Pulmonary Diseases

Question 1

What are the benefits of pulmonary rehabilitation?

Answer 1

Improves exercise tolerance, Reduces symptoms, and improves quality of life

Question 2

What adjuncts have the potential to improve exercise performance and quality of life in pulmonary patients?

Answer 2

1) Supplemental oxygen
2) Bronchodilation techniques
3) Breathing retraining techniques (Pursed lips breathing)
4) Use of rollators (walkers) or other devices

Question 3

What is the pathophysiology of asthma?

Answer 3

Heterogenous chronic inflammatory disorder characterized by a history of episodic bronchial hyperresponsiveness, variable airflow limitation, recurring wheeze, dyspnoea, chest tightness, and coughing particularly at night or early morning

Question 4

What are the benefits of exercise in patients with asthma?

Answer 4

1) Days without asthma symptoms
2) Pulmonary VE
3) Maximal work rate
4) Exercise endurance

Question 5

What is exercise induced bronchoconstriction and how may it be avoived?

Answer 5

Airway narrowing that occurs as a result of exercise.
Variable warm-up with vigorous intensity producing a 10-15 minute refractory period
Pharmacotherapy

Question 6

What are the 6 types of COPD and define them?

Answer 6

Chronic bronchitis: Chronic productive cough for 3 months in 2 successive years
Emphysema: Permanent enlargements of alveoli with destruction of alveolar walls and without fibrosis
Asthma: Chronic obstruction to bronchospasm that is reversible
Cystic fibrosis: Chronic airway mucus production that leads to recurring infection
Bronchiectasis: Abnormal chronic enlargement of airways with impaired mucus clearance

Question 7

What is restrictive lung disease and what are the 5 types? Define them

Answer 7

Extrapulmonary respiratory disease that interfere with lung expansion
1) Interstitial lung disease/pulmonary fibrosis - scarring/thickening of parenchyma (alveoli) of the lungs
2) Sarcoidosis: Lymph node enlargement throughout the body with widespread appearance of granulomas
3) Pneumoconiosis or occupational lung disease - long-term exposure to dusts especially asbestos
4) Restrictive chest wall disease (scoliosis or kyphosis)
5) Ankylosing spondylitis: A form of spinal arthritis that eventually causes deformities in the vertebral and sacroiliac joints

Question 8

What are some types of pulmonary disease? (Not COPD or restrictive lung disease)

Answer 8

1) Lung cancer
2) Pulmonary arterial hypertension
3) Before and/or after lung transplantation or lung volume reduction surgery
4) Obesity related respiratory disease

Question 9

What are the 7 exercise testing considerations for patients with asthma?

Answer 9

1) Include cardio-pulmonary capacity, pulmonary function (before and after exercise), and oxyhaemoglobin saturation via non-invasive methods.
2) Administration of an inhaled bronchodilator (Beta-2 agonists) prior to testing to prevent EIB
3) Targets for high ventilation and HR are best achieved on a treadmill
4) Oxyhaemoglobin saturation <80% criteria for termination
5) FEV1 should be measured from baseline and 5, 10, 15, and 30 minutes following exercise test with decrease <15% from baseline criteria for EIB
6) Appropriately trained staff with physician supervision for severe bronchoconstriction - immediate administration of nebulized bronchodilators with oxygen is usually successful for relief of bronchoconstriction
7) 6 MWT used with moderate-to-severe asthma when equipment is not available

Question 10

What are 9 special exercise considerations in patients with asthma

Answer 10

1) Caution in using predicted values because of wide variability in its association with ventilation and potential HR effects of asthma control meds
2) Individuals experiencing exacerbations should not exercise until symptoms and airway function improve
3) Short-acting bronchodilators may be necessary before or after to treat EIB
4) Oral corticosteroid treatment requires resistance training due to peripheral muscle wasting
5) Cold environments and those with airborne allergens should be avoided to avoid triggering bronchoconstriction
6) Inspiratory muscle training not beneficial for asthma
7) Non-chlorinated pool
8) Possibility of asthma exacerbation in high-allergen environment
9) EIB occurs with high intensity and high duration exercise

Question 11

What are the FIIT principles for aerobic training in asthma patients?

Answer 11

F: 3-5 day/s week
I: 40-59% HRR progressing to 60-70% after 1 month
T: Progressive increase to 30-40 minutes/day
T: Aerobic activities using large muscle groups (walking, swimming, running, cycling, pool exercise)

Question 12

What are the FIIT principles for resistance training in asthma patients?

Answer 12

F: At least 2 days
I: Strength: 60-70% 1 RM, >80% for experience weight trainers, <50% 1RM for endurance
T: Strength 2-4 SETS, 8-12 repetitions
Endurance <2 sets, 15-20 repetitions
T: Weight machine, free weight, or bodyweight exercise

Question 13

What is the pathophysiology of COPD, symptoms, and systemic effects?

Answer 13

• Predisposing risk factors resulting in chronic airway inflammation due to noxious gas and particles, tobacco smoke and various environmental and occupational exposures
• Dyspnoea, chronic cough, sputum production
• Systemic effects: Weight loss, nutritional abnormalities, sarcopenia, skeletal muscle dysfunction

Question 14

What are the benefits of exercise for COPD patients and how do they occur

Answer 14

Improve symptoms, lessen development of functional impairment and disability and improve quality of life. These effects occur mainly through adaptations in musculoskeletal and cardiovascular systems that reduce stress on the pulmonary system during exercise.

Question 15

What is the purpose of exercise testing in patients with COPD?

Answer 15

1) Quantifying exercise capacity prior to PR entry
2) Establishing baseline for outcomes
3) Assessing efficacy of treatments
4) Evaluating unexplained dyspnea and exercise intolerance
5) Prognostic evaluation for individual risk stratification

Question 16

What are the guidelines from the global initiative for Chronic Obstructive Lung Disease Classification for Disease Severity in COPD patients?

Answer 16

Postbronchodilator FEV1.0/FVC: <0.7 for all
Mild: >80% age predicted values
Moderate: 50-80% predicted
Severe: 30-80% predicted
Very severe: <30% predicted

Question 17

What are the 11 exercise considerations for patients with COPD?

Answer 17

1) Test duration of 8-12 minutes in mild-to-moderate COPD compared to 5-9 minutes for severe/very severe
2) Small work rate increments
3) Blood oxygenation (PaO2 or SaO2) should be made periodically during graded exercise test and during follow up tests to determine changes in peripheral blood oxygenation.
4) Ventilatory limitations to exercise so predicted VO2 peak based on age-predicted HR not appropriate with sub max tests
5) Constant work rate test (80-90% peak WR) achieved during graded test helps to assess activity in everyday life particularly when done on a treadmill
6) Modified Borg Category Ratio 0-10 scale should be given with specific instructions on how to relate their breathlessness to scale - subjective so use caution
7) 6 MWT is great but has to be standardized (staff, hallway, verbal reinforcement, walking aides, supplemental oxygen flow rate, number of trials)
8) Minimum clinical important difference of 30 metres has been cited for 6MWT
9) Incremental shuttle walk test (10 metre track to a beep), and Endurance shuttle walk test (constant rate at % OF ISWT) useful with ISWT correlating with VO2 peak.
10) Walking protocols for those without muscle strength to overcome cycle ergometer resistance
11) Arm ergometer can result in increased dyspnea so used with caution for testing
12) <80% arterial oxyhaemoglobin desaturation for test termination criteria

Question 18

What are 11 exercise training considerations for patients with COPD?

Answer 18

1) Higher intensity yields greater benefit (reduced VE and HR at given workload) and should be encouraged where appropriate
2) Mild COPD can use healthy adult guidelines - <60% peak work rate for moderate to severe
3) Light intensity exercise for severely deconditioned
4) Dyspnea, fatigue and other symptoms can make interval training easier for patients with COPD
5) Supervision enables guidance in correct execution, safety, and optimising benefit
6) Alternative to using peak work rate of O2 peak can instead use 3-6 on Borg CR 10 scale (corresponds with 53-80% of O2 peak) - dyspnea rating during exercise test can be used for workload
7) Ventilatory limitation at peak exercise co-incides with significant metabolic reserves in severe COPD enabling individuals to tolerate high work-rates
8) Intensity targets based on HRmax or HRR inappropriate as resting HR and ventilatory limitations prohibit attainment HRmax
9) Use of oximetry can identify workload at which desaturation occurs
10) Flexibility exercise can over effect of postural impairment that limit thoracic mobility and therefore lung function
11) Closely monitor sessions and adjust based on individual responses and tolerance
- Dyspnea often exceeds objective measures

Question 19

What are the 6 special exercise considerations for patients with COPD?

Answer 19

1) Peripheral muscle dysfunction contributes to exercise intolerance and is significantly and independently related to poor prognosis and mortality - RT is important
2) Bronchodilators can reduced dyspnea and improve exercise tolerance
3) Inspiratory muscle training improves inspiratory muscle strength, endurance, functional capacity, dyspnea, and quality of life which can improve exercise tolerance in COPD.
4) Training load intensity of >30% of maximal inspiratory pressure is recommended
5) Supplemental oxygen for PaO2 <55 mmHg or SaO2 <88% breathing room air. Supplemental therapy should maintain levels above this.
6) Individuals suffering with acute exacerbation of pulmonary disease should limit exercise till symptoms subside

Question 20

What are the aerobic FIIT principles for COPD patients?

Answer 20

F: 3-5
I: 50-80% peak work rate of 4-6 BORG CR10 scale
T: 20-60 minutes at mod to high intensity. If 20 not achievable accumulate 20 or more minutes interspersed with rest
T: Common aerobic activity

Question 21

What are the resistance training FIIT principles for COPD patients?

Answer 21

F: At least 2
I: Strength 60-70% 1RM, >80% 1RM for experienced. Endurance <50% 1RM
T: 2-4 sets, 8-12 repetitions (Strength)
2 or less sets 15-20 repetitions (Endurance)
T: Weight machines, Free weight, or body weight exercises