Restrictive And Transplant

Question 1

what are the traumatic causes of restrictive lung dysfunction?

Answer 1

• blunt trauma (MVA or falls)
• penetrating trauma (gunshot or stabbing)
• rib fractures (ribs 5-9 less protected)
  -pneumothorax (air or gas in pleural space causes collapse of lung tissue= tracheal deviation away from affected side with absent breath sounds)
• spontaneous pneumothorax (abrupt onset of ipsilateral pleuritic chest pain, dyspnea, increased work of breathing, tachycardia, diminished or absent breath sounds)

Question 2

list the pleural causes of RLD

Answer 2

atelectasis, pleural effusion, pleuritis “pleurisy”

Question 3

Define the types of atelectasis

Answer 3

• collapsed lung: alveoli collapse or do not expand properly
• compression: lung becomes compressed by pleural fluid
• obstruction: air is obstructed into alveoli distal to an obstructed bronchus

Question 4

what is the clinical presentation of atelectasis

Answer 4

dyspnea, shallow breathing, dry or productive cough, decreased breath sounds, hypoxia, tachypnea, crackles or wheezing, decreased tactile fremitus, low grade fever

Question 5

what is the treatment for atelectasis? what is the overall goal?

Answer 5

• incentive spirometry, supplemental O2, movement
• get airways open and perform effective cough

Question 6

what is pleural effusion? what does it limit? what are the causes?

Answer 6

• the abnormal fluid buildup in the pleural space (between visceral and parietal pleura)
• the abnormal accumulation of fluid limits lung expansion
• commonly caused by HF, pneumonia, malignant neoplasm

Question 7

what are the types of pleural effusion?

Answer 7

• Transudative: elevated hydrostatic pressures in pleural capillaries, more fluid moves into the pleural space than can be reabsorbed; excess fluid creates pleural effusion as a result of HF
• exudative: increased permeability allows fluid to move into pleural space; inflammatory or neoplastic disease is the most common reason for this type

Question 8

what is the clinical presentation of patients with pleural effusion?

Answer 8

• breath sounds will be diminished over area of pleural effusion, dullness to percussion and decreased tactile fremitus, pleural friction rub if inflamed

Question 9

what are common symptoms of pleural effusion

Answer 9

mainly asymptomatic, dyspnea, pleuritic chest pain with inflammation, dry, nonproductive cough

Question 10

what is pleuritis?

Answer 10

-swelling or irritation between the two pleural layers creating friction often associated with an effusion

Question 11

what are symptoms of pleuritis?

Answer 11

sharp or stabbing pleuritic pain that worsens with a cough or deep breath, dyspnea, pain radiating to shoulder and back

Question 12

what is the clinical presentation of pleuritis

Answer 12

sandpaper rubbing over the affected area and increased fremitus

Question 13

what is acute respiratory distress syndrome?

Answer 13

a widespread inflammatory condition affecting lung tissue that is a MEDICAL EMERGENCY

Question 14

what are the cardiovascular causes of RLD?

Answer 14

pulmonary edema, pulmonary embolism, pulmonary HTN

Question 15

what is pulmonary edema? what are the 2 categories?
how does pulmonary edema lead to RLD?

Answer 15

-Excessive fluid moving from pulmonary vascular system into the parenchyma (usually the interstitial areas then alveoli)
- cardiogenic due to HF; L sided HF results in fluid backing up into pulmonary veins, increasing pressure in pulmonary circulation, increased fluid build up into interstitial area and alveoli
- non-cardiogenic from lymphatic insufficiency
- work of breathing increases, lung compliance decreased, gas exchange disrupted which leads to RLD

Question 16

what are symptoms of pulmonary edema?

Answer 16

respiratory distress, dyspnea (worse in supine), paroxysmal nocturnal dyspnea, cyanotic, increased RR, labored breathing, pallor, diaphoresis, anxiety

Question 17

what would be exam findings for pulmonary edema? What is the treatment for pulmonary edema?

Answer 17

• exam: decreased breath sounds, crackles, increased tactile fremitus, S3, LE edema
• treatment: supplemental O2, control underlying condition, bronchial hygiene to aid in secretion clearance

Question 18

who is at risk of pulmonary embolism?

Answer 18

CHF, acute MI, CVA >40 yo, obesity, lupus, immobilized, SCI, trauma, oral contraceptives, post op orthopedic surgery, prior DVT

Question 19

what is the common cause of pulmonary embolism?

Answer 19

• often a complication of DVT (thrombus travels from systemic vein to pulmonary circulation)(thrombus most commonly from leg)

Question 20

what are the symptoms of pulmonary embolism? what are the treatments for PE?

Answer 20

• symptoms: acute dyspnea or tachypnea, chest pain, cough with hemoptysis, tachycardic and weak, hypotensive, lightheaded, dizzy, syncope, anxiety
  -treatment: prevention of DVT with exercise and medication, heparin therapy

Question 21

what is the primary management and acute management of pulmonary embolism?

Answer 21

• primary: prevention through use of compression stockings, intermittent pneumatic compression, early mobilization, anticoagulants, IVC filter
  -acute: thrombolytic therapy (heparin)+ pulmonary embolectomy

Question 22

what is pulmonary hypertension?

Answer 22

• high BP in the lungs causes the lungs to become damaged, stiff, and narrow requiring the R side of the heart to work harder

Question 23

Describe pulmonary HTN due to L sided heart disease

Answer 23

• systolic or diastolic dysfunction means that the heart muscles can squeeze or relax effectively
• L side of the heart cannot keep up with blood returning from the lungs which leads to backup of blood raising pressure in the lungs

Question 24

Describe pulmonary HTN due to lung disease

Answer 24

• arteries in the lungs will tighten so that blood can only go to well ventilated areas of the lungs

Question 25

describe pulmonary HTN due to chronic blood clots in the lungs

Answer 25

• the body is unable to dissolve blood clots in the lung which leads to scarring within the artery increasing resistance making the R side of the heart work harder

Question 26

what are the indications for lung transplant?

Answer 26

COPD, idiopathic pulmonary fibrosis, CF, idiopathic pulmonary arterial HTN, sarcoidosis

Question 27

What are preoperative pulmonary rehabilitation recommendations?

Answer 27

• minimum of 20 sessions 3x/wk or 2x/wk plus one home session
• HIT when possible
• interval training when possible
• UE and LE
• combine endurance and strength training
• inspiratory training as adjunctive therapy
• oxygen supplementation for HIT

Question 28

what is a common dysfunction following lung transplant? what are the symptoms? what is the clinical presentation? what is the treatment?

Answer 28

• restrictive dysfunction: bronchiolitis obliterans syndrome (BOS) is a major long term complication of transplantation which leads to fibrosing of terminal bronchioles
• symptoms include dyspnea, limited exercise tolerance, productive cough with sputum
• clinical presentation: decreased breath sounds, crackles and rales, pulmonary htn
  -treatment: maintenance with immunosuppression regimen, quick interventions for infections

Question 29

what are initial PT management goals post of lung transplantation?

Answer 29

• rehab begins once the patient is stable (usually 1 day post op in ICU)
• goals are bronchial hygiene, positioning, enhance cough effort, and improve mobility

Question 30

what are level 1 activities to perform for inpatient physical therapy after lung transplantation

Answer 30

• breathing and relaxation techniques
• exercises 15-20 reps supine or seated
• follow sternal precautions
• seated marches
• bridges
• ankle pumps
  -pregait activities (minisquats, weight shifting, single leg stance)
• up in chair atleast 30-60 minutes

Question 31

what are level 2 activities to perform for inpatient physical therapy after lung transplantation

Answer 31

-exercises (15-20 reps in standing)
- follow sternal precautions
- lunges
- marching in place
-minisquats, weight shifting, single leg stance
- toe raises
- ambulate in room or in the hall
-seated up in a chair

Question 32

what are level 3 activities to perform for inpatient physical therapy after lung transplantation

Answer 32

• 15 to 20 repetitions in standing
  -head and shoulder exercises with progression to wrist weights
  -toe raises with progression to single leg
• dynamic balance
• 10-15 mins continuous ambulation
• stair stepping
• cool down stretching

Question 33

what happens when you are not a candidate for lung transplant?

Answer 33

• lung volume reduction surgery (20-30% volume of each lung removed) to improve thoracic distention and chest wall mechanics
• common for severe COPD, emphysema
• non-invasive ventilation or BiPAP is a mask that delivers positive airway pressure during inhalation and exhalation
• commonly used for severe COPD (at night to aid in sleep quality) and respiratory failure