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Acute care > Week 7 > Flashcards

Week 7 Flashcards

1
Q

What is the most common cause of cardiac transplantation in america?

A
  • End-stage heart failure
  • Cardiomyopathy (48%)
  • CAD (44%)
  • Congenital
  • Valvular defect
  • Retransplant
  • Other
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2
Q

What are the indications for cardiac transplantation?

A
  • Cardiogenic shock requiring continuous inotropic support or mechanical support
  • Persistent NYHA functional class IV symptoms refractory to treatment
  • Intractable angina
  • Intractable life-threatening arrhythmias
  • Congenital heart disease with NYHA III/IV symptoms refractory to treatment
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3
Q

What are the absolute contraindications to a cardiac transplantation?

A
  • Irreversible Pulmonary vascular resistance
  • Malignancy
  • Active infection
  • HIV/AIDS
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4
Q

What are the relative contraindications to a cardiac transplantation?

A 
• Age>65*
• Poorly Controlled DM with
organ damage/failure
• Psychosocial impairment that
jeopardizes transplanted heart
  - Arnold Palmer and VA Example
• Cigarette smoking
• Unreliable Caregivers
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5
Q

What are the characteristics of the donor allocation system?

A

• Supervised by United Network of Organ Sharing (UNOS)
- Private organization designed to ensure equitable distribution of organs
• Organ Procurement and Transplantation Network (OPTN)
• Divided into 11 regions
• Prioritization based on
- Severity of illness
- Geographic Distance from Donor
- Patient time on wait list

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6
Q

What are the characteristics of a Status 1A patient on the (UNOS)?

A

• Reside in transplant listing center AND
- On mechanical ventilation
- On IABP, TAH or ECMO
- Hemodynamic monitoring with IV ionotropes
• 30 days after LVAD and/or RVAD
- Total artificial heart discharged from listing center (for 30 days post-discharge)
- LVAD with device-related complication

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7
Q

What are the characteristics of a Status 1B patient on the (UNOS)?

A
  • IV ionotropes or implanted chronic mechanical assist device
  • TAH after discharge
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8
Q

What are the characteristics of a Status 2 patient on the (UNOS)?

A

Patient who don’t meet 1A or 1B requirements

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9
Q

What are the procedures done for a cardiac transplantation?

A
  • Median sternotomy

* Cardiopulmonary bypass

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10
Q

What are the characteristics of a Status 7 patient on the (UNOS)?

A

Patients who are temporarily unsuitable for transplant

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11
Q

What are the characteristics of a ex- vivo heart perfusion?

A

Used to help keep the heart pumping and viable before being put in a body

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12
Q

What are the biopsy monitoring guidelines to follow after cardiac transplantation?

A
  • Every week for the first 4 weeks
  • Every 2 weeks for the following 6 weeks
  • Monthly for the next 3-4 months
  • Every 3 months until the end of the first year
  • 3-4 times per year in the second year
  • One to two times per years following
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13
Q

What are the physiological changes seen post transplant?

A

• Transplanted heart is denervated
• Higher resting HR (90-110bpm)
• Absence of direct neural regulation of HR/SV
- HR and SV controlled via circulating catecholamines and muscle pump
• Absence of chest pain

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14
Q

What is the exercise capacity of a patient post heart transplant?

A
  • 56% of patient exercise capacity is <70% of predicted normal
  • Only 13% achieve >90% predicted normal
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15
Q

What are the contributing factors to exercise capacity of a patient post heart transplant?

A

• Transition from type 1 to type 2 fibers
- Especially for patients with previous long standing HF
• Neuro-hormonal changes from long standing HF resulting in elevated TPR
• Side effects of corticosteroids and immunosuppressive therapy

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16
Q

What is the peak time a person gets to live after a heart transplant?

A

10 years. Unless they got it at a younger age

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17
Q

What kills most patients after a heart transplant?

A
  • Graft failure (within 1st 30 days)
  • Infection (within the 1st year)
  • Malignancy and graft failure (within 1st 5 years)
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18
Q

How many METs of exercise does a patient get after a heart transplant?

A

Up to 6-7 METs

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19
Q

What are the indications for a lung transplant?

A
  • Emphysema/COPD: Bronchiectasis, A-1-A deficiency
  • Cystic Fibrosis (younger population)
  • Pulmonary Fibrosis
  • Pulmonary Hypertension
  • Retransplant (often in cystic fibrosis)
  • Congenital
  • Sarcoidosis, RA, Inhalation burns/trauma
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20
Q

What are the contraindications for a lung transplant?

A
  • Uncontrolled infection
  • Malignancy (within past 2 yrs)
  • Significant dysfunction of other organs
  • Significant chest wall/spinal deformity
  • Active smoking, drug, alcohol dependency
  • HIV
  • Ongoing hepatitis B or C
  • Unresolved psychosocial/absence of support system
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21
Q

What are the guidelines for a lung transplant?

A
  • Appropriate age (generally <65)
  • Clinically and physiologically severe disease
  • Ineffective medical therapy
  • Limited life expectancy due to lung disease
  • Acceptable nutritional status (80-120% of ideal body weight)
  • Satisfactory psychosocial profile and support
  • Adequate financial coverage
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22
Q

What are the characteristics of the UNOS: Lung Allocation Score (LAS)?

A

• The lung allocation score (LAS) is used to prioritize waiting list candidates based
on a combination of waitlist urgency and post-transplant survival.
• Expected # days lived without
• Expected # days lived during first year post-transplant

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23
Q

What are the factors in the UNOS: Lung Allocation Score (LAS)?

A
  • FVC
  • Pulmonary Artery Pressure
  • Oxygenation Status
  • Age
  • BMI
  • Diabetes
  • Functional Status
  • 6MWD (typically 150ft)
  • Ventilation Status
  • PCWP
  • Serum Creatitine
  • PCO2
  • Diagnosis
  • Bilirubin
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24
Q

What are the procedures used for a lung transplant?

A

• Single lung transplant (thoracotomy)
- Also see this procedure used for resection and lobectomy
• Double lung transplant (clamshell)
• Lobar transplant from living donor

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25
Q

What kills most patients after a lung transplant?

A
  • Graft failure (within 1st 30 days)

- Infection (within the 1st year)

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26
Q

What is the exercise capacity of a patient post lung transplant?

A

• Peak exercise capacity following lung transplantation typically improves to
40-60% of the predicted level.
- Despite satisfactory graft lung function
• 2years post transplantation.
- Average 6MWD improvements following transplantation range between
307ft-498ft

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27
Q

Chronic disease prior to transplant leads to…?

A
  • Muscle weakness
  • Prolonged hospitalization
  • Fatigue
  • Prolonged bedrest or confinement to home
  • Decreased mobility
  • Poor breathing mechanics
  • Inability to clear pulmonary secretions
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28
Q

What are the pre-transplant rehab goals?

A 
• Preserve muscle strength and endurance
• Maximize functional independence
• Education
  - What to expect post-transplant
  - Precautions?
  - Getting them used to wearing masks
• Pre-transplant has been shown to have beneficial effects on post-transplant mortality, functional capacity and quality of life 
• Most increases are seen within the 1st couple of week, and deteriorates
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29
Q

What are the post transplant rehab guidelines in the Inpatient Phase (1-2 weeks)?

A
  • Early Mobility in ICU

* Gait, balance, ADLs, Functional Mobility etc

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30
Q

What are the potential barriers of post transplant rehab in the Inpatient Phase (1-2 weeks)?

A
  • Acuity of illness
  • Medical/cognitive
  • Ventilation/sedation
  • Line placement
  • Lab values and vital signs outside of safe ranges
  • Inpatient testing and procedures
  • Patient compliance
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31
Q

What are the inpatient goals for post transplant rehab?

A

• Increase functional capacity
• Improve level of independence
• Progression of exercise
• Education
- HEP
- Guidelines for termination of exercise
- Special considerations for exercies post-transplant

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32
Q

What are the post transplant rehab guidelines in the outpatient Phase (2-12 weeks)?

A

• Outpatient Phase (2-12 weeks)
- First 10 weeks: VO2 improvement approx. 1 MET from baseline
- 6 months to 1 year: 2 MET from baseline
- Exercise Capacity improvements typically plateau within first 1yr
• UE resistive training for cardiac and lung transplant patients should be delayed until 6
weeks post transplant when wound and tissue healing is complete
- Delayed wound healing due to medications

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33
Q

What are some rehabilitation considerations post organ transplant?

A

• Motivation and adherence to exercise are the major problems
• Studies have found that patients who have participated in exercise interventions
following transplantation have scored higher on quality of life questionnaires 1 year
and 5 years post transplant in addition to demonstrating increased exercise capacity
(measured by VO2 peak)
- HEP performed regularly may also help reduce side effects of immunosuppressant medications

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34
Q

What are some rehab considerations with heart transplants?

A

• Sternal precautions
• Denervation of heart
- Warm-up, cool down
- RPE scale to monitor
exercise intensity
• HR is higher at rest
• Risk of myopathy, osteoporosis
• Typically no anginal symptoms due to denervation
• May see 2 p-waves on ECG
• Peak HR is reduced and may remain elevated post exercise
• Peak oxygen consumption (VO2 peak) is reduced
• Systolic and diastolic BP may be elevated at rest, but peak exercise systolic pressure is
usually lower.
• Reduced sensitivity of ECG to detect ischemia

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35
Q

What are some rehab considerations with lung transplants?

A

• Quad muscle biopsies after lung transplant show reduced skeletal muscle oxidative capacity
• RPE and dyspnea- preferred methods of monitoring intensity
• Musculoskeletal complaints, post-surgical chest wall pain and osteoporosiscommon post-transplant complications
• Myopathy involving respiratory and peripheral muscles- may be related to meds
• “Bronchial hyperresponsiveness” after transplant may contribute to
bronchospasms and SOB during exercise

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36
Q

What is Cardiac rehabilitation (rehab)?

A

A medically supervised program that helps improve the health and well-being of people who have cardiovascular disease and conditions

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37
Q

What do cardiac rehab programs include?

A

Exercise training, education on heart healthy living, and

counseling to reduce stress and help you return to an active life

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38
Q

What are the components of cardiac rehab?

A 
• Exercise training
• Physical activity counseling
• Tobacco cessation
• Nutritional counseling
• Weight management
• Lipid management
• Blood pressure management
• Diabetes management
• Psychosocial Counseling
(Stress)
• Sexual counseling
• Alcohol Consumption
Counseling
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39
Q

What are the diagnoses that are eligible for cardiac rehab?

A

• Acute myocardial infarction
• Stable angina
• Coronary artery bypass graft surgery
• Heart valve repair or replacement
• Percutaneous transluminal coronary angioplasty
• Heart transplantation or heart-lung transplantation
• HEART FAILURE!!!!!
- Stable class II and class III heart failure patients without complex arrhythmias

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40
Q

What are the contraindications for cardiac rehab?

A
  • Unstable angina,
  • Decompensated heart failure,
  • Complex ventricular arrhythmias,
  • Pulmonary arterial hypertension greater than 60 mmhg,
  • Intracavitary thrombus,
  • Recent thrombophlebitis with or without pulmonary embolism,
  • Severe obstructive cardiomyopaties,
  • Severe or symptomatic aortic stenosis,
  • Uncontrolled inflammatory or infectious pathologies and
  • Any musculo-skeletal condition that prohibits physical exercise
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41
Q

What are the benefits of cardiac rehab?

A

• Risk reduction in mortality of 20% or higher, sustained up to 5yrs post
• Reduced recurrent MI by 17%, 47% mortality benefit at 2 years
• HFrEF CR demonstrate significant reductions (15%) in all-cause and cardiovascular
mortality and heart failure hospitalization.
• Decreased re-hospitalizations
• Increased rate of return to work from 38% to 53%
• 12-weeks participation in cardiac rehabilitation has demonstrated reduces
medical costs by 739$ per patient
- After only 21 months follow-up
- Possibly more cost effective than medications!
• A study in Sweden showed that participation in cardiac rehab resulted in an overall cost savings of $12,000 per patient

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42
Q

What are the risks of cardiac rehab?

A

• Overall, cardiac rehabilitation is safe and well tolerated with a very low rate of major
complications such as death, cardiac arrest, myocardial infarction or serious injuries.
• 1 event in 60,000-80,000 patient-hours of supervised exercise.
• Patients most at risk are those with residual ischemia, complex ventricular arrhythmia and severe left ventricular dysfunction (ejection fraction of less than 35%), especially NYHA III or IV

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43
Q

What are the modifiable risk factors for heart disease?

A
  • Smoking
  • DM
  • HTN
  • ApoB/A1
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44
Q

What is the participation in cardiac rehab like?

A
  • Only 14% to 35% of heart attack survivors

* Only 31% of patients after CABG participate

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45
Q

What are the barriers to participation of cardiac rehab?

A
  • Limited Financial resources
  • Transportation difficulties
  • Lack of social or emotional support
  • Limited to no physician endorsement/support
  • Lower Education level
  • Cultural beliefs and understanding of disease and treatment
  • Program availability and characteristics
  • Older individuals are less likely to be referred to and to participate in cardiac rehabilitation
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46
Q

What are some ways to address barriers to participation of cardiac rehab?

A
  • Including referral to CR/SPP in the hospital discharge plan
  • Automatically referring all eligible patients at the time of hospital discharge
  • Group Classes (Social Group)
  • Use of TeleHealth
  • Patient selection of setting
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47
Q

What are the characteristics of home based cardiac rehab?

A

• Can be implemented effectively and comparable to hospital based.
• May improve maintenance of
improvements in functional capacity.
• Cost Benefit

48
Q

What are the phases of cardiac rehab?

A 
• Phase 1: In hospital
  - Goal in general at least 3-5METs
• Phase 2: 1-12 weeks
  - Goal is at least 8METs
• Phase 3: Supervised Maintenance
• Phase 4: Unsupervised
Maintenance
49
Q

What are the goals of phase 1 of cardiac rehab?

A
  • Prevent skin breakdown, deconditioning and DVT/VTE, early mobilization
  • Direct gradual return to activity
50
Q

What are the characteristics of phase 1 of cardiac rehab?

A

• In Acute hospital
• Careful monitoring of vitals, signs and symptoms of MI
- Recurrent MI can be possible within 4-8 weeks post MI

51
Q

What are the recommended guidelines for phase 1 of cardiac rehab?

A
  • Intensity <5METs for 6-8 post-MI

* HR <120bpm OR no more than +20bpm from resting

52
Q

What are the testing recommendations for cardiac rehab before hospital discharge?

A

Discharge for prognostic assessment, activity prescription, evaluation
of medical therapy
• Submaximal at about 4 to 6 days, (ie 6MWT, Stair Climb Test etc)

53
Q

What are the testing recommendations for cardiac rehab early after hospital discharge?

A

Early after discharge for prognostic assessment, activity prescription, evaluation of medical therapy, and cardiac rehabilitation especially if the pre-discharge exercise test was not done
• (Symptom limited;Sub max test. 75-85% of sub max about 14 to 21 days).*

54
Q

What are the testing recommendations for cardiac rehab late after hospital discharge?

A

Late after discharge for prognostic assessment, activity prescription, evaluation of medical therapy, and cardiac rehabilitation if the early exercise test was submaximal. Can do max test now, done by adv cardio person
• (Symptom limited; about 3 to 6 weeks).

55
Q

What are the guidelines for phase 2 of cardiac rehab?

A
  • 12 weeks 2-3/week 45-60min
  • With or Without ECG monitoring
  • Reassessments and progressions at least every 2 weeks
  • Formal reassessment at 6 weeks
56
Q

What are the monitoring guidelines during cardiac rehab?

A 
When to hold exercise
• QRS Widening >0.12s
• >6 PVC per minute or Couplet
• Glucose >250 or below 60
  - Make sure they have snack prior
• Resting 90mmHg > SBP >180mmHg or DBP >110mmHg 
• Resting HR>100 or with Afib >110bpm
57
Q

What is the goal for aerobic training in cardiac rehab?

A

Goal is to eventually build patient up to 45minutes of continuous exercise by 3-6 weeks
• Some patients will take longer
• Progress gradually, increasing duration first to at least 20minutes (5min week)
• Consider different modes

58
Q

What is the intensity of aerobic training in cardiac rehab?

A

The intensity of exercise among patients with heart disease is recommended to be 60–80% of
the maximum heart rate or 50-85%VO2peak
• Consider 30-50% Target HR early on

59
Q

What are the characteristics of aerobic training in cardiac rehab?

A
  • Consider increasing Intensity 1 MET every 2 weeks

* Multiple Modes

60
Q

What are the dosages of cardiac rehab for stable angina?

A
  • 70% to 85% of the HR at the onset of ischemia

* Consider RPP

61
Q

What are the dosages of cardiac rehab for beta-blocker?

A

Consider RPE (12-15), or Karnoven Equation

62
Q

What are the dosages of cardiac rehab for HF?

A

70% to 85% of maximal if tolerated or to the onset of moderate dyspnea

63
Q

What is the Karnoven Equation?

A

Target Heart Rate = ((max HR − resting HR) × %Intensity) + resting HR

64
Q

What is the AHA recommended resistance training in cardiac rehab?

A
  • 1 set; 30-50% 1RM
  • 10–15 reps; 8–10 exercises
  • 2–3 d/wk major muscle groups,
  • RPE 11-13
  • Resting BP below 160/100mmHg
65
Q

What is the resistance training guideline for cardiac rehab in patients with a myocardial infarction?

A

Minimum 5wks post including 4wks of cardiac rehab

66
Q

What is the resistance training guideline for cardiac rehab in patients with CABG?

A

Minimum 8wks post including 3wks of cardiac rehab, because of sternal precautions

67
Q

What is the resistance training guideline for cardiac rehab in patients with a PCI/PTCA?

A

Minimum 2wks post including 2wks of cardiac rehab

68
Q

What are the characteristics of HIIT as it relates to cardiac rehab?

A

• HIIT appears to be a safe and effective alternative for patients with CAD and HF.
• May also assist in improving adherence to exercise training.
• HIIT significantly increases CRF by almost double that of moderate intensity continuous
training (MICT) in patients with cardiometabolic diseases,
- Similar benefits in HF
• Has demonstrated greater improvements in vascular/endothelial function than MICT
- Effects s/p Heart transplant

69
Q

In what phase of cardiac therapy is the addition of stress reduction therapy most helpful?

A

Phase 3

70
Q

What are some stress reduction therapy that can be added to cardiac therapy?

A 
• Yoga
• Tai Chi Chuan
• Waltz Dancing
  - Stable HF
• Meditation
71
Q

What are some pathophysiological changes in lung disease esp COPD?

A

• Metabolic inefficiency with some fiber type shift in skeletal muscle from type I to type II
• Reduced FFM (especially in quadriceps)
• Increased resting energy expenditure (REE), 15–20% above predicted values due to the
increased work of breathing.
• Impaired Mitochondrial function and decreased density
• Multiple suspected causes
- Disuse atrophy
- Mitophagy

72
Q

What are the common impairments of lung disease?

A 
• Functional capacity
  - 6MWD
  - Or other ETT
• Decreased strength
• Impaired balance
  - Fall risk
• Dyspnea with minimal activity
• Reduced Gait speed
• Impaired cardiorespiratory response
to exercise
• Back pain and chronic pain
73
Q

What is pulmonary rehabilitation?

A

Combines exercise training and behavioral and educational
programs designed to help patients with lung disease control symptoms and improve
day-to-day activities.

74
Q

What are some of the demonstrated benefits of pulmonary rehabilitation?

A
  • Reduced respiratory symptoms such as dyspnea and fatigue
  • Increased muscle strength and endurance
  • Increased knowledge about lung disease and management
  • Increased ability to perform tasks of daily living
  • Increased quality of life
  • Decreased depression and anxiety
  • Reduced pulmonary exacerbations and decreased use of medical resources
  • Ability to return to work or leisure activities
75
Q

What does a typical Pulmonary Rehabilitation Program look like?

A
  • Initial assessment of Respiratory disease process
  • Underlying medical disorder
  • General medical condition
  • Functional status
  • Patient’s goals
  • Select treatment goals
76
Q

What does a typical Pulmonary Rehabilitation Program include?

A 
• Medication optimization
• Adjustment of supplemental oxygen
therapy
• Airway secretion elimination
techniques and devices
• Smoking cessation program
• Exercise program
• Ventilatory muscle training
• Endurance and strength training
• Breathing retraining
• Alternative breathing techniques
• Energy conservation techniques
• Therapeutic modalities
• Adaptive devices and mobility equipment
• Psychosocial counseling
• Nutritional counseling
• Patient and caregiver education
• Maintenance program
77
Q

Who is included in the Interdisciplinary team for pulmonary rehab?

A
  • Patient
  • Medical Team
  • Physical Therapist
  • Respiratory Therapists
  • Nurses
  • Occupational therapists
  • Social workers
  • Nutritionist
  • Psychology or psychiatry services
78
Q

What are the practice setting that pulmonary rehab is usually done?

A 
• Hospital Based
• Private Cardiopulmonary Rehab Clinic
  - Physician oversight
• “Outpatient physical therapy clinic”
• Home Based
  - 12 week home-based PR program is effective in improving exercise intolerance, subjective
breathlessness, and QoL for housebound elderly COPD patients.
  - Walking programs
79
Q

What is the POC duration range for pulmonary rehab?

A

Range from 4-26 weeks(12wks is norm), 2-3times per week
• Optimal duration, unknown, large variability among centers
• Longer duration programs appear to have a more favorable effect
• Ideal if clinic provides their own oxygen

80
Q

What are the parameters for hoe long a session of pulmonary rehab last?

A

Sessions usually last 75-90minutes
• 1:3 work rest ratio (esp at the beginning)
• Maintain SpO2% >90%

81
Q

What is the evidence that supports pulmonary rehab?

A

• When compared with the treatment effect of inhaled bronchodilators, pulmonary
rehabilitation resulted in greater improvements in important domains of healthrelated quality of life and functional exercise capacity.
• Exercise-based PR interventions may reduce hospitalizations and primary care consultations.
• There is evidence supporting exercise-based PR among patients recovering from or
recently recovered from acute exacerbations of COPD.

82
Q

What is the evidence that supports pulmonary rehab in regards to COPD?

A

• It has been suggested that additional RCTs comparing pulmonary rehabilitation and
conventional care in COPD are not warranted.
- Safe
- Effective
• Future research studies should focus on identifying which components of pulmonary rehabilitation are essential:
- Ideal length and location
- Degree of supervision
- Intensity of training required and
- How long treatment effects persist

83
Q

What are the limitations of pulmonary rehab?

A

Limitations to compliance and referral
• Lack of PFT
• Readmission

84
Q

What is the evidence that supports pulmonary rehab in regards to ILD?

A

• Pulmonary rehabilitation seems to be safe for people with ILD.
• Improvements in functional exercise capacity, dyspnea and quality of life are seen immediately following pulmonary rehabilitation, with benefits also evident in IPF.
• Because of inadequate reporting of methods and small numbers of included participants, the quality of evidence was low to moderate.
- Little evidence was available regarding longer-term effects
of pulmonary rehabilitation.

85
Q

What are the patient population seen in pulmonary rehab?

A

• Any patient with chronic respiratory disease who remains symptomatic, with
decreased functional capacity despite optimal medical therapy.
• COPD: Moderate disease and beyond (Stage II-IV).
• Any stable patient with chronic lung disease disabled by respiratory symptoms.
Patients with advanced disease may benefit as well, as long as treatment and goals
are appropriate and realistic.
• Patients must have had PFTs within 1 year

86
Q

What are the specific criteria for pulmonary rehab?

A

• Chronic stable respiratory disease
AND
• Nonsmoking or currently enrolled in smoking cessation
AND
• Disabling symptoms that impair functional capacity
• PFTs
- COPD: FEV1<80% and FEV1/FVC <70%
- Other conditions: FEV1 60%, FVC <60%, DLCO 6%

87
Q

What are the characteristics of aerobic training in pulmonary rehab?

A

• Majority of studies have investigated AT interventions during pulmonary
rehab.
• Typically utilizing moderate intensity (40-60%VO2max)
- Talk test(should be able to communicate)
- OR, Use 80% of average 6MWT gait speed speed
• Durations lasting 30minutes continuously, or 10minute intervals.

88
Q

What are the characteristics of strength training in pulmonary rehab?

A

• Reductions in skeletal muscle strength, which are associated with higher health-care
utilization and poorer prognosis, have been reported to affect between 30% and 70%
of people with chronic lung disease.
• Short-term progressive resistance exercise can lead to appreciable increases in
muscle strength for people with COPD, which may carry over to the performance of some daily activities.
• Inconclusive in current literature if carryover to function occurs.
• Progressive resistance exercise has been recommended as a training modality for increasing peripheral muscle strength in people with COPD.
• May be better tolerated than AT in more severe cases.

89
Q

What is a typical strength program for pulmonary rehab?

A

• 6 to 26 weeks, 2-3/week
• 5-12 exercises
- Combination of arm, trunk and leg exercises
• 2-4 sets of 8 to 12 repetitions for each exercise,
• Intensities ranging and progressing from 32% to 90% of 1RM

90
Q

What are the characteristics of balance training in pulmonary rehab?

A

• Patients with COPD exhibit deficiencies in functional balance, coordination,
and mobility tasks
- Associated with pulmonary function.
• Patients with COPD have a high susceptibility to falls
- Associated with a worsening of dyspnea perception.
• The research supports the use of balance training as part of PR for improving balance performance, muscle strength, and self-reported physical function in patients with moderate to severe COPD.

91
Q

What are the characteristics of interval training in pulmonary rehab?

A

• In COPD patients there are indications that greater physiological benefits can be
obtained through high-intensity compared to moderate-intensity training.
• Interval training can be applied especially to those patients with advanced COPD,
who are unable to sustain exercise intensities sufficiently long enough to obtain a
physiological training effect because of ventilatory limitation
• Studies have shown that patients with severe COPD (FEV1: 40% predicted) can
almost triple the total exercise duration with significantly lower and more stable metabolic and ventilatory responses compared to continuous exercise.

92
Q

What are the guidelines for interval training in pulmonary rehab?

A

• Frequency: 3-4 times weekly.
• Interval mode: 30 seconds exercise period with 30 seconds rest or even 20 seconds exercise – 40 seconds rest.
• Intensity and duration: initially familiarize the patients on the cycle ergometer at an
intensity equivalent to 80% of the maximal work load for 15 to 20 minutes for the first 3 to 4
sessions

93
Q

What are the ways to monitor intensity during interval training in pulmonary rehab?

A

• The Borg Scale of perceived exertion can be used to more easily monitor exercise intensity.
Increase training work load by 5% to10% of peak capacity when patients rate their perceived
dyspnea as moderate.
- If the 10-point Borg scale is used to describe exercise intensity, most exercise should be performed between 5 to 6 intensity for the legs and 3 to 4 for dyspnea.
• Increase total exercise time from 30 to 90 minutes per session (including rest periods), at intensities that progressively reach 150% of the baseline maximum work load.

94
Q

What type of breathing is suggested during the breaks of interval training in pulmonary rehab?

A

Suggest pursed-lip breathing during rest periods to increase tidal volume and reduce breathing frequency.
• Teach patients to perform all daily activities (eg, stair climbing, uphill walking) at an interval mode consisting of short bouts of activity lasting 10 to 15 sec and rest periods of 15 sec.
• Give written instructions to the patients for home practice.

95
Q

What are the characteristics of inspiratory muscle training in pulmonary training?

A
  • Intensities range from 15-60% PIMax
  • Indicated for patients with inspiratory strength deficit <60cmH20
  • 10-15minutes, 2-3times per day, at least 5 weeks
  • Does not significantly improve PFT, FEV1, or FVC
96
Q

In what aspects so we see significant improvements in inspiratory muscle training in pulmonary training?

A
  • Inspiratory muscle strength, inspiratory muscle endurance, exercise capacity 6MWT), Dyspnea Rating during exercise
  • May see more clinically important changes in more deconditioned patients
97
Q

What are the effects of tai chi in pulmonary rehab?

A

• Emphasizes fluid movements,
controlled breathing and
meditation.
• Tai Chi has beneficial effects on exercise capacity, balance and HRQoL in COPD patients.

98
Q

What some general interventions to use for patients with pulmonary disease?

A
  • Endurance exercise
  • Resistance exercise
  • Upper limb exercise
  • Flexibility exercise
99
Q

What are the characteristics of COPD and neuro-muscular impairments?

A

• Patients with COPD report almost 2.5 times greater pain compared to healthy adults.
• Pain interferes with daily activities 3.7 times more often in people with COPD than in healthy people.
• Moderate to severe pain was self-reported 7.5 times more often in patients COPD than
matched healthy people as measured by the MPQ.
• Pain in the neck and trunk is more common than in other body locations.
• Several possible causes for this increased incidence of pain amongst patients with COPD
including:
- Biomechanical changes, increased comorbidities, systemic inflammatory cytokines IL-6 & TNF-α and protracted central processing of dyspnea and pain.

100
Q

Besides respiratory function, what is the other role of the diaphragm?

A

The diaphragm also plays an important role in stabilizing the spine during balancing and loading tasks.

101
Q

To maintain homeostasis the CNS will always prioritize ___ over postural control

A

To maintain homeostasis the CNS will always prioritize respiration over postural control

102
Q

The diaphragm and abdominal muscles together create a hydraulic effect in the abdominal cavity, which does what?

A

Which assists spinal stabilization by stiffening the lumbar spine through increased intraabdominal pressure

103
Q

What are some functions of the diaphragm that healthy individuals have, and those with COPD do not?

A

• The stability of spine, shoulder girdle, and pelvic girdle is established before execution of a postural task by a central mechanism of anticipatory postural adjustments, which occur independently from
the respiratory activity of the diaphragm
• Healthy individuals seem to be capable of efficiently compensating for reductions in the postural control role of the diaphragm due to increases in inspiratory demand by increasing multisegmental
control

104
Q

What are the characteristics of the anatomy and biomechanics of the diaphragm?

A

• Inspiratory diaphragm position (DP) in both UE and LE activities is significantly lower when compared to tidal breathing.
• Expiratory DP is in a lower level only during lower extremities activities
• The diaphragm during the LE activities does not, relax fully and remains in higher tonic state of activity.
• It appears that individual sections of the diaphragm contribute differently to postural function during movement tasks.
- Apex (Middle Region) and Crural (Posterior Region)

105
Q

What are the postural changes we see in COPD?

A

• Levine et al demonstrated that patients with severe COPD generate 60% of normal maximal
transdiaphragmatic pressure
- An indirect measure of inspiratory muscle strength.

106
Q

According to Levine, what are the changes at the cellular and molecular level in the diaphragm can fully account for the reduced diaphragm strength?

A

• Fiber type “switch” to type 1 to compensate for increased diaphragmatic loading
• The reduction of maximum force generated by COPD diaphragm fibers was associated with an
approximate 30% loss of heavy chain myosin content.
• These physiological changes are present in mild and moderate cases as well

107
Q

According to Similowski et al, the weakness of the diaphragm in COPD can be explained by..?

A

Hyperinflation-induced diaphragm shortening, which places the diaphragm on a
suboptimal position on its pressure–length relationship

108
Q

What are the characterstics of the postural sway characteristics that were assessed by the CoP displacement?

A

• Postural sway characteristics were assessed by center of pressure (CoP) displacement using a 6-channel force plate which recorded the moment of force around the frontal axis (Mx), anteriorposterior force (Fy) and the vertical ground reaction force (Fz).
• Local muscle vibration was used to investigate the role of
proprioception in postural control.
• The amount of CoP displacement with vibration to a muscle represents the extent to which an individual makes use of the proprioceptive signals of the vibrated muscles to maintain the upright posture

109
Q

What were the results of the postural sway characteristics that were assessed by the CoP displacement?

A

When the triceps surae is vibrated, a postural sway in a

backward direction is expected, whereas during back muscle vibration, a forward postural body sway is expected

110
Q

During upright stance on unstable support surface, individuals with COPD showed what?

A

An increased body sway in anterior-posterior direction when compared to controls (p = 0.037).

111
Q

Individuals with COPD showed an ____ reliance on ankle proprioceptive signals during postural control as shown by a larger posterior body sway during ankle muscle vibration compared to controls (p = 0.047)

A

Individuals with COPD showed an increased reliance on ankle proprioceptive signals during postural control as shown by a larger posterior body sway during ankle muscle vibration compared to controls (p = 0.047)

112
Q

____ ankle-back muscle vibration elicited significantly larger posterior body sways
in individuals with COPD compared to controls (p =0.002), indicative of a dominant use of
ankle proprioceptive signals during postural control.

A

Simultaneous ankle-back muscle vibration elicited significantly larger posterior body sways in individuals with COPD compared to controls (p =0.002), indicative of a dominant use of ankle proprioceptive signals during postural control.

113
Q

Individuals with COPD, especially those with inspiratory muscle weakness, increased their reliance on ankle
muscle proprioceptive signals and decreased the reliance on back muscle proprioceptive signals during balance control, resulting in ____

A

Individuals with COPD, especially those with inspiratory muscle weakness, increased their reliance on ankle muscle proprioceptive signals and decreased the reliance on back muscle proprioceptive signals during
balance control, resulting in a decreased postural stability compared to healthy controls.

114
Q

This maladaptive ankle-steered strategy in individuals with COPD might be explained by ____

A

This maladaptive ankle-steered strategy in individuals with COPD might be explained by an impaired postural
contribution of the inspiratory muscles to trunk stability.

115
Q

What happens when the respiratory function of the diaphragm is challenged?

A

When the respiratory function of the diaphragm is challenged, e.g. when respiratory demand increases, its postural function may also be challenged, resulting in a negative effect upon postural control.

Acute care (9 decks)

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