Emphysema

Question 1

what is emphysema?

Answer 1

1. pathologic accumulation of air in the lungs
2. disease of exhalation → pts have difficulty w/exhalation
3. characterized by air trapping in the lungs
   
   1. causes an increase in residual volume, total lung capacity (TLC) and a decrease in FVC1/FVC ratio

Question 2

what causes the increased TLC in pts with emphysema?

Answer 2

flattened diaphragm (length-tension relationship)

Question 3

describe the changes to lung anatomy in emphysema

Answer 3

creates hyperinflated lungs with enlarged alveoli (super alveoli)

forced expiration causes smaller airways to collapse during expiration which “traps air” in the alveoli

Question 4

what is considered a bad FEV1/FEV ratio?

Answer 4

less than 0.5 = bad news

Question 5

list volume changes that may occur in obstructive lung diseases like emphysema

Answer 5

1. increase in RV
2. increase in TLC
3. increase in FRC

Question 6

compare FEV1 in COPD to normal pts

Answer 6

the volume of air exhaled in the first second (FEV1) is less in COPD compared to a normal individual

Question 7

summary: emphysema causes __________

Answer 7

1. reduced lung elastic recoil
2. increased lung-compliance
3. increased lung volumes with reduced maximal expiratory flow rates

Question 8

T/F: there is inflammation associated with emphysema at the level of the lung

Answer 8

TRUE

corticosteroids may help manage this which can cause osteoporosis, immune suppression, proximal muscle weakness, weight gain (moon face) and diabetes

Question 9

list clinical manifestations of emphysema

Answer 9

1. first complaint = SOB at rest
2. apprehensive, anxious, addicted to O2
3. thin, cachectic
4. deformed chest with prolonged expiration
5. absent or non-productive cough
6. accompanying cardiac problems, cor-pulmonale
7. mild COPD → mild hypoxemia
8. with progression → hypoxemia worsens CO2 retained (hypercapnia)
9. chronic pulmonary metabolic acidosis
10. deconditioning

Question 10

prognosis for emphysema

Answer 10

Poor

is a chronic, progressive, and debilitating diseases

may present with lung cancer

Question 11

Emphysema implications for PT treatment

Answer 11

1. reducing airway edema secondary to inflammation and bronchospasm
2. facilitating the elimination of bronchial secretions
3. preventing and treating respiratory infection
4. increasing exercise tolerance
5. avoiding airway irritants and allergens
6. relieving anxiety and treating depression

Question 12

long term oxygen therapy implications for PT

Answer 12

1. pts with PaO2 of 55 or less, or a resting oxygen saturation of 88% or less, measured at 2 time periods 3 weeks apart are eligible (under Medicare rules) for long term O2 treatment

Question 13

how does an oxygen concentrator work?

Answer 13

1. N2 scrubber
2. increases the PO2 in the air breathed in
3. replaces other gases in atmospheric air with O2, increasing the PO2 of the inhaled air

Question 14

monitoring vitals in emphysema pts

Answer 14

1. use pulse ox
2. monitor HR and BP
3. the first heart sound is best heard under the distal sternal area
   
   1. hyper inflated lungs causes the heart to elongate, displacing the left ventricle downward and medially

Question 15

what is hypoxic drive?

Answer 15

a form of respiratory drive in which the body uses oxygen chemoreceptors instead of CO2 receptors to regulate the respiratory cycle

Question 16

describe how normal respiration differs from hypoxic drive

Answer 16

1. Normal
   
   1. driven mostly by the levels of CO2 in blood
   2. those levels are detected by peripheral chemoreceptors
   3. an increase in arterial CO2 leads to an increase in respiration
   4. dissolved O2 typically only plays a minor role in regulating respiration
2. pts on emphysema are more reliant on PaO2 to drive O2

Question 17

how does hypoxic drive influence pts on oxygen?

Answer 17

be careful with bumping up their O2 delivery when you exercise them, this could interfere with hypoxic drive

if you turn up O2 do it incrementally and observe RR and pulse oximeter readings

Question 18

emphysema: implications for the PT

metered-dose inhaler (MDI)

Answer 18

used to deliver drugs to the lungs

1. users must take in a slow deep breath over the course of 10 seconds while maintaining a good seal on the device and pressing on the device
2. some devices use spacers
3. get a new MDI when the appropriate number of doses has been delivered
4. evaluate the ability of the child or adult to correctly use the MDI

Question 19

List Emphysema meds

Answer 19

1. Bronchodilators
   
   1. Beta-2 adrenergic agonists
      
      1. SABAs
      2. LABAs
   2. anticholinergic agents
   3. steroids/glucocorticoids
2. mucolytic/expectorants
3. mast cell stabilizers
4. antibiotics

Question 20

describe SABAs

Answer 20

short acting beta-agonists

1. first line med for exacerbations
2. used in conjunction with LABAs
3. delivered via MDI
4. increased therapeutic action (delivered nasally), decreased systemic effects
5. onset of action 5 min
6. salbutamol (albuterol)

Question 21

describe LABAs

Answer 21

long-acting beta-agonists

1. duration of up to 12 hours
2. second line med
3. often given in conjunction with glucocorticoids
4. dual therapy

Question 22

what are ultra-long-acting beta-agonists?

Answer 22

once a day treatment dosage

administered via nebulizers generally

Question 23

issues of concern with beta-2 adrenergic agonists

Answer 23

1. receptor downregulation (tolerance)
2. “off target” stimulation of other adrenergic receptors
3. reduce morbidity and mortality is debated

Question 24

describe anticholinergic agents

Answer 24

1. the vagus nerve helps to regulate respiration rates
2. inhibition of this nerve allows airway dilation to occur
3. inhibit reflex cholinergic bronchoconstriction
4. ipratropium and oxitropium
5. often given in combination with B2-agonist

Question 25

describe mucolytic/expectorants

Answer 25

1. modulate mucus production and reduce mucus viscosity 2. useful for reducing flare-ups, days of disability, and hospital admissions in ppl with COPD 3. taken orally or via nebulizer 4. are not considered part of the current standard of care for COPD treatment 5. but are considered useful in ppl who cannot take inhaled corticosteroids

Question 26

describe mast cell stabilizers

Answer 26

1. mast cells are a type of resident inflammatory cell 2. may contribute to the inflammation associated with COPD 3. antihistamines and leukotriene antagonists 4. cromolyn and nedocromil

Question 27

why are antibiotics included in the medical management of emphysema?

Answer 27

1. most exacerbations of COPD are caused by respiratory tract infections 2. are used empirically - based on experience and observation

Question 28

T/F: pulmonary rehab is reimbursable?

Answer 28

TRUE

Question 29

what are the goals of pulmonary rehab?

Answer 29

1. Primary goal → restore the chronic lung disease pt to the highest possible level of independent function 2. DOES NOT reverse the disease process, simply allows pt to better live with the disease 3. improve QOL and dyspnea issues

Question 30

what does pulmonary rehab involve?

Answer 30

* integrates multidisciplinary services with the goal of helping the pt achieve a max level of independent function

Question 31

pulmonary rehab indications

Answer 31

1. indicated for pts with chronic pulmonary impairment who are dyspneic, have reduced exercise tolerance, and/or experience a restriction in activities 2. currently no specific functional criteria to meet to enter a pulmonary rehab program 3. referral is often offered only to the more advanced pt 4. often a referral earlier in the disease progression would be of more benefit

Question 32

pulmonary rehab exclusion criteria

Answer 32

1. conditions that place pt at undue risk 1. unstable angina 2. uncontrolled pulmonary HTN 3. recent MI 2. conditions that make participation impossible 1. severe arthritis or other joint problems 2. continued cigarette smoking 3. lack of motivation 4. progression of disease

Question 33

pt populations for pulmonary rehab

Answer 33

1. COPD 2. asthma 3. interstitial diseases 4. CF 5. bronchiectasis 6. thoracic cage abnormalities 7. neuromuscular disorders 8. S/P lung transplant 9. surgeries for lung cancer 10. lung volume reduction surgery

Question 34

nature of the emphysema pt

Answer 34

1. said to live in an “emotional straightjacket” 2. express a pattern of: 1. low self-esteem, sense of worthlessness, feeling of hopelessness, depression/anxiety, unable to vent their emotions for fear of not being able to breath 3. sleep deprivation 4. constant need for O2 supplementation 5. many use CPAP device 6. cachexic

Question 35

List several pulmonary function tests

Answer 35

1. Spirometry 2. Spirometry after bronchodilator → tests effectiveness of pt's drug regime 3. single breath diffusion capacity

Question 36

what does single breath diffusion capacity do?

Answer 36

1. D_LCO → diffusing capacity of Lung for CO 2. assesses the transfer of gas (CO) from air in the alveoli, the the RBCs in lung vasculature 3. compares the difference in the amount of CO in the inhaled and exhaled air 4. results speak to the quality of the diffusion surfaces in the lungs

Question 37

single breath diffusion capacity DLCO is reduced in \_\_\_\_\_\_\_\_

Answer 37

1. Emphysema 2. Interstitial fibrosis 3. Pulmonary embolism 4. Pulmonary HTN 5. Sarcoidosis 6. Lung Hemorrhage 7. Asthma 8. CF

Question 38

PFT and severity of disease

Answer 38

1. normal PFT outcomes → 85% of predicted values 2. mild disease → \>65% and \<85% of predicted values 3. moderate disease → \>50% but \<65% of predicted values 4. severe disease → \<50% of predicted values

Question 39

T/F: exercise is the centerpiece of pulmonary rehab?

Answer 39

TRUE * aerobic training consisting of walking/cycling with a goal to reach 20-30 min of continuous work (may require intermittent bouts of activity) * intensity = dyspnea scale of 3-4 BORG 1-10 scale OR 11-13 on BORG 6-20 scale * limit use of HR to define intensity

Question 40

describe the incremental shuttle walking test

Answer 40

1. the pt is required to walk between 2 cones (10 m) in time to a set of auditory beeps played on a CD 2. initially, the walking speed is very slow, but each minute the required walking speed progressively increases 3. the pt walks for as long as they can until they are either too breathless or can no longer keep up with the beeps

Question 41

Exercise prescription in pulmonary rehab: aerobic training parameters

Answer 41

1. work at 50% of VO2 max test 2. RPE → 12-14 3. HR → may be of limited use 4. monitor O2 sat with pulse oximetry 5. remember pt may quickly surpass their AT 6. perceived as LE training 7. may have limited central effects\

Question 42

strength training/UE activities in pulmonary rehab

Answer 42

1. arm ergometry 2. true resistance exercises 1. active ROM 2. light weights 3. cane exercises 4. theraband

Question 43

strength training/UE activities parameters in pulmonary rehab

Answer 43

1. duration = 5-15 min 2. frequency = 3x/week 3. intensity = 1 set of 8-12 reps

Question 44

strength training/UE activities usually lead to \_\_\_\_\_\_\_\_

Answer 44

1. increased ventilatory demand 2. early fatigue 3. dyssynchronous breathing pattern and increased dyspnea 4. adaptation tends to reduce these problems

Question 45

T/F: flexibility exercises should be included in pulmonary rehab?

Answer 45

TRUE especially upper body/accessory muscles standard flexibility activities → 5 reps and hold for 30 seconds

Question 46

T/F: an inspiratory muscle trainer is the same thing as an incentive spirometer

Answer 46

FALSE inspiratory muscle trainer is used to strengthen the diaphragm

Question 47

T/F: dyspnea is the most common symptom in COPD

Answer 47

TRUE which is why dyspnea scales are very important to include

Question 48

list general tools aimed at QOL issues

Answer 48

1. SF-36 (general health status questionnaire) 2. disease specific tools 1. St. George respiratory questionnaire 2. UCSD shortness of breath questionnaire 3. chronic respiratory disease quesionnaire