Pulmonary Rehabilitation

Question 1

COPD

Answer 1

respiratory disorder caused largely by smoking, characterized by PROGRESSIVE partially reversible airway obstruction and lung hyperinflation, systematic manifestations, and increase freq/sev of exacerbations

Question 2

Premature infants

Answer 2

80% predicted FEV1 because lungs are not developed.

Question 3

Age of exacerbation symptoms

Answer 3

50-55 years

Question 4

Top reason for hospitalization/ambulatory care sensitive conditions

Answer 4

COPD

• 1/3 COPD pt will revise the ED within 30 days in AB

Question 5

COPD exercise limitation: Gas exchange efficiency

Answer 5

Gas exchange = PAO2 - PaO2

• we want little to no pressure difference between alveolar and arterial

Question 6

COPD exercise limitation: What determines VO2max?

Answer 6

Thick Equation
VO2 = (HR x SV) x (CaO2-CvO2)

• stroke volume response (the bigger the larger the response)

Question 7

COPD exercise limitation: exercise stress on gas exchange

Answer 7

PAO2-PaO2 = VO2/DLO2

• during exercise VO2 increases
• we need to increase diffusion capacity ignorer to keep arterial and alveolar pressure difference close

Question 8

hyperventilation results in what in the brain?

Answer 8

hypocapnia
(ventilation is greater than metabolic demand)

• rate of CO2 removal from blood increases

Question 9

PETO2 (alveolar PO2/end tidal) during exercise

Answer 9

will increase as we need to breathe more (exercise = ventilation)

• accumulate lactic results in hyper ventilation as we pass the anaerobic threshold

Question 10

limitation: out of breath - what stops us from exercise

Answer 10

cardiovascular system (not lungs)

Question 11

Breathing reserve

Answer 11

• should be 30% VE reserve

Question 12

EILV and EELV compensation for ventilation needed for exercise

Answer 12

• EILV will increase and EELV will decrease in response to exercise

Question 13

Tidal volume & resp response to exercise

Answer 13

Healthy FEV1 = 100% predicted

Question 14

Ventilatory Response in obstructive disease

Answer 14

• cannot ventilate as much, DEV1 = 40% predicted
• dynamic hyperinflation: deep breath-in and prolonged expiration, but brain wants us to keep breathing so we take a breath in

Question 15

Rehabilitation of lung function

Answer 15

• pulmonary rehab does not improve lung function, rather we get adaptation through cardiac function, muscle strengthening, produce less lactic acid, ventilate less
• maximal ability to ventilate doesn’t change

Question 16

Exercise training - MMV pre- and post-rehab

Answer 16

exercise training decreases ventilatory response to exercise

Question 17

5 year survival in COPD based on peak VO2

Answer 17

Grade I: > 995mL/min 99% survival rate after 5 years

Grade IV: < 650mL/min 40% survival rate after 5 years

Question 18

What is pulmonary rehabilitation?

Answer 18

multidisciplinary: comprehensive intervention (optimize physiological, psychological, and social outcome) for COPD patients followed by patient tailored therapies (behaviour change, education, exercise training, support/teach medications)

PR has been shown to ↑ health outcomes in: • Asthma
• Bronchiectasis
• Cystic Fibrosis
• Interstitial Lung Disease • Lung Cancer

Question 19

Goals of COPD management

Answer 19

1. Prevent disease progression (smoking cessation)
2. Reduce the frequency and severity of exacerbations
3. Alleviate breathlessness & symptoms
4. Improve exercise tolerance
5. Improve quality of life
6. Reduce mortality

Question 20

COPD: downward spiral

Answer 20

lose 50% of lung function during first hospital visit

- COPD, dyspnea, inactivity, decondtioning, psychological, QOL

Question 21

Pulmonary rehab: upward spiral

Answer 21

COPD - Dyspnea - Rehab program - improve activity/conditioning - decrease dyspnea and psychological conditions

Question 22

Goal of pulmonary rehab

Answer 22

increase their capacity to self-manage

Question 23

COPD: Exercise training goals

Answer 23

1. Flexibility exercises
2. Strengthening exercises
3. Endurance exercises
4. Breathing exercises

Question 24

Exercise Action Plan: Individual Session

Answer 24

Utilizes FITT (Frequency, Intensity, Time, Type) to set targets/goals for long term maintenance

• Endurance, Strength, Breathing, Flexibility
• Create a “Good day plan”, “Bad day plan” and a “Re-integration plan”
• Must include location of exercise

Question 25

Exercise Action Plan: Address barriers of exercise

Answer 25

• Motivation (goal setting, motivational interviewing, social support)
• Financial (home exercise, low income programs, social work referral)
• Self Efficacy (reassurance, refer to supervised exercise programs)
• Lack of Time (scheduling, fitness calendar, activity vs. exercise)

Question 26

COPD: aerobic exercise goal

Answer 26

Frequency:

• 3-5 days/week
• > 20min (interval or continuous)

Intensity:
– 40-85% of VO2peak reserve
– 60-80% VO2peak
– Based around Anaerobic Threshold – Based on Dyspnea

↑intensity/volume→↑physiological benefit

Question 27

COPD Strength training goals:

Answer 27

Strength training which focuses on maintaining activities of daily living necessary

• increase strength, muscle mass
• no change to exercise capacity

Question 28

Oxygen supplementation: Issues

Answer 28

2 Issues:

1. O2 to prevent hypoxemia
2. O2 added to non-hypoxemic patients

Question 29

Oxygen supplementation: goals

Answer 29

1. ↓ Ventilation/dyspnea
2. ↑ O2 delivery to muscle
3. Increase exercise workload

Question 30

Oxygen supplementation: who?

Answer 30

Supplemental O2 should be used w/ hypoxemia (<90% SpO2)

Supplemental O2 in non-hypoxemia patients?

Question 31

Long-term goal of pulmonary rehabilitation

Answer 31

Behaviour change: Increase (and maintenance) of physical activity key

Question 32

When should a COPD have an ICH

Answer 32

when FEV1 = <60% predicted

Question 33

Effect of PR on exacerbating prevention

Answer 33

PR done immediately after a COPD hospitalization reduces chance of future exacerbations

Question 34

PR vs. medication

Answer 34

PR improves quality of Iife and functional capacity better than traditional pharmacological management’

• RCT are no longer wanted because confirmed that PR is so effective

Question 35

Final question about PR:

Answer 35

question is no longer should patients with COPD receive PR, but rather how should PR be delivered to patients and which components form the basis of the success of PR programs’