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Flashcards in Chapter 14 Pulmonary Rehabilitation Deck (10):
1

Pulmonary Rehabilitation (PR) is a multidisciplinary program that provides persons with the ability to _______ to chronic lung disease. Rehabilitation for patients with chronic lung conditions is well established and widely accepted as a means of alleviating symptoms and optimizing function.

Pulmonary Rehabilitation (PR) is a multidisciplinary program that provides persons with the ability to adapt to chronic lung disease. Rehabilitation for patients with chronic lung conditions is well established and widely accepted as a means of alleviating symptoms and optimizing function.

2

In COPD, PR has been shown to improve _______, _______ capacity, and health-related _______ of life, while reducing health care utilization. When considering PR interventions, the respiratory disorders can be generally characterized as ventilatory disorders (CO2 retention) or obstructive disorders (oxygen impairment).
The characteristics of obstructive and restrictive disorders are shown in Table 14-1.

In COPD, PR has been shown to improve dyspnea, exercise capacity, and health-related quality of life, while reducing health care utilization. When considering PR interventions, the respiratory disorders can be generally characterized as ventilatory disorders (CO2 retention) or obstructive disorders (oxygen impairment).
The characteristics of obstructive and restrictive disorders are shown in Table 14-1.

3

VENTILATORY DISORDERS (RESTRICTIVE OR MECHANICAL DISORDERS)
Caused by:
1. _______ disorders or _______ disorders.
2. respiratory muscle function decreasing with a decrease in _______, _______, _______, and _______ (e.g., myopathy, motor neuron disease, myelopathy, MS, and chest wall deformity).

VENTILATORY DISORDERS (RESTRICTIVE OR MECHANICAL DISORDERS)
Caused by:
1. neuromuscular disorders or skeletal disorders.
2. respiratory muscle function decreasing with a decrease in VC, RV, FRC, and TLC (e.g., myopathy, motor neuron disease, myelopathy, MS, and chest wall deformity).

4

VENTILATORY DISORDERS (RESTRICTIVE OR MECHANICAL DISORDERS)
Keys to clinical monitoring include _______ for _______ and max insufflation capacity, peak cough flows, and noninvasive CO2 monitoring. Expiratory flow should exceed _______ L/min (≈_______ L/s) for secretions to be adequately cleared from the airways. If these flows cannot be achieved naturally, insufflation followed by a caregiver-provided abdominal thrust (“quad cough”) or use of an insufflator–exsufflator device (CoughAssist, Respironics) may be beneficial. Invasive suctioning is a less ideal alternative and must be used with caution. With paralyzed abdominal muscles due to a UMN lesion, cough can be produced by FES. Positive expiratory pressure mask therapy and autogenic drainage are additional methods to mobilize secretions.4Glossopharyngeal breathing can be used to maximize insufflation and can serve as a backup in the event of ventilator failure.

VENTILATORY DISORDERS (RESTRICTIVE OR MECHANICAL DISORDERS)
Keys to clinical monitoring include spirometry for VC and max insufflation capacity, peak cough flows, and noninvasive CO2 monitoring. Expiratory flow should exceed 160 L/min (≈3 L/s) for secretions to be adequately cleared from the airways. If these flows cannot be achieved naturally, insufflation followed by a caregiver-provided abdominal thrust (“quad cough”) or use of an insufflator–exsufflator device (CoughAssist, Respironics) may be beneficial. Invasive suctioning is a less ideal alternative and must be used with caution. With paralyzed abdominal muscles due to a UMN lesion, cough can be produced by FES. Positive expiratory pressure mask therapy and autogenic drainage are additional methods to mobilize secretions.4Glossopharyngeal breathing can be used to maximize insufflation and can serve as a backup in the event of ventilator failure.

5

VENTILATORY DISORDERS (RESTRICTIVE OR MECHANICAL DISORDERS)
Respiratory muscles can be aided by devices such as mouthpiece or nasal IPPV and intermittent IAPV. The latter can augment _______ by _______ to _______ mL. _______ and _______ can be useful at night in patients with obstructive sleep apnea by keeping airways patent. Intubation, tracheostomy, and supplemental oxygen therapy are probably overutilized in patients with ventilatory disorders, whereas noninvasive assisted ventilation and assisted cough are probably underutilized.

VENTILATORY DISORDERS (RESTRICTIVE OR MECHANICAL DISORDERS)
Respiratory muscles can be aided by devices such as mouthpiece or nasal IPPV and intermittent IAPV. The latter can augment TV by 250 to 1200 mL. CPAP and BiPAP can be useful at night in patients with obstructive sleep apnea by keeping airways patent. Intubation, tracheostomy, and supplemental oxygen therapy are probably overutilized in patients with ventilatory disorders, whereas noninvasive assisted ventilation and assisted cough are probably underutilized.

6

OBSTRUCTIVE DISORDERS (INTRINSIC DISORDERS)
These include _______, _______ _______, and _______ fibrosis, characterized by a decrease in _______, _______, and _______ and an increase in _______, _______, and _______. A PR program includes evaluating the nutritional state, optimizing pharmacologic management (e.g., anticholinergics, bronchodilators, steroid inhalers, and expectorants), supplemental O2 use, controlled breathing methods (e.g., pursed lip breathing to help manage dyspnea), airway secretion management techniques, and an exercise program.

OBSTRUCTIVE DISORDERS (INTRINSIC DISORDERS)
These include COPD, asthmatic bronchitis, and cystic fibrosis, characterized by a decrease in VC, FEV1 (forced expiratory volume in 1 second), and MVV (maximal voluntary ventilation) and an increase in RV, FRC, and TLC. A PR program includes evaluating the nutritional state, optimizing pharmacologic management (e.g., anticholinergics, bronchodilators, steroid inhalers, and expectorants), supplemental O2 use, controlled breathing methods (e.g., pursed lip breathing to help manage dyspnea), airway secretion management techniques, and an exercise program.

7

OBSTRUCTIVE DISORDERS (INTRINSIC DISORDERS)
_______ limb exercises and _______ programs can greatly improve exercise tolerance and are strongly recommended for patients with COPD. Additionally, high- and low-intensity programs, _______ training, and _______ training are all considered clinically beneficial for patients with COPD. Long-term psychological interventions, e.g., relaxation therapy, are yet to be proven beneficial in randomized controlled trials, but are supported by expert opinion.

OBSTRUCTIVE DISORDERS (INTRINSIC DISORDERS)
Lower limb exercises and ambulation programs can greatly improve exercise tolerance and are strongly recommended for patients with COPD. Additionally, high- and low-intensity programs, strength training, and endurance training are all considered clinically beneficial for patients with COPD. Long-term psychological interventions, e.g., relaxation therapy, are yet to be proven beneficial in randomized controlled trials, but are supported by expert opinion.

8

OBSTRUCTIVE DISORDERS (INTRINSIC DISORDERS)
Supplemental home O2 may be indicated when Po2 is consistently ≤ _______ to _______ mm Hg. Medicare guidelines for coverage of home O2 generally require documentation of resting, sleep, or exercise Po2 ≤ _______ mm Hg or Sao2 ≤ _______% (on room air). Patients with Po2 of 56% to 59% or Sao2 of 89% may be eligible with concomitant _______, pulmonary HTN, or other criteria. Long-term oxygen therapy has been shown to improve survival and quality of life in COPD.

OBSTRUCTIVE DISORDERS (INTRINSIC DISORDERS)
Supplemental home O2 may be indicated when Po2 is consistently ≤55 to 60 mm Hg. Medicare guidelines for coverage of home O2 generally require documentation of resting, sleep, or exercise Po2 ≤55 mm Hg or Sao2 ≤ 88% (on room air). Patients with Po2 of 56% to 59% or Sao2 of 89% may be eligible with concomitant CHF, pulmonary HTN, or other criteria. Long-term oxygen therapy has been shown to improve survival and quality of life in COPD.

9

OBSTRUCTIVE DISORDERS (INTRINSIC DISORDERS)
Lung volume reduction surgery:
Patients with advanced _______.
20% to 30% of one or both lungs _______.
Found to reduce _______, improve FEV1 and forced vital capacity (FVC), and improve quality of life.
Suggested that patients first enroll in trial of PR.

OBSTRUCTIVE DISORDERS (INTRINSIC DISORDERS)
Lung volume reduction surgery:
Patients with advanced emphysema.
20% to 30% of one or both lungs removed.
Found to reduce hyperinflation, improve FEV1 and forced vital capacity (FVC), and improve quality of life.
Suggested that patients first enroll in trial of PR.

10

OBSTRUCTIVE DISORDERS (INTRINSIC DISORDERS)
Lung transplant:
Used in children with _______ fibrosis and primary pulmonary _______ and adults with _______, pulmonary HTN, and pulmonary fibrosis.
_______ is an absolute contraindication.
History of cancer, psychiatric diagnoses, obesity, and correctable coronary artery disease are relative contraindications.
Majority of the programs require some baseline functional exercise capacity – 600 feet by some patients and 250 feet by some other patients in the 6-minute walk test.

OBSTRUCTIVE DISORDERS (INTRINSIC DISORDERS)
Lung transplant:
Used in children with cystic fibrosis and primary pulmonary HTN and adults with COPD, pulmonary HTN, and pulmonary fibrosis.
Smoking is an absolute contraindication.
History of cancer, psychiatric diagnoses, obesity, and correctable coronary artery disease are relative contraindications.
Majority of the programs require some baseline functional exercise capacity – 600 feet by some patients and 250 feet by some other patients in the 6-minute walk test.