The Aging Pulmonary System

Question 1

An increase in production of CO2 from muscles lead to what in circulatory and pulmonary circulation

What about increase in uptake of O2

Answer 1

CO2 ->Peripheral Circulation dilation -> Increase SV -> Recruit Pulmonary System -> Increase in Tidal Volume

O2 ->Recruit -> Increase HR ->Dilate -> increase respiratory rate

Question 2

Minute ventilation is calculated which 2 ways

Answer 2

Product of tidal volume and respiratory rate

Or

Sum of alveolar and dead space ventilation

Question 3

What happens with VO2max with aging? Difference between men and women?

Answer 3

Declines about 1 ml/kg/min per year, faster in men, increases with age
Rate of decline in inactive men 2x of active individuals

Question 4

Resting VO2 equivalent to 1 MET
What is 50 year old’s max? Activities example
80 year old?

Answer 4

3.5 ml/kg/min
At 50 about 10 times this so 35, equivalent of running 6mph, carrying 60 lb load up stairs
At 80 it’s about 21, walking uphill at 3.5 mph, pushing a lawn mower.

Question 5

What stays consistent over time in the lungs in terms of morphology and physiology?

Answer 5

Elastin, lung cell populations (type I vs II)

Reduction in elastic recoil is offset by a stiffer chest wall, so TLC remains relatively stable.

Question 6

How does vital capacity and residual volume change over time

Forced expiration volume

Answer 6

Even though TLC relatively constant,
VC decreases over time as RV increases
FEV1 decreases

Question 7

What causes the gradual decrease in partial pressure difference between the alveolus and the systemic arterial blood

Answer 7

Pulmonary perfusion does not decrease with age but there is an increase in physiological dead space, which decreases alveolar ventilation. This causes an increased inequality in alveolar ventilation and perfusion, which leads to a gradual decrease in in arterial partial pressure,

Question 8

COPD includes which 2 diseases
How are they structurally different?
How are they functionally the same

Answer 8

Emphysema and chronic bronchitis
Often difficult to distinguish the 2 and often occur at the same time
Emphysema: Enlargement of distal airspaces
CB: hypertrophy of mucous glands, small airway inflammation, bronchial smooth muscle hypertrophy.
Functionally they both limit expiratory flow

Question 9

Stages of COPD, FEV1 values and FEV/FVC

Answer 9

FEV1/FVC stays <70 for every stage
Stage I:  Mild, FEV1 >/=80% predicted
Stage II:  Moderate: 50-80%
Stage III:  Severe: 30-50
Stage IV:  Very severe: <30 or <50 plus chronic respiratory failure.

Question 10

ldiopathic pulmonary fibrosis: Structural change, what happens to lung volumes, noise that can be heard

Answer 10

Thickening of the alveolar walls
Virtually all volumes decrease
Fine inspiratory crackles on inspiration

Question 11

Clinically how does pulmonary edema present?

Answer 11

Orthopnea (dyspnea in supine) paroxysmal nocturnal dyspnea, frothy and pink if cough is productive, bilateral lobe crackles with auscultation

Question 12

6 signs of medium sized PE

Answer 12

Pleuritic chest pain, dyspnea, tachypnea, tachycardia, hemoptysis, hypoxemia

Question 13

Definition of cor pulmonale

Answer 13

R sided heart failure that developers due to pulmonary hypertension, which develops due to chronic hypoxemia, which leads to pulmonary vasoconstriction and increased arterial pressure, is common with most end stage lung disease, will develop peripheral edema and perhaps jugular venous distention

Question 14

Top 2 reasons for hospitalization in adults over 65

Answer 14

1 acute CHF-causing pulmonary edema/congestion
2 pneumonia

Lung cancer most common cause of cancer related deaths in US

Question 15

Chest auscultation reveals what in ppl with pneumonia:

Other signs of pneumonia: 6

Answer 15

Crackles or low pitched wheezes (rhonchi) diminished or bronchial lung sounds over th affected lobe
Tachypnea, tachycardia, fever, cough, malaise, pleuritic chest pain

Question 16

Albuterol- how should PTs time this drug if short acting

Answer 16

Benefit begins about 10 minutes post-tx, peaks 1 hour, lasts about 4 hours

Question 17

Metered dose inhaler vs nebula zero for albuterol

Answer 17

Higher HR and increased risk of vomiting with nebulizer

Question 18

Glucocorticosteroids are used for treatment of which stages of COPD

Answer 18

Stable III and IV or during acute exacerbation of COPD or IPF

Question 19

Inhaled glucocorticosteroid example and when used vs oral (prednisone/prednisolone)

Answer 19

Inhaled to prevent acute exacerbation, oral for acute exacerbations

Question 20

What should the PT do with a patient who is on prednisone/isolone?

Answer 20

Test proximal LE muscles (due to potential myopathy) monitor for skin breakdown, limit sliding transfers, eliminate extreme thoracic flexion and or rotation due to osteoporosis

Question 21

Tendinopathy/tendon rupture, especially the Achilles’ tendon, is associated with use of which drug, and especially if combined with which additional drug?

Answer 21

Fluoroquinolones, glucocorticosteroids

Question 22

What should PT watch for in terms of adverse reactions of furosemide

Answer 22

First line of treatment for pulmonary edema, but can cause volume depletion (orthostatic hypotension) and electrolyte imbalance (potassium depletion, watch for fatigue, confusion, nausea, weakness, cardiac dysrhythmias.

Question 23

The 6MWT predicts that for patients with COPD, a distance >______m predicts survival rate of _____ at 5 years, while a distance of

Answer 23

350m 75%

<250m 40%

Question 24

Some though the initially proposed MCID of 54m or 180 feet too high for people with low functional abilities, what did they propose for people with COPD?

Answer 24

35m or 115 feet or 10% over baseline

Question 25

Does ascites or pedal edema come first?

Answer 25

Pedal edema, abdominal swelling is last, dyspnea is first sign, due to R side heart failure from pulmonary disease or L side heart failure.

Question 26

Wells criteria, 8 positive points, 1 negative point

Answer 26

1) Active cancer
2) Paralysis, paresis, or recent plater immobilization of the LE
3) Recently bedridden >3 days or major surgery within past 4 weeks
4) Tenderness along distribution of deep venous system
5) Entire LE swelling
6) Calf swelling by >3cm compared to asymptomatic LE
7) Pitting edema >asymptomatic LE
8) Collateral superficial veins (nonvaricose)

Alternative diagnosis that is as likely, subtract 2 points, this includes cellulitis, calf strain, post-op swelling

> /=3 points, probability of 75%
1-2 points, probability of 17%

Question 27

What may be a better alternative to MMT for people with pulmonary disease

Answer 27

Sit-to-stand test, either number of reps in 10 seconds or number of seconds for 10 reps, or 60 second stst, may be more sensitive to change, is correlated with maximum gait speed and stair climbing ability, and may be motivating for the patient.

Question 28

Medical Research Council Dyspnea Scale

Answer 28

1-5
1 No trouble except strenuous exertion
2 Short of breath when hurrying on the level or asking up slight hill
3 Walks slower than others on level surface or has to stop to catch breath after about a mile
4 Stops for breath after walking about 100 yard or after a few minutes on level ground
5 Too breathless to leave or house or breathless after dressing/undressing

Question 29

What is the benefit of using the Borg CR10 scale for dyspnea?

Answer 29

Not linear in nature so can allow for more specificity in quantifying dyspnea beyond moderate severity.  1 unit is the MCID. 
0 nothing at all
.5 extremely weak
1 very weak
2 weak
3moderate
5 strong
7 very strong
10 extremely strong

Question 30

Adventitious lung sounds can be classified into which 2 types? What does each indicate?

Answer 30

Continuous such as wheezes, during expiration, indicates some sort of airway obstruction such as bronchitis, bronchial constriction, bronchial tumor.
Discontinuous: crackles, typically occur with inspiration, Amy indicate atelectasis, pneumonia, PF, COPD, or pulmonary edema due to CHF.

Question 31

Breathing techniques good for COPD and not recommended. Who is not appropriate for traditional chest therapy?

Answer 31

Pursed lip and positioning (forward leaning posture). Diaphragmatic breathing not beneficial for COPD.
Chest therapy not good evidence for use for people with pneumonia and chronic bronchitis, but can be good for people with a lot of secretions.

Question 32

What did the Long-term Oxygen Treatment Trial from the National Heart, Lung, and Blood institute Find?

Answer 32

Long term oxygen treatment not beneficial in terms of outcomes like survival in people with moderate oxygen deficits (89-93 at rest, <90 upon exertion)