Pulmonary Rehabilitation Flashcards
1
Q
Part 1: Noninvasive Ventilation
Ventilatory Support
- (1) ventilation
- (1) Ventilation
- Other ventilatory assists
A
- Noninvasive ventilation
- Invasive Ventilation
- Other ventilatory assists
2
Q
Question 1
Which of the following conditions is not treated with pulmonary rehabilitation?
- high level tetraplegia
- myasthenia gravis
- pulmonary edema
- emphysema
A
Ans: 3 (not for acute pulmonary edema)
3
Q
Respiratory Failure
Can be seen in:
- Neuro______disease
- (1) Injury
- ____pathy (guillain barre common in winter after flu vax)
- M___pathy
- My_______
- Primary P______ disease
A
- Neuromuscular disease
- Spinal Cord Injury
- Neuropathy (guillain barre common in winter after flu vax)
- Myopathy
- Myasthenia
- Primary Pulmonary disease
4
Q
Neurologic Diseases
- SCI – injuries above (1)-(1) which cause diaphragmatic paralysis
- Motor Neuron Disease - ex (1)
- _____ and Post _____ Syndrome
- _______ Neuropathies
- Guillain-Barre
- CIDP =
- Charcot-Marie-Tooth
A
- SCI – injuries above C3-5 which cause diaphragmatic paralysis •
- Motor Neuron Disease - ALS
- Polio and Post Polio Syndrome
- Peripheral Neuropathies
- Guillain-Barre
- CIDP Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a rare type of autoimmune disorder. In an autoimmune disease, the body attacks its own tissues. In CIDP, the body attacks the myelin sheaths. These are the fatty coverings on the fibers that insulate and protect the nerves.
- Charcot-Marie-Tooth
5
Q
Neuromuscular Junction Disease
- Myasthenia G_____
- Myasthenic S_______
- Myopathy
- Acquired in______ Myopathies
- ______ Myopathies
- D______ Muscular Dystrophy (majority)
- Becker Muscular Dystrophy
- Myotonic Dystrophy
- Congenital Muscular Dystrophy
A
- Myasthenia Gravis
- Myasthenic Syndrome
- Myopathy
- Acquired inflammatory Myopathies
- Inherited Myopathies
- Duchenne Muscular Dystrophy (majority)
- Becker Muscular Dystrophy
- Myotonic Dystrophy
- Congenital Muscular Dystrophy
6
Q
Primary Lung Disease
Obstructive disease
- (2)
- CO2 = (1), O2 = (1)
- ___crease tidal volumes due to air tr_____
- ____ pCO2 , ___ pO2– similar end effects with muscle weakness => ventilatory failure
Restrictive lung disease
- Sh______ breathing with high pCO2 , low pO2 at end stage disease.
A
Obstructive disease
- COPD/Emphysema
- Increased pCO2 , hypoxia - the CO2 buildup is worse than the hypoxia bc its a ventilatory disease - cannot exhale CO2
- Decreased tidal volumes due to air trapping
- High pCO2 , low pO2– similar end effects with muscle weakness => ventilatory failure
- Alot of undiagnosed OSA that would definitely benefit from ventilation
Restrictive lung disease
- Shallow breathing with high pCO2 , low pO2 at end stage disease.
7
Q
Causes of Ventilatory Failure
- M_____ weakness
- Restrictive physiology
- Severe Ky_________
- In______ lung disease
- Loss of n______ control
- Involves both _______ weakness and ______ weakness (can’t cough expel secretions)
- Poor c____, leading to pn_______
A
- Muscle weakness
- Restrictive physiology
- Severe Kyphoscoliosis
- Intrinsic lung disease
- Loss of neural control
- Involves both inspiratory weakness and expiratory weakness (can’t cough expel secretions)
- Poor cough, leading to pneumonia
8
Q
Sleep Disordered Breathing
- What happens in normal sleep? how do you breath and what happens to your CO2 levels?
- ____ sleep with further reduction in tone in skeletal muscles and further decline in ventilation.
- Normal individuals with mild alterations of gas exchange, can be m_____ in patients with abnormal neuromuscular function.
- Nocturnal _____ventilation common in NM disease. – _____ SpO2 , ____ pCO2
A
- Normal sleep has shallow rapid breathing in Non REM sleep with resultant increase in pCO2 and altered chemosensitivity
- REM sleep with further reduction in tone in skeletal muscles and further decline in ventilation.
- Normal individuals with mild alterations of gas exchange, can be marked in patients with abnormal neuromuscular function.
- Nocturnal Hypoventilation common in NM disease. – Lower SpO2 , Higher pCO2
9
Q
Sleep Disordered Breathing Cont.
- Over time can pr_____
- Long periods of hypoxia and hypercarbia
- Promotes bi____ retention (increased CO2 on basic metabolic tests)
- Results in _____ventilation at night AND daytime
- Can progress to severe respiratory failure and death
- O___ also common as an additional factor
- Especially in DMD, ALS, myotonic dystrophy
- Chem 7 will show?
A
- Over time can progress
- Long periods of hypoxia and hypercarbia
- Promotes bicarb retention (increased CO2 on basic metabolic tests)
- Results in hypoventilation at night AND daytime
- Can progress to severe respiratory failure and death
- OSA also common as an additional factor
- Especially in DMD, ALS, myotonic dystrophy
- Chem 7 will show renal buffering with elevated bicarb to counteract increased CO2 → send to sleep study
10
Q
Detection of Ventilatory Failure
Symptoms
- F_____/weakness
- ___nea/leg edema/____pnea
- Morning (1),hyper_______, mood disturbance, psychiatric changes
- Restless sleep/nightmares/en______/ar_____
A
- Fatigue/weakness
- Dyspnea/leg edema/orthopnea
- Morning headaches,hypersomnolence, mood disturbance, psychiatric changes
- Restless sleep/nightmares/enuresis/arousals
11
Q
Detection of Ventilatory Failure
Signs
- ____pnea/____cardia
- ______ muscle use/para_____ breathing/diminished __cursion
- J_ _/edema
- _____ heart failure (what kills ppl with OSA)/Pulmonary hypertension
- Increased P2/sp______ of 2nd heart sound
- Acro____, clubbing
Get a?
A
- Tachypnea/tachycardia
- Accessory muscle use/paradoxical breathing/diminished excursion
- JVD/edema
- Right heart failure (what kills ppl with OSA)/Pulmonary hypertension
- Increased P2/splitting of 2nd heart sound
- Acrocyanosis, clubbing
Get a sleep study!
12
Q
Evaluation of Suspected Respiratory Failure in NM Disease
-
(1)
- Low sensitivity as muscles must be very impaired (>50%) before changes in VC or TLC
-
(1) and (1) have better sensitivity (but requires specific equipment)
- PImax (>___ cm H2O) and Pemax (>___ cm H2O) excludes significant weakness
- (1) (SNIP) can be done in patients with too much weakness to do normal PImax (assesses diaphragmatic movement while sniffing)
-
Trans______ pressure can also be measured
- Difficult as needs esophageal balloon
A
-
Pulmonary Function Studies (PFT)
- Low sensitivity as muscles must be very impaired (>50%) before changes in VC or TLC
-
PImax and PEmax have better sensitivity (but requires specific equipment)
- PImax (>80 cm H2O) and Pemax (>80 cm H2O) excludes significant weakness
- Sniff inspiratory test (SNIP) can be done in patients with too much weakness to do normal PImax (assesses diaphragmatic movement while sniffing)
-
Transdiaphragmatic pressure can also be measured
- Difficult as needs esophageal balloon
13
Q
Frequency of PFT Monitoring
- Depends on rapidity of progression of underlying condition
- ______ for stable patients
- As frequently as every __-__months for progressive disease
- Must also assure no corr______ issues in progression such as electrolyte disturbances and OSA
- Sl____ studies may be useful as well
A
- Depends on rapidity of progression of underlying condition
- Yearly for stable patients
- As frequently as every 1-2 months for progressive disease
- Must also assure no correctable issues in progression such as electrolyte disturbances and OSA
- Sleep studies may be useful as well
14
Q
Question #2
Which of the following is not an option for a patient with ventilatory failure?
- weight loss
- non invasive ventilatory support
- stimulants
- secretion management
A
Ans: 3 stimulants
15
Q
Treatment Options
- ______ control for obese patients
- Maintenance of lean body mass for cachectic patients, what type of diet?
- Management of oral sec______
- Physical Therapy (CRT certified respiratory therapist)
- Cough assist, breathing ex_____
- Possible role for ___piratory muscle training
- Controversial as study data not clear and overfatigue is an issue (ie in MG may cause too much fatigue vs. better use in long term ICU pt)
A
- Weight control for obese patients
- Maintenance of lean body mass for cachectic patients (want high protein, high fat, less carbs bc increases CO2)
- Management of oral secretions
- Physical Therapy (CRT certified respiratory therapist)
- Cough assist, breathing exercises
- Possible role for inspiratory muscle training
- Controversial as study data not clear and overfatigue is an issue (ie in MG may cause too much fatigue vs. better use in long term ICU pt)
16
Q
Treatment Options Cont.
-
Management of ________
- Common in DMD and other muscular dystrophy
- May be seen as kyphosis in older patients with long history of steroid use
- (1) may have a role in selected patients (as early as possible)
-
Supplemental ______
- Useful in (1) disease
- Limited role in (1) disease
- May be harmful as in hypercarbic patients
- Usually hypoxia in this population is due to hypoventilation, not diffusion limitation.
- Possible role for medications such as (2) (best use for high altitude sickness, diamox not a strong diuretic but resets CO2 (prevents CO2 breakdown) levels so you hyperventilate)
A
-
Management of Scoliosis
- Common in DMD and other muscular dystrophy
- May be seen as kyphosis in older patients with long history of steroid use
- Surgery may have a role in selected patients (as early as possible)
-
Supplemental Oxygen
- Useful in primary lung disease
- Limited role in NM disease
- May be harmful as in hypercarbic patients
- Usually hypoxia in this population is due to hypoventilation, not diffusion limitation.
- Possible role for medications such as Megestrol and Acetazolamide (best use for high altitude sickness, diamox not a strong diuretic but resets CO2 (prevents CO2 breakdown) levels so you hyperventilate)
17
Q
Mechanical Ventilation Overview
- Allows for restoration of ventilation
- Allows for r_____ muscles and normalization of arterial ___ and __ .
- History starts with negative pressure ventilation
- ____ Lung now evolved to the Cuirass
- Positive pressure ventilation introduced in the 1960’s
- Then standard became tr______
- L______ of trach with infections, loss of vocalization, led to development of noninvasive ventilation.
A
- Allows for restoration of ventilation
- Allows for resting muscles and normalization of arterial CO2 and O2 .
- History starts with negative pressure ventilation
- Iron Lung now evolved to the Cuirass
- Positive pressure ventilation introduced in the 1960’s
- Then standard became tracheostomy
- Limits of trach with infections, loss of vocalization, led to development of noninvasive ventilation.
18
Q
When to Start Ventilation
-
Symptoms
- F____, dy____, m____ headaches
-
AND
-
One of the following:
- PaCO2 >___ mmHg on ABG
- Nocturnal oxygen desaturation below __% on oximetry for
- >__ consecutive minutes
- Maximal Inspiratory pressure
-
One of the following:
A
-
Symptoms
- Fatigue, dyspnea, morning headaches
-
AND
-
One of the following:
- PaCO2 >45 mmHg on ABG
- Nocturnal oxygen desaturation below 88% on oximety for
- >5 consecutive minutes
- Maximal Inspiratory pressure <60 cm H2O or FVC <50% predicted
-
One of the following:
19
Q
Initiation of NPPV
- When ventilatory failure is manifest
- PaCO2 >___ mmHg, pH
- In setting of pulmonary in______
- To avoid int______
- However, with infection and secretions, intubation may initially be needed to _____ airways
- For patients with OSA alone, (1) may be sufficient before bilevel ventilation is started
A
- When ventilatory failure is manifest
- PaCO2 >45 mmHg, pH <7.35
- In setting of pulmonary infection
- To avoid intubation
- However, with infection and secretions, intubation may initially be needed to clear airways
- For patients with OSA alone, CPAP may be sufficient before bilevel ventilation is started
20
Q
Contraindications to NPPV
- Absolute:
- Upper airway ob_____
- Uncontrollable secretion re______
- Inability to coo_____
- Inability to achieve p____ flow
- Inability to interface with de____
- Relative:
- Impaired sw_____
- Inadequate fi_____ or family resources
- Need for ____ time ventilation
A
- Absolute:
- Upper airway obstruction
- Uncontrollable secretion retention
- Inability to cooperate
- Inability to achieve peak flow
- Inability to interface with device
- Relative:
- Impaired swallowing
- Inadequate financial or family resources
- Need for full time ventilation
21
Q
Noninvasive Positive Pressure Ventilation (NPPV)
- Can be used in a variety of ways
- Noc_____ only for rest
- Allows normalization of blood gases and resting muscles
- Allows normal daytime eating, conversation and mobility
- Additional _____ daytime use – for support in more severe ventilatory failure
- Can be ____ time as well.
- Noc_____ only for rest
A
- Can be used in a variety of ways
- Nocturnal only for rest
- Allows normalization of blood gases and resting muscles
- Allows normal daytime eating, conversation and mobility
- Additional intermittent daytime use – for support in more severe ventilatory failure
- Can be full time as well.
- Nocturnal only for rest
22
Q
NPPV
- Initial devices had o___ application
- Poorly tolerated
- N____ delivery with continuous positive airway pressure (CPAP) made NPPV more tolerable
- Improves ventilation, normalizes gas exchange and slows disease progression in DMD
- Lower cost and less invasive than tr______
- NPPV most common ventilation used
A
- Initial devices had oral application
- Poorly tolerated
- Nasal delivery with continuous positive airway pressure (CPAP) made NPPV more tolerable
- Improves ventilation, normalizes gas exchange and slows disease progression in DMD
- Lower cost and less invasive than tracheostomy
- NPPV most common ventilation used
23
Q
NPPV Masks/Interfaces
- ______ mask most commonly used
- Gel seals may help to reduce facial irritation
- Custom fitted masks can help to reduce leak in difficult cases
- _____ full face masks also used
- Usually in acute respiratory failure
- Interferes with speech, eating, oral hygiene, secretion management
A
- Nasal mask most commonly used
- Gel seals may help to reduce facial irritation
- Custom fitted masks can help to reduce leak in difficult cases
- Oronasal full face masks also used
- Usually in acute respiratory failure
- Interferes with speech, eating, oral hygiene, secretion management
24
Q
Ventilators
- Portable ventilators are readily available
- Two main types
- _____ limited (normally what we see at work)
- Better for ___ time ventilated patients
- _____ limited
- Better suited for ____ time mo____ ventilated patients
- _____ limited (normally what we see at work)
A
- Portable ventilators are readily available
- Two main types
- Volume limited (normally what we see at work)
- Better for full time ventilated patients
- Pressure limited
- Better suited for part time mobile ventilated patients
- Volume limited (normally what we see at work)
- Find out what the settings are in primary care - usually will have a medical card with the settings written down*
- Must also be registered with local fire department/police bc if power is out cannot ventilate - will have someone sent right away*
25
Q
Pressure Limited Ventilators
- Pressure limited also called __level ventilation
- Cycle between two levels of pressure in the ventilatory cycle
- Used with either flow or volume triggering
- Cycle between two levels of pressure in the ventilatory cycle
- Best for patients with need for ____ time support
- Can be used in (1) and (1) lung disease
A
- Pressure limited also called bilevel ventilation
- Cycle between two levels of pressure in the ventilatory cycle
- Used with either flow or volume triggering
- Cycle between two levels of pressure in the ventilatory cycle
- Best for patients with need for part time support
- Can be used in neuromuscular and primary lung disease
26
Q
Pressure Limited Ventilator Settings
- Inspiratory pressures between __-__ cm H2O (ie __-__), what happens if its too high?
-
Expiratory pressure (PEEP) at __-__ cm H2O
- May need ____er pressures in cases with OSA
- Need to increase inspiratory pressure as well
- Advantages include:
- ____ cost
- ___ tolerated
- Port___
- May need ____er pressures in cases with OSA
- Not as well suited to per_____ ventilation
A
- Inspiratory pressures between 12-22 cm H2O (5-20 or will blow aire into stomach)
-
Expiratory pressure (PEEP) at 3-6 cm H2O (5)
- May need higher pressures in cases with OSA
- Need to increase inspiratory pressure as well
- Advantages include:
- Low cost
- Well tolerated
- Portable
- May need higher pressures in cases with OSA
27
Q
Volume Limited Ventilators
- Usually used in ass___ control mode to deliver a large tidal volume in compensation for any l____ in the interface
- Advantage for ____ time ventilation
- Greater mon____ capacity
- Better al____
- Longer backup b_____ life
- Can stack breaths to assist with c_____
A
- Usually used in assist control mode to deliver a large tidal volume in compensation for any leaks in the interface
- Advantage for full time ventilation
- Greater monitoring capacity
- Better alarms
- Longer backup battery life
- Can stack breaths to assist with cough
28
Q
Locations for Initiation of NPPV
- Can be in ____ or ____ stay health care setting
- ____patient physicians office or cl____
- Sl_____ laboratory
- H____
A
- Can be in short or long stay health care setting
- Outpatient physicians office or clinic
- Sleep laboratory
- Home
30
Q
Initiation of Noninvasive Ventilation
- Dur____ should be gradually __creased as tolerated
- Initiate with pr_____ sessions and then graduate to several hour usage sessions
- Full nighttime tolerance occurs within ____ to _____, depending on the patient
- If the patient cannot sleep with NIPPV, consider (1). If that fails then (1) may be only alternative.
A
- Duration should be gradually increased as tolerated
- Initiate with practice sessions and then graduate to several hour usage sessions
- Full nighttime tolerance occurs within weeks to months, depending on the patient
- If the patient cannot sleep with NIPPV, consider cuirass. If that fails then tracheostomy may be only alternative.
34
Q
Very effective form of pacing, but limited to only those with intact phrenic nerve, has high cost
Possible direct version of this pacing as well
A
Diaphragm Pacing
(more often phrenic nerve pacing)
36
Q
Adjunctive Respiratory Aids for Patients with Ventilatory Failure
(1) = Rocking bed, Relatively ineffective, Requires good chest and abdominal compliance
(1) = can assist in high tetraplegia (timed with breathing and assists with relaxing and pressing on belly)
A
Abdominal Displacement Ventilators = Rocking bed, Relatively ineffective, Requires good chest and abdominal compliance
Pneumobelts = can assist in high tetraplegia (timed with breathing and assists with relaxing and pressing on belly)
37
Q
Secretions and Cough
- Assisted cough
- M_____ assisted cough
- Mechanical in_____/ex______
- Os______
- Per_______
- ______ to Parotids (treats excessive drooling)
- ________ used more in bronchiectasis and cystic fibrosis to help with secretions
A
- Assisted cough
- Manually assisted cough
- Mechanical insufflator/exsufflator
- Oscillation
- Percussion
- Botox to Parotids (treats excessive drooling)
- Percussion used more in bronchiectasis and cystic fibrosis to help with secretions
38
Q
Invasive Ventilation
- Only for patients in whom there are?
- Patients who desire agg______ support
- Simplify regimens
- Trial of n_____ support only
- Trial of ventilation with cuff down to allow sp_____
- Trial of oral f_____
- Multiple complications including hem______, fis_____, tracheal st____
A
- Only for patients in whom there are no other options
- Patients who desire aggressive support
- Simplify regimens
- Trial of nocturnal support only
- Trial of ventilation with cuff down to allow speech
- Trial of oral feeding
- Multiple complications including hemorrhage, fistulae, tracheal stenosis
49
Q
Lung Volumes
- TLC =
- FRC =
- TV =
- ERC =
- RV =
- IC =
- VC =
A
- Total lung capacity (TLC)
- Functional residual capacity (FRC)
- Tidal volume (TV)
- Expiratory reserve capacity (ERC)
- Residual volume (RV)
- Inspiratory capacity (IC)
- Vital capacity (VC)
52
Q
Pulmonary Distress Analysis
A
1st question: Are they moving air? Pulse ox is second
