Rehab two jongs Flashcards
It is a program of education and exercise that focuses on restoring ________ patients to the highest functional capacity possible
Pulmonary rehabilitation, chronic respiratory
It is a comprehensive education and exercise program designed to
improve the ______ of patients with known cardiac dysfunction
Cardiac rehabilitation, cardiovascular fitness
Both pulmonary and cardiac rehabilitation requires a _______ to evaluate the patient’s condition and status. Both programs are _______ in approach; both incorporate_______ and ________; and
both are ______ by insurance.
stress test, multidisciplinary, patient education, physical exercise. reimbursable
The basic equipment used during exercise sessions—__________—and the space requirements of the two types of rehab are essentially the same
treadmills, exercycles, and arm ergometers
Pulmonary rehabilitation differs from cardiac rehabilitation with respect to the ______ affected and hence to the _______implemented. Pulmonary patients have exercise limitations due to ______ resulting from primary pulmonary impairment and dysfunction
organ, type of program, dyspnea
Cardiac programs are more concerned with a _________ via telemetry during exercise sessions.
patient’s pulse, blood pressure, and electrocardiogram
Pulmonary patients are monitored for ______ during exercise.
pulse rate, respiratory rate, oxygen saturation, and peak flow rates
In ______, the ______ defined rehabilitation as “the restoration of the individual to the fullest medical, mental, emotional, social, and vocational potential of which he/she is capable.
1942, Council on Rehabilitation of the American College of Chest Physicians (ACCP)
In ______, the ACCP became more specific and formed the ________, which specified a medical practice that was intended to help pulmonary patients attain their optimum state of health.
1974, Committee on Pulmonary Rehabilitation
The ACCP definition of pulmonary rehabilitation formed the basis for an official statement on pulmonary rehabilitation that was adopted by the American Thoracic Society (ATS) Executive Committee in _____
1981
In most instances, pulmonary rehabilitation is aimed at _______, in particular, those with ______and _______, but it is also a viable option for ventilator-dependent and quadriplegic patients
chronic lung patients, asthma, chronic obstructive pulmonary disease (COPD)
In ___, the ________ formed its specialty sections, including one for rehabilitation and continuing care, now referred to as the Continuing Care/Rehabilitation section
1977, American Association for Respiratory Care (AARC)
The __________ was incorporated in_____ to continue the advancement of pulmonary rehabilitation in terms of programs, services, professional practice, networking, and continuing education.
American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR), 1983
In ___, the_______ conducted the first joint national survey to ascertain the extent of pulmonary rehabilitation programs in the United States in terms of numbers, design, and scope.
1987, AACVPR and AARC
In _____, the _______ released new evidence-based guidelines recommending pulmonary rehabilitation for patients with COPD
2007, American College of Chest Physicians (ACCP) and the AACVPR
Council on Rehabilitation of the American College of Chest Physicians (ACCP) presents general definition of rehabilitation.
1942
Barach and associates comments on need for training programs for chronic lung patients.
1951
Pierce and associates publishes study that demonstrated Barach’s insight into the value of pulmonary reconditioning
1962
Paez and associates indicate that reconditioning techniques using both activity and oxygen benefited patients with chronic lung disease.
1964
Christie demonstrates that rehabilitative benefits could be offered on an outpatient basis with minimal supervision
1968
ACCP forms the Committee on Pulmonary Rehabilitation.
1974
American Association for Respiratory Care (AARC) forms its specialty sections, including the Continuing Care/Rehabilitation section.
1977
American Thoracic Society (ATS) Executive Committee ACCP releases an official statement on pulmonary rehabilitation (based on the ACCP definition).
1981
American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) is incorporated to continue the advancement of pulmonary rehabilitation.
1983
AACVPR and AARC conduct the first joint national survey to ascertain the extent of pulmonary rehabilitation programs in the United States
1987
Medicare approves a national coverage policy for beneficiaries enrolled in pulmonary rehabilitation programs [Medicare Improvements for Patients and Providers Act (MIPPA)].
2008
The overall rationale for pulmonary rehabilitation is to ________ some of these processes, which lead to decreased physical activity
control and perhaps reverse
what is the major goal of pulmo rehab
The major goal of pulmonary rehabilitation is to restore the patient to the highest possible functional capacity, given the patient’s degree of pulmonary impairment and overall life situation
What are the two principal objectives of pulmo rehab
To control and alleviate as much as possible the symptoms and pathophysiologic complications of respiratory impairment
To teach patients how to achieve optimal capability for carrying out their activities of daily living (ADLs)
What are the four pillars of pulmo rehab
Education, breathing techniques, physical reconditioning, strategies to conserve energy and pacing activities.
What are the basis for patients selection
- Abnormal pulmonary mechanics—namely, changes in compliance and airway resistance.
- Abnormal gas exchange resulting in hypoxemia and arterial desaturation.
- Impaired cardiac output.
- Sensation or perception of dyspnea.
Abnormal pulmonary mechanics often results in _______ for a set level of ventilation. This increase in the work of breathing may be due to ____________.
increased respiratory muscle work, increased airway resistance (Raw), to hyperinflation, or to decreases in lung or chest wall compliance
Gas exchange abnormalities are manifested in hypoxemia with ____________
arterial desaturation, reduced delivery of oxygen to the tissues, and lactic acidosis
Cardiac dysfunction frequently follows chronic lung disease as a result of the effects of hypoxemia on the cardiovascular system. COPD patients with normal cardiac function at rest may develop ______ and _________ during exercise.
pulmonary hypertension, cor pulmonale (elevated right atrial
pressures)
An elevated right atrial pressure can produce a drop in the gradient for ________ to the heart, which diminishes cardiac output
venous return
In addition, if right ventricular hypertrophy is present, __________ are evident, resulting in __________ and interference with cardiac output.
elevations in left ventricular filling pressure, pulmonary vascular congestion
Finally, in patients with increased airway resistance, decreased compliance, or hyperinflation, ________ can become more negative. This more negative pleural pressure, in turn, increases
the pressure gradient against which the heart must pump, limiting the amount of blood ejected from the left ventricle. ___________ follow, resulting in dyspnea and tightness in the chest.
pleural pressure, Pulmonary vascular congestion, and trans-vascular fluid filtration
What are the different testing regimens?
Chest X-ray, ABG analysis, Pulmonary Function Test, CPX Test
Before any testing is performed, a _________ should be completed. This includes:
complete patient workup
A complete patient history consisting of medical/surgical, occupational, family, and social (outside activities plus any smoking and alcohol consumption) components.
• Physical examination.
• Laboratory testing (complete blood count, blood chemistry, theophylline level, and alpha-1 antitrypsin titer).
• Electrocardiogram and chest X-ray.
Pulmonary Function Test. The standard pulmonary function test (PFT) consists of:
- Pre- and postbronchodilator spirometry with a timed forced vital capacity (FVC) and flow-volume loop.
- Maximum voluntary ventilation (MVV) maneuver.
- Lung volume and capacity determination using a helium equilibration or nitrogen washout technique.
- Diffusing capacity of the lung (DLCO) using the single-breath method.
PFTs:
• Allow for the differentiation between __________
• Establish a _____ for the patient.
• Determine the extent of _______ present.
• Identify the degree of reversal _________
obstructive and restrictive disease, baseline, pulmonary impairment, produced by bronchodilator therapy
Arterial Blood Gas Analysis. Arterial blood gas (ABG) analysis, commonly performed during the PFT, identifies any __________
hypoxemia, carbon dioxide retention, and acid-base imbalance
________ is also used to determine a patient’s level of oxygenation. However, this technique is more useful in serial determinations to determine the degree of arterial desaturation with physical activities, such as walking or stair climbing.
Pulse oximetry (SpO2)
The most important aspect of patient evaluation and testing before any pulmonary rehabilitation effort is the cardiopulmonary exercise (stress, or CPX) test. This is the most complex test but the most important in terms of the patient data and information it provides.
Cardiopulmonary Exercise Testing
- Allows for the differentiation between _________ of dyspnea.
- Determines the degree of _______ that occurs with physical exertion.
- Establishes a baseline for each patient’s___________
- Determines each patient’s ________, which is used in the exercise prescription (amount and intensity of exercise recommended) and physical reconditioning program. A target heart rate approximates the actual heart rate at _______. It is the heart rate at which the patient achieves maximum physical and cardiovascular conditioning with exercise.
- Enables physicians and practitioners to ______
- May be used to _____ patients from pulmonary rehabilitation.
pulmonary and cardiac causes, oxygen desaturation and hypoxemia, level of physical conditioning, target heart rate, 65–75% of the maximum oxygen consumption, track and document patient progress, exclude
Major indication of CPX testing
- Patient assessment and evaluation.
* Differentiating between pulmonary or cardiac dysfunction and overall poor physical conditioning.
The main contraindications involve a_______ associated with serious ________and _______
cute electrocardiographic changes, cardiac dysrhythmias and angina.
A CPX test should last about _______or ______if the patient is elderly.
10–12 minutes or 6 minutes
CRITERIA FOR PATIENT INCLUSION
• Demonstrate a respiratory limitation to exercise that results in termination of exercise stress testing at a level of _______
• Demonstrate significant, irreversible airway obstruction with an FEV1 ______ or an FEV1/FVC (FEV1%)__
• Show significant restrictive lung disease with a total lung capacity (TLC) ____ of predicted value and a single-breath carbon monoxide
diffusing capacity (DLCO) of ____ of predicted
• Show pulmonary vascular disease where the DLCO using the single-breath method is ____ of predicted value or exercise is limited to _____ of the predicted VO2max
<75% of the predicted VO2max, <2.0 L, < 60%, <80%, <80%, <80%, <75%
CRITERIA FOR PATIENT EXCLUSION
• Does not fulfill the criteria for inclusion.
• Has a significant _____ component to exercise limitation (excluding patients with pulmonary vascular disease)
• Demonstrates an adverse cardiovascular response to exercise, such as _______ and requires cardiovascular monitoring during rehabilitation
cardiovascular, major arrhythmia or significant change in blood pressure
Examples of Chronic obstructive pulmonary diseases.
Pulmonary emphysema, chronic bronchitis, bronchial
asthma, bronchiectasis, cystic fibrosis
Examples of Restrictive lung diseases
Sarcoidosis, pulmonary fibrosis, kyphoscoliosis, occupational lung
diseases (pneumoconioses), adult respiratory distress syndrome (ARDS), obesity, poliomyelitis
Examples of Atypical conditions
Lung resection, lung transplantation, pulmonary vascular disease, obstructive sleep apnea (OSA)
It is believed that ______may be more beneficial to the patient with pump failure than exercise
ventilatory assistance and rest
The closed format is more ______ than the open format. It uses a set period of time with a designated _______. Sessions may be conducted once, twice, or three times a week for anywhere from ______. Closed-format programs are usually_____ in nature
traditional, number of class sessions and a specific end date, 6 to 16 weeks, introductory
At the ________, patients are instructed to continue individually the breathing and exercise routines they learned in the program.
program’s conclusion
Open-format programs, on the other hand, have _______. Patients continue in the program and progress at their own pace until they achieve specific objectives and attain prescribed performance levels. These programs are ____, and participants meet ______.
no designated number of class sessions or specific end dates, ongoing, regularly
Individual sessions, which may be conducted in the hospital, at the patient’s home, or at the rehab facility, requires _______ and ______ than do group sessions
less equipment, personnel
Individual programs are especially effective for _______ who are being weaned from ventilatory support or for those with ________. This type of program is also helpful to patients with _____ injuries who are learning to breathe on their own
ventilator-dependent patients, neurological disorders, spinal cord
This technique enables patients to remain off ventilatory support for
minutes to hours at a time
glossopharyngeal breathing
Glossopharyngeal breathing also allows for some increase in _____ and a more forceful cough, resulting in more effective removal of secretions and less frequent infections
vital capacity
Patients who live in a rural area or who have _____ difficulties can also benefit from_______
transportation, individual programs
Group sessions involve classes of ____ patients, depending on space, equipment, personnel, and the number of patients who qualify. Group programs are more______ than individual sessions. Many patients attend rehabilitation programs more for ______ than for physical reasons.
4–12, cost-effective, psychosocial
The key elements of designing a pulmonary rehabilitation program are:
- Location.
- Space.
- Equipment.
- Supplies.
- Personnel.
- Resources
Location is the first concern. Pulmonary rehabilitation can be conducted on either an ______ basis
inpatient or an outpatient
The amount of actual space, in terms of square footage, depends on available ______
space, projected class size, and budgetary and financial considerations.
For an average class of 8–12 patients, a classroom that is ______is adequate, and an exercise area approximately twice that size (_____) should suffice.
12 feet by 16 feet (192 square feet), up to 400 square feet
Besides a respiratory therapist and a physician, other personnel who may be involved with the implementation of pulmonary rehabilitation are:
- A nurse with rehab experience.
- A physical therapist.
- An occupational therapist.
- A dietitian.
- A pharmacist.
- A clinical psychologist.
- An office manager.
A pulmonary rehabilitation session can follow any effective format. A typical group session should be approximately _______, whereas individual sessions can range from a ______
2 hours long, half-hour to an hour
Normally, _____ of each session can be devoted to patient education
30–60 minutes
Structure of the heart and lungs and how they work in supplying the body with oxygen and removing carbon dioxide
Cardiopulmonary anatomy and physiology
Major differences between obstructive and restrictive lung diseases, with specific examples; an explanation of how chronic lung disease can bring about cardiac dysfunction
Cardiopulmonary pathophysiology
Diaphragmatic and pursed-lip breathing techniques, inspiratory resistance breathing, basal expansion exercises, and sustained maximal inhalation through incentive spirometry for patients with restrictive lung disease
Breathing techniques and
retraining
Ways to cope with stress, proper breathing techniques, avoidance of panic breathing, and relaxation methods
Stress management and relaxation
Ways to exercise properly to promote agility, strength, and endurance using aerobic and isokinetic techniques and calisthenics
Physical reconditioning
Major cardiopulmonary medications and their effects on the body; proper use of metered-dose and dry powder inhalers
Pharmacology
Use of oxygen in the home; use of other respiratory care devices including small-volume nebulizers and patient monitoring systems
Respiratory home care
Postural drainage positions and techniques for percussion, vibration, coughing, and bronchial hygiene, including the use of a Flutter device and other similar breathing adjuncts
Chest physiotherapy
Key elements of good nutrition and weight control with a focus on ways of avoiding dyspnea after eating, the right food groups to eat, and trouble foods to avoid
Nutrition and diet
Vocational counseling focuses on activities that promote a more active, productive life
Activities of daily living
ADLs
Each session should begin with a ______ followed by the patients’ ______ on their progress. The formal presentation can then be delivered and followed by_______.
welcoming remark, comments, patient questions and discussion
To physically recondition patients and increase their exercise tolerance, the following goals need to be accomplished:
• Overall oxygen utilization must be improved.
• Essential muscle groups must be strengthened.
• The cardiovascular response to exercise must be
enhanced.
What are the three principles of exercise training
specificity of training, overload, and reversibility
The ______ is founded on observations that programs can be designed to achieve specific goals and objectives and that exercising muscles is beneficial only to the targeted group. In other
words, specific muscles, or groups of muscles must be targeted to achieve beneficial result.
specificity of training
The principle of ____ contends that muscles must be forced or pushed beyond a certain level of activity to produce a ____
overload, training effect
The principle of reversibility, or _____ implies that the benefits of exercise are transient and persist only as long as exercise is continued. Patients who stop exercising quickly lose any exercise-induced changes or benefits
detraining effect
Specific exercises used in pulmonary rehabilitation can be grouped into two major categories: _____
breathing retraining and physical reconditioning.
Specific exercises used in pulmonary rehabilitation can be grouped into two major categories: _____
breathing retraining and physical reconditioning.
Breathing Retraining. Breathing retraining techniques for both chronic obstructive and restrictive lung patients include specific methods, such as:
- Diaphragmatic breathing with pursed lips.
- Incentive spirometry.
- Inspiratory or flow-resistive breathing.
- Threshold loading
_________ is considered to be the cornerstone of breathing retraining for COPD patients in pulmonary rehabilitation.
Diaphragmatic breathing with pursed lips
_______ comes naturally to many patients. By adjusting the size of the orifice created by their lips, patients can vary the degree to which they can retard expiration.
Pursed-lip breathing (PLB)
Retarding expiration: • Slows their \_\_\_\_\_\_. • Reduces the \_\_\_\_\_. • Creates\_\_\_\_\_\_ that prevents collapse of the smaller airways. • Lessens the probability of \_\_\_\_\_\_. • Promotes more effective \_\_\_\_\_\_.
respiratory rate, work of breathing, backpressure, air trapping, ventilation
The time spent on diaphragmatic breathing depends on the patient’s available time. Practice time can range from _____ a day and, in most instances, can be performed in conjunction with other types of breathing exercises. It may take_____ before some patients breathe diaphragmatically
15 to 30 minutes, 6–8 weeks
_______using any currently available disposable device, is far more beneficial in treating restrictive lung disease than COPD
Incentive spirometry
Breathing retraining employing sustained maximal inspiration with an incentive spirometer should be performed for up to _______ a day on a regular basis to be effective.
15 minutes, three or four times
Respiratory dysfunction associated with COPD can be managed with _______, using either inspiratory or flow resistive breathing or threshold loading.
inspiratory muscle training (IMT)
_______ breathing is accomplished with a device such as the PFlex. This device uses decreasing hole sizes numbered 1–6. These hole sizes set the _______ as long as rate, tidal volume, and inspiratory time remain constant. Training begins at hole size number 1 for up to 30 minutes a day
Inspiratory or flow-resistive, inspiratory training load
Threshold loading is achieved with the Threshold IMT device. This apparatus uses a spring-loaded valve mechanism to provide a consistent _______, independent of inspiratory flow rate.
inspiratory pressure training load
The manufacturer recommends that the training load be set at approximately _____ of the patient’s _____ and that training sessions increase gradually from ______ to ______
30%, maximal inspiratory pressure (PImax), 10–15 minutes a day, 20–30 minutes a day
To slow the rate of breathing while creating backpressure to maintain airway patency, thereby preventing airway collapse and air trapping.
It can be used to retard expiratory airflow
Pursed-lip breathing
Abdominal muscles promote diaphragmatic excursions, resulting in more effective ventilation and reducing use of accessory muscles.
Diaphragmatic breathing (abdominal breathing)
Promotes and maintains chest wall mobility by having patients breathe against hand pressure applied over localized areas of the chest wall.
Segmental breathing
A flow-resistive device uses inspiratory load to strengthen ventilatory muscles, promoting ventilatory muscle endurance.
Inspiratory resistance (flow resistance)
A ________ device uses inspiratory pressure as a prescribed load to strengthen ventilatory muscles, promoting ventilatory
muscle endurance
Threshold loading
Inspiratory capacity maneuver with breath-hold at the end of inspiration (sustained maximum inspiration) promotes lung expansion.
Incentive spirometry (sustained maximal inspiration or SMI)
Use of glossopharyngeal muscles promotes capture and swallowing of air, resulting in some increase in vital capacity.
Glossopharyngeal breathing (frog breathing)
Useful for ventilator-dependent or spinal cord injury patients who are able to come off ventilatory support for brief periods. This is both an exercise and a breathing technique.
Glossopharyngeal breathing (frog breathing)
useful after thoracic or abdominal surgery, and for neurological and musculoskeletal conditions, asthma, and COPD.
segmental breathing
Exercises that combine low resistance or low tension with movement or repetition over a long duration overload enzymes of the tricarboxylic acid cycle (TCA, or Krebs, cycle) and electron transport system, resulting in increased ________. Walking on level ground and cycling without tension are an excellent way to achieve this type of conditioning
aerobic/isotonic exercise, endurance and stamina
exercises that combine high resistance or high tension with movement or repetition over a short duration are____ and produce increased ______. Cycling with tension applied is one example of an isokinetic activity.
isokinetic, muscle tone and strength
______ exercises employ tension with muscle contraction but without any movement of joints or limbs. Pressing two hands together with periods of rest produce the_____effect, resulting in an increase in ________
Isometric, isometric, muscle tone and strength
______, which encompass stretching and bending exercises, enable patients to develop _______ in movement
Calisthenics, flexibility and gracefulness
______ of the VO2maxto be a safe and effective target because it reflects two-thirds to three-fourths of a patient’s maximum capability
65%–75%
- ___ minutes of warm-up calisthenics.
- ____ minutes of breathing exercises using an inspiratory resistive device or incentive spirometer.
- ___ minutes of walking and cycling with gradual increases in duration and tension
3–5, 15–30, 6–12
____ is recognized as a safe and effective physical conditioning technique requiring only a measured indoor area (outdoor if weather conditions allow)
Walking
The ____ is a standard in many rehabilitation programs. It represents a _______ that most chronic pulmonary patients should be able to perform.
12- minute walk, finite parcel of activity
In addition, patients who have a stationary bicycle or a floor pedal unit are prescribed daily _____, which is also possible for most rehab patients.
cycling
Patients should exercise no more than__ days each week, including group and home exercise sessions. ___ nonconsecutive days of rest each week allow muscles to repair and provide each patient with a
respite from the daily physical routine
5, Two
Positive results can be lost in a_____. To regain what was
lost will take almost _____ through gradual increases in exercise duration and progressive resistance
few weeks, 2 months
Patient treatment plan
• Aids in monitoring patient _____ and confirms that ____ and _____ have been met.
• Identifies which patient education topics must be covered, which breathing retraining techniques and exercises are best suited for each
patient, and what physical exercises should be promoted in the form of an ______
progress, goals and objectives, exercise prescription
A key component of any patient treatment plan is the _______. The physician or health care practitioner overseeing the medical aspects of the the program must complete this plan for each patient before the start of rehabilitation
exercise prescription
What are the elements of exercise prescription
Mode, duration, frequency, intensity
_____ is the type of physical activity performed by the patient, such as walking, stair climbing, cycling, or weight lifting to increase upper body
strength
Mode
______depends on a patient’s level of fitness. Very deconditioned patients should start with _____ intervals of exercise, according to their tolerance, with brief rest periods as needed. As conditioning increases, the duration of exercise should be increased by _____ a day with a goal of having patients perform ____ minutes
of continuous exercise daily
Duration, short,1–2 minutes, 20–30
_____if continuous exercise is less than 15 minutes a day, should be _______ a day, _ days a week. If continuous exercise is greater than 20 minutes a day, frequency should be ____ a day, ___days a week
Frequency, two or three times, 5, once, 3–7
______ depends on a patient’s fitness level, health status, and _____. The ______ of exercise is usually based on the results of the _____ and is increased gradually according to a patient’s tolerance
Intensity, program goals, intensity, CPX test
______ depends on a patient’s fitness level, health status, and _____. The ______ of exercise is usually based on the results of the _____ and is increased gradually according to a patient’s tolerance
Intensity, program goals, intensity, CPX test
Intensity may be determined on the basis of the ______, as previously discussed, or on the basis of _______
target heart rate, metabolic equivalents of energy expenditure or oxygen consumption (METs)
therapist must determine the desired range of energy expenditure
(usually ____ of maximal functional capacity), expressed in METs.
60–85%
Absolute contraindication of walk test
Unstable angina for the previous month
Myocardial infarction during the previous month
Reasons for stopping the walk test
Chest pain, intolerance dyspnea, leg cramps, staggering, diaphoresis
Patient O2 sat. less than 88% perform the 6mwt with the patient on
continuous oxygen at 2L/min via nasal cannula
Wait for ____mins. after any change in oxygen delivery to start the walk test.
10
Don’t titrate the oxygen during the walk test. T/F
T
Don’t use pulsed oxygen for the 6mwt. T/F
T
