Pulmonary Quiz Flashcards

1
Q

obstructive lung disease

A

chronic inflammation of the lungs causing obstruction in exhalation

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2
Q

COPD

effect on lungs

A

chronic obstructive pulmonary disease
leads to deterioration of small airways
airflow obstruction can come from retaining secretions, inflammation of lining, bronchial constriction, weakened support structure, increased compliance of tissue
airways close prematurely and trap air, causing hyperinflation

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3
Q

progression of COPD

A

causes mismatched perfusion at capillaries, results in hypoxemia and decreased O2 in arterial blood
progresses further to hypercapnia/increased CO2 in blood and contributing to pulmonary hypertension

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4
Q

COPD prevalence

A

most common chronic respiratory disease
common cause of death

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5
Q

COPD demographics

A

40+ y/o
slightly more women than men
smoking
low SES
unemployed/retired/disability
southwest/midwest
rural
poor air quality

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6
Q

risk factors for COPD

A

occupational exposure
air pollution
age
cigarette smoking
childhood respiratory conditions
genetics
SOB w activity

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7
Q

COPD clinical presentation

A

dyspnea worse w exertion
chronic cough
barrel chest
wheezing
reduced/absent breath sounds
retaining CO2
excess sputum coughed up

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8
Q

COPD function testing (PFT)

A

spirometry measuring time-volume relationship in lung - test for delayed and incomplete emptying
forced expiratory volume
forced expiratory volume over 1 sec/forced expiratory capacity should be >75%

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9
Q

Gold Staging of COPD

A

mild: FEV1 is 80% of normal, mild symptoms and SOB, chronic cough
mod: FEV1 is 50-80% of normal, chronic cough, sputum, dyspnea
severe: FEV1 is 30-50% of normal, chronic cough, sputum, dyspnea
very severe: FEV1 is less than 30% of normal, chronic cough, sputum, dyspnea, R HF, weight loss

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10
Q

changes in lung values with COPD

A

all are elevated volume, total lung capacity is higher due to trapped air
same tidal volume amount but higher residual volume

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11
Q

BODE Index

A

index for COPD severity
predicts hospitalization, survival
0-10 points
0-2 80% 4 year survival
3-4 67%
5-6 57%
7-10 18%

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12
Q

Medical management of COPD includes

A

smoking cessation
pharm: mucolytics, bronchodilators, steroids
flu vaccine
pneumonia vaccine
treat any sleep disorders
pulmonary rehab and exercise training
surgery to remove damaged lung segments

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13
Q

emphysema

A

lung condition where alveolar walls are destroyed and airspaces distal to terminal bronchioles are enlarged
end stage COPD

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14
Q

causes of emphysema

A

smoking is main cause
also environmental toxins

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15
Q

emphysema s/s

A

non productive dry cough or absent cough
not eating
NOT cyanotic
accessory muscle use
pursed lip breathing
lean forward

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16
Q

chronic bronchitis

A

presence of chronic productive cough for 3 months in each of 2 successive years
mucus hyper secretion in large airways, progressing to smaller airways
hypertrophy of submucosal glands
crackling breath sounds

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17
Q

emphysema vs chronic bronchitis

A

pink puffer vs blue blower
emphysema:
- accessory muscles for breathing
- pursed lip breathing
- absent cough
- leans forward to breathe
- dyspnea on exertion
chronic bronchitis:
- excess body fluid
- chronic cough
- SOB
- increased sputum
- cyanosis

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18
Q

COPD thorax ROM

A

decreased excursion
muscles of ventilation become stretched and diaphragm unable to return to dome shape, flattening
accessory muscles required to breathe

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19
Q

asthma s/s

A

wheezing, SOB, chest tightness, fatigue during exercise, poor athletic performance, avoid activity, coughing
cough worse at night and morning

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20
Q

asthma mechanism

A

inflammatory response caused by trigger
narrowed airways/bronchospasm
increased secretions
resistance to airflow and trapping of exhalation
can lead to airway remodeling in uncontrolled asthma

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21
Q

asthma risk factors

A

genetics
boys>girls
environmental
infections
allergens
obesity

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22
Q

spirometry for asthma

A

provoke attack with bronchoconstrictor agent and measure
compare measurement with bronchodilators
decreased FEV1 with increased RV and functional residual capacity
should be reversible with bronchodilators/inhaler

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23
Q

peak flow meter

A

measures expiration in one quick blast 1 second
compare to age or personal norms

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24
Q

asthma severity levels

A

intermittent: <2x week, not interfering with normal activities, spirometry above 80%
mild persistent: >2x week, nighttime symptoms 3-4x month, spirometry above 80% when not having an attack
mod persistent: daily symptoms and daily meds, nighttime symptoms >1x week, interferes with activity, abnormal spiromatry >60%
severe persistent: continuous symptoms day and night, severely limited activity, frequent attacks, spirometry <60%

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25
Q

asthma medical management

A

prevention: avoiding triggers/exposures
long term control with pharm: anti inflammatory, bronchodilators, combo
exercise within activity parameters that won’t trigger attack

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26
Q

asthma clinical presentation

A

altered breathing pattern
wheezing breath sounds
decreased breath sounds in attack
dyspnea on exertion
coughing at night/after infection
accessory muscle use
pursed lip breathing
postural changes

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27
Q

asthma prevention

A

lifestyle modification: diet, sleep, reduce irritant exposure, hydration, weight, activity, flu shot
reduce household: mold, pets, wash bedding, HEPA filters, sanitize fabrics
exercise induced asthma should warm up, hydrate, cover nose in cold

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28
Q

PT implications with COPD

A

clear secretions
control breathing w rest and activity
ambulate
endurance
strength
thoracic stretching
postural reeducation

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29
Q

PT implications with asthma

A

secretion clearing
controlled breathing
exercise and strength
thoracic stretching
postural reed
pt edu/HEP
start once medication regiment stable

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30
Q

how does aerobic exercise impact asthma?

A

controls symptoms and lung function but does not affect airway inflammation
decreased exacerbation
low intensity, 3-5x week
progressively increase as tolerated without aggravating

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31
Q

cystic fibrosis

A

genetic condition
life threatening
abnormal protein affects cells to produce thickened mucus and sweat which gets stuck, reducing function and causing infection
affects respiratory, digestive, reproductive

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32
Q

prevalence of cystic fibrosis

A

recessive gene, need two carrier parents
genetic testing/sweat test

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33
Q

CF medical management

A

control: lung infections, mucus clearance, nutritional status, pancreatic status
nutrient supplementation
increase in survival to 38

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34
Q

CF symptoms

A

persistent cough: productive with sputum
recurrent lung infections
nutrient malabsoprtion
vitamin deficiency
pancreatic insufficiency
muscle pain
reduced bone density
diabetes
pursed lip breathing
accessory muscle hypertrophy
abnormal breath sounds: crackle, wheeze
cyanosis
digital clubbing

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35
Q

s/s of acute CF exacerbation

A

increased cough, sputum production, temperature, respiratory rate, WBC count
decreased FEV1, appetite, weight, activity level

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36
Q

PT treatment of CF

A

secretion clearance
controlled breathing
exercise/strength
inspiratory muscle training
thoracic stretching
postural reed
pt education on infection control and home management

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37
Q

restrictive lung disease

A

less common than obstructive
caused by intrinsic impairment or extrinsic condition affected chest wall mobility, NM function, obesity
results in reduced lung expansion, lung volume
hard to get air into lungs bc they can’t expand fully

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38
Q

FEV1/FVC ratio in RLD

A

cannot inhale as much but no issue exhaling
ratio will be normal or increased
in general all lung volumes are reduced
FEV1 and FVC are both decreased

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39
Q

s/s of restrictive lung disease

A

tachypnea
hypoxemia
fatigue
weight loss
decreased lung volumes
chronic dry cough
pulmonary HTN/signs of HF

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40
Q

interstitial lung disease types

A

exposure related: chemo/meds, environmental/dust/fumes/radiation
autoimmune: RA, lupus, scleroderma, polymyositis, dermatomyositis
idiopathic

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41
Q

interstitial lung disease is…

A

inflammatory process of alveolar wall that causes fibrotic scarring
progressive
many types

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42
Q

risk factors for pulmonary fibrosis

A

age
smoking
genetic predisposition
air pollution
viral infection
GERD
more common in men

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43
Q

s/s idiopathic pulmonary fibrosis

A

dry cough, weight loss, fatigue, digital clubbing, LE edema

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44
Q

Sarcoidosis

A

inflammatory autoimmune condition
multisystem
presence of tiny granulomas
lungs and lymph nodes
women more than men, 30-55 y/o

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45
Q

RA

A

chronic peripheral joint inflammation
results in progressive destruction of articular/periarticular structures
pleural involvement, pulmonary nodules/vasculitis, bronchiolitis, bronchogenic cancer

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46
Q

risk factors for interstitial lung disease

A

RA (esp severe)
smoker
age
male

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47
Q

clinical presentation of RA and interstitial lung disease

A

progressive dyspnea
non productive cough
cyanosis
warm/swollen joints
diminished breath sounds/rales

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48
Q

systemic lupus

A

multi system autoimmune disorder causing chronic inflammation of connective tissue
skin, joints, kidneys, lung, NS, heart
affect lungs: pleuritis and diaphragmatic weakness

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49
Q

clinical presentation of SLE -systemic lupus erythematosus

A

articular pain and swelling
OA
dyspnea
fatigue
cough
weight loss
raynaud’s phenomenon
photosensitivity
fever
mouth ulcers
chest pain
hair loss
eye disease
kidney
anemia

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50
Q

scleroderma

A

autoimmune, idiopathic
progressive fibrosing in skin, blood vessels, esophagus, GI, lung, heart, kidneys, joints
appears as interstitial fibrosis
no cure, symptom management

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51
Q

s/s scleroderma

A

skin thickening/swell/tighten
enlarged blood vessels
calcium deposits on skin
HTN from kidney dysfx
heartburn
GI involvement
weight loss
decreased lung volume
raynaud’s
dy cough
joint pain

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52
Q

polymyositis/dematomyositis

A

inflammatory autoimmune
progressive muscle weakness/skin changes
pulmonary characteristics:
aspiration pneumonia, neck muscle weakness, respiratory muscle weakness, elevated diaphragm
SOB, dry cough

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53
Q

SCI and pulmonary involvement

A

C3: vent dependent
C4: may need support
C5: may or may not need depending on zone of partial preservation
pts less likely to be able to cough or breathe fully, increased risk of infection
paradoxical breathing: belly expands and ribs depress or belly flattens and ribs expand

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54
Q

diaphragm paralysis impact on respiration

A

commonly from phrenic nerve
causes diaphragm to pull up and ribs in
results in alveolar hypoventilation/poor gas exchange
UL won’t need treatment, teach compensation
BL needs vent support

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55
Q

ALS and pulmonary function

A

reduced due to weakness, secretions, infiltrates
decreased breath sounds, poor airway clearance, dyspnea w mild exertion

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56
Q

poliomyelitis and pulmonary function

A

reduced lung volume, rhonchi, weak cough, anxious, poor airway clearance, dyspnea, fatigue, poor endurance

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57
Q

Guillain Barre and pulmonary function

A

reduced lung volume, rhonchi/crackles, BL LE weakness, anxious, poor cough, poor clearance, reduced endurance/fatigue

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58
Q

Myasthenia Gravis and pulmonary function

A

chronic NM disease
progressive muscle weakness on exertion
reduced lung volumes, breath sounds, poor airway clearance, crackles/rhonchi
weakness, fatigue, dyspnea, weak cough

59
Q

ankylosing spondylitis and pulmonary function

A

chronic inflammatory of spine, immobility of SI and vertebral joint, ligament ossification
arthritic
decreased chest wall compliance

60
Q

kyphosis/scoliosis and pulmonary function

A

often idiopathic
angle of >120 degrees can affect chest movement and respiratory failure

61
Q

pectus excavatum

A

funnel chest with sternal depression, could restrict lung volume

62
Q

pectus carinatum

A

pigeon breast, associated with childhood asthma

63
Q

obesity and pulmonary function

A

central fat deposits affecting breathing mechanics
restricted chest wall making expansion difficult
reduced volumes
shallow breathing

64
Q

supportive therapies for RLD

A

supplemental O2
antibiotics for secondary infection
ventilation
prevention secretion accumulation
nutritional support

65
Q

total lung capacity in restrictive lung disease

A

<80%
70-80 mild
60-70 mod
50-60 mod severe
<50 severe

66
Q

thoracic trauma and restrictive lung dysfunction

A

blunt or penetrating
respiratory compromise with lung contusion, rib fracture, flail chest
cause shallow breathing, chest wall excursion, decreased lung expansion

67
Q

flail chest

A

free floating rib segment from Fx
pain causes splinting, holding ribs in so can’t take full breath
paradoxical breathing due to compromised motion

68
Q

rib Fx and pulmonary function

A

often lower ribs
restrictions due to pain
shallow breathing to prevent thoracic expansion
hemothorax taking up space
fluid in lungs, fibrosis, scarring

69
Q

pneumothorax and pulmonary function

A

air in pleural space collapsing lung
tracheal deviation away from affected lung
absent/decreased breath sounds
UL pain in chest, dyspnea, tachycardia
can be spontaneous or traumatic

70
Q

atelectasis

A

alveoli collapse
common post op or RLD
treat w deep breathing to open alveoli

71
Q

pleural effusion

A

fluid build up in space
limits lung expansion
caused by HF, pneumonia, neoplasm

71
Q

transudative pleural effusion

A

elevated hydorstatic pressure in pleural capillaries
increased pressure causes more fluid being reabsorbed into pleural space
result of HF

72
Q

exudative pleural effusion

A

increased permeability allows more fluid in pleural space
inflammatory neoplastic diseases cause
infection or tumor

73
Q

s/s pleural effusion

A

diminished sounds over pleural effusion
dullness to percussion
decreased tactile fremitus
pleural friction rub
dyspnea
pleuritic chest pain
dry cough

74
Q

pleural effusion treatment

A

target underlying cause
thoracocentesis
O2 supplemental
pain management

75
Q

pleurisy

A

swelling/irritation between pleural layers
associated with effusion

76
Q

s/s pleurisy

A

shapr/stabbing pain, worse w cough/breath, dyspnea, radiating, chest palpation shows sandpaper sensation, increased fremitus

77
Q

Acute respiratory distress syndrome (ARDS)

A

widespread inflammatory condition
triggered by illness, trauma, complication of surgery
organ fills with fluid causing respiratory failure
dyspnea at rest, increased RR, cyanotic, anxiety

78
Q

ARDS treatment

A

mechanical vent
treat cause
position in prone for oxygenation

79
Q

pulmonary edema

A

excess fluid from pulmonary vascular system into interstitial areas and alveoli
cardiogenic, ARDS, lymphatic insufficiency
increases work of breathing w decreased lung compliance, reduced gas exchange

80
Q

s/s pulmonary edema

A

respiratory distress, dyspnea worse in supine, paroxysmal noctural dyspnea, cyanotic, increased RR, labored breathing, pallor, diaphoresis, anxiety
decreased breath sounds, crackles, increased tactile fremitus, S3, LE edema

81
Q

pulmonary edema treatment

A

supplemental O2, target cuase, bronchial hygiene for secretions

82
Q

Pulmonary embolism risk

A

CHF, acute MI, CVA, obesity, lupus, immobilized, SCI, trauma, oral contraceptives, post op, prior history

83
Q

PE incidence

A

1-2/1000
25% sudden death
10-30% die 1 mo later
30-50% have long term complications
33% have recurrence in 10 years

84
Q

s/s PE

A

acute dyspnea/tachycardia, chest pain, cough w blood, tachypnea, weak, hypotensive, lightheaded, dizzy, syncope, anxiety

85
Q

treat PE

A

prevent w exercise, meds
heparin to treat DVT
low risk pt test D dimer for blood clot breakdown
mod/hi risk straight to CT w contrast

86
Q

pulmonary hypertension

A

high BP in lungs
damages lung blood vessels

87
Q

pulmonary HTN s/s

A

JVD, irregular heart sounds, LE edema/abdomen
only able to work at low levels

88
Q

pulmonary arterial hypertension

A

arteries narrow/stiffen
advanced resistance can form lesions and thrombus
cause R HF and death

89
Q

pulmonary HTN from L sided HF

A

heart can’t pump effectively, back up of blood from L side leads to increased pressure in the lungs
treat by managing heart failure

90
Q

pulmonary HTN due to lung disease

A

chronic lung disease or hypoexmia like obstructive/restrictive/sleep apnea/altitude
arteries in lungs constrict so blood only goes to well ventilated areas of lungs

91
Q

pulmonary HTN due to chronic blood clots

A

bpdy not able to dissolve blood clots in the lungs, causing scarring in arteries
this increases resistance and leads to pulmonary hypertension and R sided issues
treat by thromboendarterectomy surgery, medication

92
Q

other conditions causing secondary pulmonary hypertension

A

sarcoidosis, sickle cell anemia, splenectomy, metabolic disorder

93
Q

who qualifies for a lung transplant

A

progressive/terminal cardiopulm disease
limited life expectancy
many have emphysema, others include COPD, pulomnary fibrosis, CF, idiopathic pulmonary artery HTN, sarcoidosis

94
Q

stats on lung transplant

A

80% surivive 1 year post
50% survive 5 years
80% have minimal activity limitations

95
Q

evaluation for lung transplant

A

to get on donor list
need:
- social support
- compliance w medical regimen
- coping style
- caregiver stress

96
Q

UNOS ranking

A

based on:
- tissue match
- blood type
- time on list
- immune status
- distance

97
Q

lung transplant absolute contraindications

A

active malignancy in 2 years
abuse of alc, tobacco, narcotics
HIV infection
chest wall/spinal deformity
Hep B positive
Hep C positive w liver disease
limited ability to comply to med regimen
untreatable psych condition making unable to comply
absence of support system

98
Q

relative contraindications to lung transplant

A

symptomatic osteoporosis
65+
limited functional status, poor rehab potential
morbid obesity
mechanical vent
resistant bacteria
unstable clinical condition

99
Q

preop rehab for lung transplant

A

20 sessions 2-3 times week + home session
as high intensity as is possible
interval training
UE/LE
endurance and strength
inspiratory training
O2 supplementation while training

100
Q

pt education pre op lung transplant

A

breathing strategies
lung function
pathophysio of disease
med use
bronchial hygiene
exercise benefits
energy conservation
nutrition
smoking cessation
sexuality
need for healthcare

101
Q

restrictive dysfunction after lung transplant

A

long term complication
fibrosing of terminal bronchioles
s/s: dyspnea, reduced exercise tolerance, productive cough, decreased breath sounds, crackles, rales, pulmonary HTN
treat: prevent through immunosuppressants, intervene quickly w infections/rejection

102
Q

post op of lung transplant

A

start rehab once pt is stable, usually 1-2 days after in ICU
protective isolation
train ineffective cough and mucus secretion by teaching positioning and hygiene

103
Q

levels of pulmonary rehab progression

A

1-2 in hospital, may progress as fast or as slow as pt tolerates based on pre op status
3 is home or inpt rehab
4 is home

104
Q

levels of pulmonary rehab: 1

A

breathing/relaxation techniques
exercise bed/seated
shoulder movement
trunk rotation
seated marching, bridge, knee extension
ankle pumps
standing pregait activities
seated in chair

105
Q

levels of pulmonary rehab: 2

A

shoulder exercise
lunges
marching
mini squats
weight shifts
SLS
toe raises
ambulate in room, hall as tolerated
independent transfer to chair

106
Q

levels of pulmonary rehab: 3

A

head/shoulder exercise w wrist weights
toe raises
dynamic balance
gait ambulating 10-15 min
cool down stretch LE

107
Q

levels of pulmonary rehab: 4

A

level 3 exercise
progress ambulation to 20 min consistently
stationary cycle 10-20 min - mild resistance, 2-3 min warm up/cool down

108
Q

alternatives to lung transplant if not a candidate

A

lung volume reduction
remove dead parts to improve thoracic distension and chest wall mechanics
non invasive BiPAP: biphasic airway pressure - mask delivering pressure for respiratory failure at night or flareup

109
Q

pneumonia

A

inflammatory reaction in lungs from inhaling/aspirating bacteria
moist/warm lungs promotes growth in smaller distal tissue

110
Q

process of pneumonia

A

pathogen inhlaed, travels to deep lungs, alveoli inflamed
fill w fluid, harder to fight rising infection count
consolidation/accumulation of fluid/pus impairs gas exchange

111
Q

pneumonia risk factors

A

age
impaired immune system
multiple comorbidities
smoker
acute head/neck/chest trauma
severe illness
mech vent
trach/GI tube
nosocomial acquired infection
aspiration

112
Q

community acquired pneumonia

A

person gets pneumonia from community :) so silly

113
Q

hospital acquired pneumonia

A

nosocomial infection where pt acquires pneumonia from being in hospital/SNF

114
Q

diagnosis of pneumonia

A

abnx lung sounds
crackles on inspiration
blood test
xray
sputum culture
CT/ABG/bronchoscopy/thoracentesis

115
Q

lobar pneumonia

A

bacterial
affects a lobe of the lung
at risk: post op, weakened immune system
more common form
more serious
symptoms: high fever, increased HR/RR/cyanosis/confusion

116
Q

viral pneumonia

A

commonly caused by flu or RSV
not as serious, faster recovery

117
Q

fungal pneumonia

A

common in those w chronic condition or weakened immune systems

118
Q

aspiration pneumonia

A

caused by dysphagia, NG/trach, trauma, poor mental status, poor oral hygiene
obstruction or chemical

119
Q

aspiration pneumonia: airway obstruction

A

obstructed area due to aspiration
decreased breath sounds over area

120
Q

aspiration pneumonia: chemical pneumonitis

A

inhale toxic substance
aspirate GI contents
contributes to acute lung injury/inflam/infection
rapid progression causing atelectasis/edema

121
Q

complications of pneumonia

A

pleural effusion
bacteremia - bacteria in the bloodstream
septic shock
lung abscess
respiratory failure
kidney failure
heart failure

122
Q

pneumonia treatment

A

prevention
vaccination
reduce risk of aspiration with positioning recumbant
dental hygiene
early mobilization
drug therapy
supplemental O2
mech vent
postural drainage

123
Q

pneumonia clinical presentation

A

fever
productive cough
elevated WBC
positive sputum
fatigue
weight loss
sweating
chills
severe: dyspnea, tachypnea, tachycardia, hypoxemia, O2 desat, confusion

124
Q

PT exam findings

A

fremitus, dullness to percussion over consolidated area
SOB
exercise limitation
weak proximal UE
limited endurance

125
Q

pneumonia PT interventions

A

ACT
pursed lip breathing
coughing techniques
IMT
exercise to enhance QOL and improve function

126
Q

TB

A

bacterial infection in the lungs, curable and preventable but most deadly disease in the world
1/3rd infected
higher rism w HIV
spread through airborne droplets

127
Q

active TB

A

contagious, symptomatic, active infection

128
Q

latent Tb

A

TB bacteria in the body that is nto making you sick
asymptomatic, not contagious
+ TB skin text, negative chest xray/sputum

129
Q

diagnose TB

A

TB skin test
blood test
chest xray
biopsy
bronchoscopy
thoracentesis
spirometry
V/Q scan

130
Q

pathophys of TB

A

incubation 2-12 days
disease lasts 10 days-2 weeks
give meds for 3-12 months to reduce risk of secondary infection
not contagious after 2 weeks on medication

131
Q

TB precautions

A

negative pressure room
TB mask/N95
universal precautions
for pt to leave room where N95

132
Q

TB clinical prsentation

A

cough lasting longer than 3 weeks
pain in the chest
coughing blood/sputum
weakness/fatigue
weight loss
no appetite
fever/chills/night sweats

133
Q

TB damage to lung

A

acute inflammatory response
structural changes, damage due to complications
chronic complications can develop imapiring pulmonary function
also cause long term joint damage, liver/kidney problems, bone/brain/lymph infection

134
Q

TB prevention

A

diagnose latent - complete all medications to reduce chance of active infection
limit contact w active infection
vaccination
TB screening

135
Q

lung cancer screening

A

high risk screen w scan:
current smokers or those who quit in last 15 years
counsel to quit smoking
30 pack year smoking history
explain risks and benefits of scan

136
Q

risk factors for lung cancer

A

smoking
radon exposure
environmental exposure
pulmonary fibrosis
genetics
presence of HIV
alcohol

137
Q

lung cancer treatment

A

surgery: remove tumor in early stages
radiation: targte all types
chemo: effect depends on type

138
Q

diagnose lung cancer

A

often incidental finding of nodule or mass
CT scan first, then repeat to monitor size, shape, location, appearance

139
Q

non-small cell bronchogenic carcinoma

A

most common type in US, 90%
slower growing

140
Q

adenocarcinoma

A

common form of non small cell lung cancer found in outer lungs in mucus glands
symptoms: cough, hoarse, weight loss, weakness

141
Q

small cell lung cancer

A

less common than all non small cell types

142
Q

pancoast tumor

A

rare, 3-5%
symptoms: shoulder pain
often small cell
superior sulcus tumor in apex of either upper lung and surrounding tissues: muscle, bone, vertebrae, sympathetic NS