PRE-MID Flashcards
Steady improvements in acute care have resulted in _______ and _____
improved patient survival and
increasing numbers of individuals with chronic disorders.
These chronic disorders are associated with a wide spectrum of ______
physiologic, psychologic, and social disabilities.
Foremost among these disorders is ________, which is now the third leading cause of death in the United States.
chronic obstructive pulmonary disease (COPD)
All of these patients have difficulty coping with the physiologic limitations of their diseases and these physiologic limitations result in many ________. The end result often is an _________ .
psychosocial problems / unsatisfactory quality of life
The high incidence of repeated hospitalizations and the progressive disability of these patients require _________
well-organized programs of rehabilitative care.
With the passage in_____ of the _______ , the reduction of early hospital readmissions for various chronic diseases, including COPD, is a major concern and focus of health care today.
2010 / Patient Protection and Affordable Care Act (PPACA)
This chapter provides foundational knowledge regarding the ___ and ____ involved in pro- viding planned programs of rehabilitation for individuals with chronic pulmonary disorders.
goals, methods, and issues
The Council on Rehabilitation defines rehabilitation as “ ________.”
the restoration of the individual to the fullest medical, mental, emotional, social, and vocational potential of which he or she is capable
The overall goal is to ____. (Rehabilitation)
maximize functional ability and to minimize the impact the disability has on the individual, the family, and the community
______ is the “art of medical practice wherein an individually tailored, multidisciplinary program is formulated, which through accu- rate diagnosis, therapy, emotional support and education stabi- lizes or reverses both the physio- and psychopathology of pulmonary diseases and attempts to return the patient to the highest possible functional capacity allowed by his or her pul- monary handicap and overall life situation.”
Pulmonary rehabilitation
The general goals of pulmonary rehabilitation are to ______
control and alleviate symptoms, restore functional capabilities as much as possible, and improve quality of life.
____ does not reverse or stop progression of the disease, but it can improve a patient’s overall quality of life.
Pulmonary rehabilitation
_____ is not a new concept.
Pulmonary rehabilitation
In______ , _____ recommended reconditioning programs for patients with chronic lung disease to help improve their ability to walk without dyspnea.
1952, Barach and colleagues
_____ before clinicians paid any attention to this concept.
Decades passed
Instead of having their patients participate in reconditioning programs, most physicians simply prescribed ___ and ____. The result was a
oxygen (O2) therapy and bed rest.
vicious cycle of skeletal muscle deterioration, progressive weak- ness and fatigue, and increasing levels of dyspnea including at rest.
Patients became homebound, then room-bound and even- tually bed-bound. Improved ___ and ____ were needed.
avenues of therapy and rehabilitation
In ________ published results confirming Barach’s insight into the value of reconditioning.
1962, Pierce and associates
_______ They observed that patients with COPD who participated in physical recondi- tioning exhibited ______ during exercise.
1962, Pierce and associates
lower pulse rates, respiratory rates, minute volumes, and carbon dioxide (CO2) production
However, they also found that these benefits occurred without significant changes in pulmonary function.
1962, Pierce and associates
______ showed that reconditioning could improve both the efficiency of motion and O2 consumption in patients with COPD.
Paez and associates
____ showed that the benefits of reconditioning could be achieved on an outpatient basis with minimal supervision. Since____ work in____
Christie / 1968
_____ benefits patients with chronic obstructive and restrictive pulmonary diseases.
pulmonary rehabilitation
When combined with smoking cessation, optimization of blood gas results (arterial pO2, pCO2, and pH), and proper medication use, _______ offers the best treat- ment option for patients with symptomatic pulmonary disease.
pulmonary rehabilitation
Programs for pulmonary rehabilitation must be founded on the sound application of current knowledge in the ___ and ____ .
clinical and social sciences
In fall ____ , the_____ and _____ released their evidence-based guidelines relating to pulmonary rehabilitation aimed at improving the way pulmonary rehabilitation programs are designed, implemented, and evaluated through patient outcomes.
2006
American College of Chest Physicians (ACCP) and the American Association of Cardiovas- cular and Pulmonary Rehabilitation (AACVPR)
______ must focus on the patient as a whole and not solely on the underlying disease.
Rehabilitation
effective pulmonary rehabilitation programs combine knowledge from both the___ and ____
clinical and the social sciences.
Knowledge from the _____ can help quantify the degree of physiologic impairment and establish outcome expectations for reconditioning.
clinical sciences
Application of the___ is helpful in determining the psychological, social, and vocational impact of the disability on the patient and family and in establishing ways to improve the patient’s quality of life.
social sciences
At rest, an individual maintains homeostasis by _______
balancing external, internal, and cellular respiration.
Physical activity, such as _____, increases energy demands.
aerobic exercises
To maintain homeostasis during exercise, the _____ must keep pace.
cardiorespiratory system
Ventilation and circulation increase to supply ___ and ___ and to eliminate the higher levels of CO2 produced by metabolism.
tissues and cells with additional O2
Exercise (Cardiovascular)
Increase Stroke volume and pulse rate
Exercise (pulmonary)
Increase tidal volume and respiratory rate
Neuroendocrine stimulation of chemo and stretch receptors
Increase Catecholamines, Sympathetic tone, Vagal tone
___ and _____ also increase in linear fashion as exercise intensity increases.
O2 consumption and
CO2 production
If the body cannot deliver sufficient O2 to meet the demands of energy metabolism, blood lactate levels increase above normal. In exercise physiology, this point is called the ___
onset of blood lactate accumulation (OBLA).
As this excess lactic acid is buffered, _____ and the stimulus to ____ increases.
CO2 levels increase / breathe
The result is an abrupt upswing in both
CO2 and VE (referred to as the ventilatory threshold).
Beyond this point, metabolism becomes ____ , the efficiency of energy production _____, ___ and ____ sets in.
anaerobic / decreases / lactic acid accumulates and fatigue
A good estimate of a patient’s _____ is derived by multiplying the FEV1 (forced expiratory volume in 1 second) by a factor of ____.
maximum voluntary ventilation (MVV) / 35
To estimate the MVV of a patient with FEV1 of ___
1.5 L
Benefits from Exercise Reconditioning
ACCEPTED BENEFITS
Increased physical endurance Increased maximum O2 consumption Increased activity levels with:
Decreased ventilation
Decreased VO2
Decreased heart rate
Increased ventilatory threshold Improved blood lipids
POTENTIAL BENEFITS
Increased sense of well-being Improved secretion clearance Increased hypoxic drive Improved cardiac function
Prolonged survival
Improved pulmonary function test results Decreased pulmonary artery pressure Improved blood gases
Change in muscle O2 extraction
Change in step desaturation
UNPROVEN BENEFITS
Patients with COPD who lack adequate pulmonary function have severe limitations to their ______
exercise capabilities.
Patients with COPD their high rate of CO2 production during exercise results in ___ and ____ out of proportion to the level of activity.
respiratory acidosis and a shortness of breath
as ventilation increases, the rate of O2 consumption in a patient with COPD _____ significantly
increases
_____ must include efforts to recondition patients physically and increase their exercise tolerance.
Pulmonary rehabilitation
____ involves strengthening essential muscle groups, improving overall O2 utilization and enhancing the body’s car- diovascular response to physical activity
Reconditioning
If the overall goal of pulmonary rehabilitation is to improve the quality of patients’ lives, physical reconditioning alone is ____
insufficient.
___ indicators generally are good predictors of morbidity in patients with COPD.
Psychosocial
Studies show that the relative success of reconditioning plays __ of a role in determining whether patients complete a program than meeting their ____
less / psychosocial support needs
emotional states such as ___ and ___ can aggravate an existing physical problem.
anxiety and stress
physical manifestations of disease, such as recurrent dyspnea, can increase an individual’s ____ .
stress level
The progressive nature of ____ can negatively affect the patient’s overall outlook on his or her disease and reduce moti- vation to adapt to its consequences.
COPD
Patients with COPD often have a tendency to develop severe
__ ,___, and___ as a direct consequence of their disability.
anxiety, hostility, and stress
Because patients are fearful of economic loss and death, they can develop ____ toward the disease and often toward the people around them.
hostility
In terms of ____ , the
physiologic impairment of chronic lung disease combined with other variables can severely restrict a patient’s ability to perform routine tasks requiring physical exertion.
social function
patients’ potential loss of confidence in their ability to care for themselves reduces ____ and ____
feelings of dignity and self-worth.
It is here that the link between the ____ and _____ components of rehabilitation becomes most evident.
physical reconditioning and psychosocial support
By reducing exercise intolerance and enhancing the body’s cardiovascular response to physical activity, patients can develop a more ___ and ____
independent and active lifestyle
For some patients, simply being able to walk to the market or play with their grandchildren can contribute to a greater feeling of _____
social importance.
For others, _____ may allow a return to near-normal levels of activity, including vocational pursuits.
physical conditioning
Many patients disabled with pulmonary disease are in their economically productive years and are anxious to return to economic self-sufficiency. For these patients, ___ and ____ are key ingredients in a good ______
occupational retraining and job placement
rehabilitation program.
An _______ can play a vital role here and should be included, if possible, as a member of the interdisciplinary rehabilitation team and in the pulmonary rehabilitation program.
occupational therapist
The ______ program should be based on the individual needs and expectations of each patient.
pulmonary rehabilitation
Evaluation and placement of the rehabilitation patient may require the skills of ___ and _____ along with the cooperation of _____
vocational counselors and occupational therapists
business and industry.
______ vary in their design and implementation but generally share common goals.
Pulmonary rehabilitation programs
These general goals assist ___ in formulating more specific program objectives.
planners
When determining objectives, both ___ and _____ should have input.
patients and members of the rehabilitation team
These ___ should always be stated in measurable terms because this helps facilitate the determination of both patient outcomes and the therapeutic success and value of pulmonary rehabilitation.
objectives
• Development of diaphragmatic breathing skills
• Development of stress management and relaxation
techniques
• Involvement in a daily physical exercise regimen to condition both skeletal and respiratory-related muscles
• Adherence to proper hygiene, diet, and nutrition
• Smoking cessation (if applicable)
• Proper use of medications, O2, and breathing equipment (if applicable)
• Application of airway clearance techniques (when indicated)
• Focus on group support
• Provisions for individual and family counseling
program objectives
When program objectives are specifically defined and structured in a measurable way, ____ can be tailored to ensure the ___ and ____
strategies / maximum results and benefit.
Demonstration of program effectiveness also becomes easier and more acceptable by the ______.
medical community
_____ realized by participating patients are not always easy to identify and may be controversial.
benefits
• Control of respiratory infections
• Basic airway management
• Improvement in ventilation and cardiac status
• Improvement in ambulation and other types of physical
activity
• Reduction in overall medical costs
• Reduction in hospitalizations
• Psychosocial support
• Occupational retraining and placement (when and where
possible)
• Family education, counseling, and support
• Patient education, counseling, and support
• Control of respiratory infections
Common Goals for Pulmonary Rehabilitation Programs
Before beginning a ____ , clini- cians need to define and establish criteria for entry or selection.
pulmonary rehabilitation program
They need to be aware of any___ a patient may have along with the effects exercise may have on ___ and ____
comorbidity / blood chemistry and a patient’s overall physical status.
____ requires comprehensive evaluation and testing.
Patient selection
Pulmonary rehabilitation programs must have a qualified medical director, usually a ______, to provide overall medical direction of the program and to screen prospective patients.
pulmonologist
Patient evaluation begins with a complete ____
patient history—medical, psychological, vocational, and social.
A well- designed patient ____ and ____ assist with this step.
questionnaire and interview form
The patient history should be followed by a complete ____
A recent __
physical examination / chest film, resting electrocardiogram (ECG), complete blood count, serum electrolytes, and urinalysis provide additional information on the patient’s current medical status
To determine the patient’s cardiopulmonary status and exercise capacity, both ___ and ____ may be performed.
pulmonary function testing and a cardiopulmonary exercise evaluation
Pulmonary function testing includes assessment of ______
pulmonary ventilation, lung volume determinations, diffusing capacity (DLCO), and spirometry before and after bronchodilator use
The ______ serves two key purposes in pulmonary rehabilitation. First, it quantifies the patient’s initial exercise capacity.
cardiopulmonary exercise evaluation (CPX)
First, it quantifies the patient’s initial exercise capacity. This quantification provides the basis for the exercise prescription (including setting a _____ ) and yields the baseline data for assessing a patient’s progress over time.
target heart rate
_____ helps determine the degree of hypoxemia or desaturation that can occur with exercise; this provides the objective basis for _____ during the exercise program.
cardiopulmonary exercise evaluation (CPX) / titrating O2 therapy
To guide practitioners in implementing exercise evaluation, the ____ has published clinical practice guidelines on exercise testing for evaluation of hypoxemia or desaturation or both and pulmonary rehabilitation.
American Association for Respiratory Care (AARC)
The ____ involves serial or continuous measurements of several physiologic parameters during various graded levels of exercise on either an ergometer or a treadmill
exercise evaluation procedure
To allow for steady-state equilibration, these graded levels are usually spaced at
_____ intervals.
3-minute
Work levels are increased progressively until either (1) _____ or (2) ______
- the patient cannot tolerate a higher level
- an abnormal or hazardous response occurs.
___ and _______ measures are obtained at rest and at peak exercise.
Blood gas and arterial saturation
Samples from ______ are as good as samples drawn from indwelling catheters.
single arterial punctures
If the peak exercise puncture is unsuccessful, a sample drawn within _______ of test termination usually suffices.
10 to 15 seconds
_______ has a limited but nonetheless important role in exercise evaluation.
pulse oximetry
The best use of____ is as a monitor to warn clinicians of gross desaturation events during testing.
pulse oximetry
the _____ can be used to assess the patient’s response to supplemental O2 during exercise.
pulse oximeter
• Inability or unwillingness of patient to perform the test
• Severe pulmonary hypertension or cor pulmonale
• Known electrolyte disturbances (hypokalemia, hypomagne-
semia)
• Resting diastolic blood pressure greater than 110 mm Hg or
resting systolic blood pressure greater than 200 mm Hg
• Neuromuscular, musculoskeletal, or rheumatoid disorders
exacerbated by exercise
• Uncontrolled metabolic disease (e.g., diabetes)
• SaO2 or SpO2 less than 85% with the subject breathing
room air
• Untreated or unstable asthma
• Angina with exercise
contraindications to exercise testing
____ also can help differentiate among patients with primary respiratory or cardiac limitations to increased work capacity.
Exercise evaluation
Common Physiologic Parameters Measured During Exercise Evaluation
• Blood pressure
• Heart rate
• ECG
• Respiratory rate
• Arterial blood gases/O2 saturation
• Maximum ventilation (VEmax)
• O2 consumption (either absolute VO2 or METS)
• CO2 production (VE/VCO2)
• Respiratory quotient (RQ)
• O2 pulse ( VO2:heart rate)
____ can assist in placing patients in the appropriate type of rehabilitation program.
test results
To minimize patient risk during exercise evaluation, certain ____ are implemented.
safety measures
To minimize patient risk during exercise evaluation, certain safety measures are implemented. First,second,third, fourth and last
First, the patient should undergo a physical examination just before the test, including a resting ECG.
Second, a qualified physician should be present throughout the entire test.
Third, emergency resuscitation equipment (cardiac crash cart with monitor, defibrillator, O2, cardiac drugs, suction equipment, and airway equipment) must be readily available.
Fourth, staff conducting and assisting with the procedure should be certified in basic and advanced life- support techniques.
Last, the test should be terminated promptly whenever indicated.
With regard to test preparation, patients should fast ___ before the procedure.
8 hours
With regard to test preparation, patients should fast ___ before the procedure.
8 hours
If the purpose of the test is to formulate an exercise prescription, the patient can take his or her_____.
regular medications
The patient should wear _____ for treadmill or ergometer activity.
comfortable, loose-fitting clothing and footwear with adequate traction
The ______ used during the test should be sized properly and fit comfortably with no leaks.
mouthpiece or face mask
Test conditions should be as _____ as possible to allow for comparison of results before and after rehabilitation periodically from year to year as the patient is treated and followed.
standardized
Patients most likely to benefit from participation in pulmonary rehabilitation are patients with persistent symptoms caused by____ who have _____
COPD / low maximum O2 uptakes at baseline.
_______ should be a part of the discharge planning process when a patient is released from the hospital after an exacerbation of the existing chronic respiratory condition.
Pulmonary rehabilitation
The feasibility of rehabilitation should be reviewed with the_______ and_______
patient, physician, and respiratory therapist (RT).
Regardless of underlying conditions, patients also should be ______.
ex-smokers
Any patients who smoke should enroll in a _______ before starting pulmonary rehabilitation.
smoking cessation program
Patients are excluded from pulmonary rehabilitation activities if ______
(1) concurrent problems limit or preclude participation in exercise or (2) their condition is complicated by malignant neoplasms, such as lung cancer
• Patients in whom there is a respiratory limitation to exercise
resulting in termination at a level less than 75% of the pre-
dicted maximum O2 consumption (V O2max)
• Patients in whom there is significant irreversible airway obstruction with a forced expiratory volume in 1 second (FEV1) of less than 2 L or an FEV1% (ratio of FEV1 to forced vital capacity [FVC]) of less than 60% (refer to the Global Initiative on Obstructive Lung Disease [GOLD] standards for COPD severity)
• Patients in whom there is significant restrictive lung disease with a total lung capacity (TLC) of less than 80% of pre- dicted and single breath carbon monoxide diffusing capacity (DLCO) of less than 80% of predicted
• Patients with pulmonary vascular disease in whom single breath DLCO is less than 80% of predicted or in whom exer- cise is limited to less than 75% of maximum predicted O2 consumption (predicted V O )
candidates considered for inclusion in a pulmonary rehabilitation program
Groups or classes for pulmonary rehabilitation should be kept ______.
homogeneous
Placing individuals in a program who are at different stages of cardiopulmonary disability can be very______.
defeating
Individuals with mild to moderate impairment may become ______ on how severe lung disease can become,
discouraged
individuals with severe impairment may feel they _____ of activity exhibited by others with less severe impairment.
cannot keep up with or maintain the level
