow
~Reduction in surface area for gaseous exchange
~Thickening of the respiratory membrane
~Bullae (distended over-large air sacs) reduce overall lung functional volumes
7
Q
What does COPD stand for?
A
Chronic Obstructive Pulmonary Disease
8
Q
What is emphysema?
A
Destruction of alveoli leading to loss of surface area and reduced gaseous exchange with/without thoracic shape changes
9
Q
What is Chronic bronchitis?
A
Presence of a cough and sputum for at least 3 months for 2 consecutive years
10
Q
What is pulmonary rehab?
A
multidisciplinary comprehensive intervention for patients with chronic respiratory diseases. The programme has two parts; circuit-based exercise and education /coping techniques
11
Q
When is COPD normally diagnosed? What is the classic COPD patient?
A
Long-term smoker/ occupational worker
12
Q
How is COPD diagnosed?
A
Pulmonary function tests [PETs] used to evaluate the resp. system. Can help define severity and progression of COPD. FEV1/FVC ratio is equal to or less than 70%
13
Q
What functional limitations can be caused by COPD?
A
Breathlessness affects activities of daily living (ADL) SOB on exertion(SOBOE) and in later stages of disease –SOB at rest (SOBAR)
Depression
- Affects over 40% of elderly patients with COPD
- severity is greater in those most disabled by
their condition
- Affects quality of life and ability to perform ADL
Early retirement, activity avoidance and secondary health complications (obesity, osteoporosis)
14
Q
What does FEV1 stand for?
A
Forced Expiratory Volume in one second- the volume of air in the first second in a forced expiration
15
Q
What does FVC stand for?
A
Forced Vital Capacity- maximum volume of air that can be forced out of the lungs.
16
Q
What can cause an acute exacerbations of COPD?
A
- Only 40-50% of exacerbations are primarily caused by a bacterium
- Lifestyle, activity, stress, fatigue, atmospheric conditions and time of year can also play a significant part in them
17
Q
What is the possible medical management for COPD?
A
Inhaled bronchodilators [2 types]
Preventers: Corticosteroid and Anticholinergics
Relievers: Beta-2 agonists- short acting or long acting
18
Q
What are some examples of short term goals for a COPD patient?
A
Sputum clearance
Control of dyspnoea
Assess ventilation and O2 levels
Assess mobility
19
Q
What are some examples of long term goals for a COPD patient?
A
Self-management
Sputum clearance and Breathing Control
Pulmonary rehab MDT
Smoking cessation
20
Q
What does the educational aspect of pulmonary rehab cover?
A
What is COPD?Breathlessness management Anxiety management Energy Conservation Chest Clearance Medications Benefits of exercise Management of own condition MDT input from Dietician, OT, Stop Smoking Service, Breathe Easy Group & Expert Patient Programme
21
Q
What MDT members are typically involved with pulmonary Rehab?
A
Respiratory Nurses Dieticians Occupational Therapists Stop Smoking Service British Lung Foundation Expert Patient Programme Social Worker (? Caution needed) Pharmacist Consultant Active Case Manager
22
Q
What can be used to monitor response to exercise?
A
Modified BORG Scale (0-10) Oxygen Saturations Respiratory Rate Heart Rate Blood Pressure Self-Score (fitness to exercise
23
Q
What are the contraindications for Pulmonary rehab?
A
Recent MI (in last 6 weeks) Unstable angina Severe hypoxic lung failure unable to be corrected with supplementary oxygen Uncompensated heart failure Severe psychiatric impairment Patient non-consenting
24
Q
What are the cautions for Pulmonary rehab?
A
Very severe COPD (FEV1 <30%) Requirement for ambulatory oxygen (consider number of people in group with oxygen) Cardiac arrhythmia disorders Substance abuse issues Mental health concerns Ongoing metastatic lung disease Epilepsy Heart failure Mobility issues / falls Recent stroke Recent thoracic or upper GI surgery Recent fracture / soft tissue injury Ongoing LBP
25
What outcome measures can be used to measure physical changes in COPD patients?
Six Minute Walk Test (6MWT)
Incremental Shuttle Walk Test (ISWT)
Timed Up and Go Test (TUG)
Ten Metre Walk Test
26
What outcome measures can be used to measure psychological/ ADLs changes in COPD patients?
-St George’s Respiratory Questionnaire (SGRQ)
-Chronic Respiratory Disease Questionnaire (CRDQ)
-London Chest Activities of Daily Living Scale (LCADL)
Hospital Anxiety and -Depression Scale (HAD) ?
-Medical Outcomes Short Form 36 Questionnaire (SF-36)
-Patient Health Questionnaire 9 (PHQ-9)
27
What are the benefits of pulmonary rehab?
- Improved exercise tolerance and quality of life.
- Reduction in healthcare utilisation.
- Greater ability to manage their condition in everyday life
- Increased social interaction
- Reduced hospital admissions
28
How is pulmonary rehab different from cardiac rehab?
```
Less intense (work on 2-3 levels above resting Borg rather than maximal heart rate)
Rest rather than active recovery
Encouragement for patient to set own limits (links with long-term self-management, consider nature of disease)
Otherwise, format and structure of group similar
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29
What does a wheeze sound like? What does it suggest?
Continuous high pitched musical tones- caused by Monophonic wheeze is a single obstructed airway (inhaled a pea, small tumour) whereas polyphonic wheeze is due to widespread disease (bronchospasm)
30
What does a crackle sound like? What does it suggest?
Clicking sounds- fine crackles is the opening of resp. bronchioles and alveoli
coarse crackles is the opening of bronchioles
31
What does plural rub sound like? What does it suggest?
Creaking or rubbing sound “walking on snow”
32
What is an MI?
Myocardial Infarction is the irreversible death (necrosis) of heart muscle secondary to prolonged lack of oxygen supply (ischemia).
33
What is CAD?
Coronary Artery Disease
34
Who is most likely to suffer an MI?
men (3x more likely), family history of premature coronary heart disease, hypertension, psycho-social stress
35
What are the risk factors of an MI?
High cholesterol, Smoker, Depression, Physical activity
| History, Age, Hypertension, Alcohol, Obesity
36
What are the contraindications for cardiac rehab?
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Unstable angina
Uncontrolled arrhythmia
Uncontrolled tachycardia (>100bpm)
Moderate / severe aortic stenosis
Dissecting aneurysm
Active thrombophlebitis
Active pericarditis / myocarditis
Severe uncontrolled hypertension (200/110mmHg)
Significant drop (>20mmHg) SBP
Symptomatic CCF
Resting ST displacement >3mm
Uncontrolled metabolic disorders – diabetes, thyroid
Poorly controlled mental disturbance
Physician decision due to other chronic illness
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37
How long is cardiac rehab?
minimum of two supervised sessions a week; 6-12 weeks are recommended, in community
38
What are the four stages of cardiac rehab
Step 1- Step change; in hospital [2-5 days/ however long they are in hospital]; “get going” quad exercises; dvt exercises. Try to get them out of bed asap. Important to monitor BP and HR <30 above rest
Step 2- The early post-discharge period- within two weeks discharge. 2/52- non STEMI/ACS 4/52-STEMI 6/52- CABL/valve some exercise; gentle walking 5x week 25-40 mins
Step 3- Structured exercise training with continuing education and psychological support and advice on risk factors
Step 4- Long term maintenance or physical activity and lifestyle change
39
What is cardiac rehab?
The coordinated sum of activities required to influence favourably the underlying cause of cardiovascular disease, as well as to provide the best possible physical, mental and social conditions, so that the patients may, by their own efforts, preserve or resume optimal functioning in their community and through improved health behaviour, slow or reverse progression of disease
40
What is an angioplasty?
Angioplasty, also known as balloon angioplasty and percutaneous transluminal angioplasty, is a minimally invasive, endovascular procedure to widen narrowed or obstructed arteries or veins, typically to treat arterial atherosclerosis.
41
How is an MI diagnosed?
The ECG is the most important tool in the initial evaluation and triage of patients in whom an acute coronary syndrome (ACS), such as MI, is suspected. It is confirmatory of the diagnosis in approximately 80% of cases.
42
How is the MDT involved in the treatment of an MI patient?
Resp. nurses- can look as pacing, inhaler use, look at medicines OT- goal setting, help with ADLs, Dietician- help with education, healthy eating etc., Smoking cessation- stop smoking advice, pharmacist/GP- Specialist supervision is required, OT, community nurses, SALT, dietician
43
What are the signs and symptoms of an MI?
Fatigue, chest discomfort, (can occur days before the event) severe chest pain which often radiates up to neck, shoulder and jaw. Patients can also have a feeling of indigestion
44
How is the MDT involved in the treatment of a post-op patient?
Dietician, surgical team, nursing staff, physiotherapist, speech therapist, ancillary staff, occupational therapist
45
What complications can occur in post-op patients?
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Pneumonia
Atelectasis
Pleural effusion
Acute respiratory failure
Sputum retention
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46
What are the risk factors for post-op complications?
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Age (≥ 60)
Malnutrition
Obesity (BMI ≥ 27)
Incision site
Gender (F>M)
Impaired cognitive function
Impaired mobility
Co morbid conditions
Smoking history
Recent acute URTI or LRTI
No pre-op pulmonary education re DBE & IS
Prolonged pre-op LOS
Length of procedure
Presence of nasogastric tube on leaving post-op recovery ward
History of cancer
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47
What are the contraindication for the use of vibration?
Severe osteoporosis, pulmonary oedema, cancer, TB, fractured ribs, long term steroid use, Pulmonary embolism, and frank (fresh) haemoptysis; vigorous and rapid chest clapping may lead to breath holding and may induce bronchospasm in a patient with hyper-reactive airways
48
What are the indications for the use of percussion?
weak cough, fatigue, unable to cough, weak abd. Muscles, reduced cognition, narrowing airways e.g COPD
49
What are the contraindication for the use of shaking?
Severe osteoporosis, pulmonary oedema, cancer, TB, fractured ribs, long-term steroid use, Pulmonary embolism, and frank (fresh) haemoptysis; vigorous and rapid chest clapping may lead to breath-holding and may induce bronchospasm in a patient with hyper-reactive airways
50
What is atelectasis?
partial collapse or incomplete inflation of the lung
51
What are the side effects of general anasthesia?
```
↓ciliary action
drying of airways
↓ functional residual capacity
↓ cough reflex
sore throat
```
52
What are some examples of short-term for a post-op patient?
Increase comfort post-operatively:
Manage post-operative pain and nausea to:
Reduce surgical stress;
Facilitate early mobility and diet.
Improve post-operative care:
Continued focus on pain management / mobility / nutrition;
Clear discharge planning
53
What can cause sputum retention?
```
↑ Work of breathing
Bronchospasm
↑ secretions
↓ muscocillary clearance
unable to cooperate
dehydration
ineffective cough
```
54
What are some examples of long-term for a post-op patient?
full recovery
55
What is the physiotherapy intervention possible for post-op patients?
```
Techniques to improve ventilation
Breathing control
Chest clearance techniques
Circulatory exercises
General mobility
Postural re-education
Increase / maintain muscle strength
Gait re-education
Psychological support
Treatment of co-existing pathology
```
56
What causes an MI?
most MIs result from acute thrombus that obstructs an atherosclerotic coronary artery
57
Explain the pathophysiology of an MI?
The atheromatous plaque responsible for acute MI develops in a dynamic process in multiple stages. Starting with arterial intimal thickening, which consists of vascular smooth muscles with very minimal or no inflammatory cells, this process can be observed soon after birth. Subsequently, the formation of fibrous cap atheroma occurs, which has a lipid-rich necrotic core that is surrounded by fibrous tissue. Eventually, a thin-cap fibroatheroma develops, this is also known as a vulnerable plaque which is composed mainly of a large necrotic core separated from the vascular lumen by a thin fibrous cap that is infiltrated by inflammatory cells and is deficient of smooth muscle cells, making it vulnerable to rupture.
58
What are the symptoms of atelectasis?
coughing, difficulty breathing and rapid shallow breathing
59
How is atelectasis caused?
Mucus is retained in the bronchial tree, blocking the finer bronchi; the alveolar air is then reabsorbed, with collapse of the supplied lung segments, usually the basal lobes. The collapsed lung may become secondarily infected by inhaled organisms.
60
What are the steps of using an inhaler?
1. Remove the cap from the MDI and shake well to mix drug and propellant.
2. Breathe out all the way.
3. Place the mouthpiece of the inhaler between your teeth and seal your lips tightly around it.
4. As you start to breathe in slowly, press down on the canister one time (at very start of breath).
5. Keep breathing in as slowly and deeply as you can. (It should take about 5 seconds for you to completely breathe in.)
6. Hold your breath for 10 seconds (count to 10 slowly) to allow the medication to reach the airways of the lung.
7. Repeat the above steps for each puff ordered by your doctor. Wait about 1 minute between puffs.
8. Replace the cap on the MDI when finished.
9. If you are using a corticosteroid MDI, rinse your mouth out with water
61
What effect does cigarette smoke have on the airways?
.
62
What is the normal routine progression / management would be for a patient having an open cholecystectomy;
,
63
Describe the pathological changes that occur in Asthma, including the clinical features, signs and symptoms
.
64
What is Flixotide?
Preventer inhaler- contains fluticasone propionate which is a corticosteroid. Reduces swelling and irritation in the walls of the small air passages in your lungs
65
What is salbutamol?
Beta-2-agonists, works to open up the air passages in your air passages on your lungs
66
What is ipratromium bromide?
Ipratropium bromide, sold under the trade name Atrovent among others, is a medication which opens up the medium and large airways in the lungs. It is used to treat the symptoms of chronic obstructive pulmonary disease and asthma. It is used by inhaler or nebulizer.
67
What is Seretide?
Fluticasone, a corticosteroid, is the anti-inflammatory component of the combination which decreases inflammation in the lungs which can lead to better breathing. Salmeterol, a long acting beta-adrenoceptor agonist (LABA), treats constriction of the airways. Both combined are meant to be used as maintenance therapy and not as a rescue therapy for sudden symptoms. Together, they help prevent symptoms of coughing, wheezing and shortness of breath.
68
What is tiotropium bromide
Tiotropium bromide, originally marketed as Spiriva, is a long-acting, 24-hour, anticholinergic bronchodilator used in the management of chronic obstructive pulmonary disease (COPD).
69
In the management of reversible airways obstruction what is the difference between a ‘preventer’ and a ‘reliever’?
,
70
What are the effects of oral prednisolone on the respiratory system?
.
71
What are the long term effects of oral steroids on the body (side effects)?
Osteoporosis; cataracts, high blood sugar; high blood pressure; thin skin and bruising
72
How may respiratory drugs be delivered?
Orally
73
What is a spacer?
A device which aids in the inhalation of resp. drugs. Made from plastic
74
What conditions does pulmonary rehabilitation benefit?
COPD mainly but other chronic lung diseases also e.g CF, ILD, sarcoidosis, Bronchiectasis
75
What is the basic duration of pulmonary rehabilitation (length and frequency?)
minimum of two supervised sessions a week; 6-12 weeks are recommended, in community
76
What is the basic structure of a pulmonary rehabilitation programme?
A combination of progressive muscle resistance and (interval or continuous) aerobic training should be delivered. Debate around whether warm up/cool down is effective
77
Which other disciplines might be involved?
Resp. nurses- can look as pacing, inhaler use, look at medicines OT- goal setting, help with ADLs, Dietician- help with education, healthy eating etc., Smoking cessation- stop smoking advice, pharmacist/GP- Specialist supervision is required, OT, community nurses, SALT, dietician
78
Consider what secondary prevention interventions should be included in a cardiac rehabilitation class
.
79
What type of incision is a median sternotomy? What potential complications are there?
.
80
What type of incision is a postero-lateral thoracotomy? What potential complications are there?
.
81
What type of incision is a postero-lateral thoracotomy (muscle sparing)? What potential complications are there?
.
82
What type of incision is a thoraco-abdominal incision? What potential complications are there?
.
83
Normal breath sounds are sounds that we hear through the stethoscope and they are related to both the inspiratory and the expiratory phases of respiration. How are these sounds generated?
.
84
Why is it that the breath sounds that we hear toward the bases of the lungs are of lower frequency and are quieter than the sounds that we hear more centrally?
.
85
Wheezes are often first heard in expiration, occurring only during inspiration when the patient’s airway obstruction is severe. Why do you think that this might be?
.
86
A silent (wheeze-free) chest is a danger sign in severe asthma. What do you think has happened when the patient’s wheezing ceases?
.
87
How is an MI diagnosed?
.
88
Explain thrombolysis
.
89
Explain troponin
.
90
Explain the possible surgical interventions for an MI?
.
91
Explain the mucocilliary escalator
.
92
Discuss the cost of falls to the NHS
.
93
Explain the reasons why patients may fall?
.
94
What interventions that may help prevent/rehabilitate fallers?
.
95
What is the role of the physiotherapist in preventing falls?
.
96
Describe the subjective assessment of a respiratory patient
.
97
Describe the objective assessment of a respiratory patient
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98
What is meant by V/Q ratio? Give its normal value.
Ventilation/ perfusion ratio - it is around 3.3 in the apex and 0.63 at the base, so the overall figure is around 0.8
99
Briefly describe the events in thorax and associated muscles during inspiration
During inhalation, the volume of the lungs and thoracic cavity increases, decreasing the pressure of the air inside the lungs and essentially creating a weak vacuum into which air moves in from outside the body. During exhalation, the cavity constricts, the air inside the lungs is put under a higher pressure and forced out
