PCM 3 Unit 3: CHF and COPD Flashcards
(91 cards)
1
Q
What is Cardiac Muscle Dysfunction (aka “Heart Failure”)?
A
Forward output of blood by the heart is insufficient to meet the metabolic needs to the body
- A syndrome with a variety of interrelated pathophysiologic phenomena of which impaired ventricular function is the most important
- Results in a reduction of exercise capacity and other characteristic clinical manifestations
2
Q
With individuals with HF, what are some physiologic compensatory strategies when cardiac output decreases?
A
Increasing B-adrenergic stimulation and activation of the RAAS system
- B-adrenergic stimulation becomes less effective over time and the RAAS system can eventually work against the heart’s function
3
Q
With those individuals with HR and physiologic compensatory strategies, what happens as cardiac muscle dysfunction worsens?
A
The heart becomes less sensitive to preload and less able to tolerate increases to afterload
We MUST monitor:
- Fluid status: reduced sensitivity to preload impairs the hearts ability to pump efficiently, leading to fluid retention as the kidneys compensate for perceived low blood volume
- Conditions that create excessive afterload such as unmanaged hypertension which can place additional strain on the heart, exacerbating myocardial workload and potentially worsening HF
4
Q
With the Etiologies of Congestive Heart Failure, one of the causes is Hypertension. What is the Description of this?
A
Increased arterial pressure leads to left ventricular hypertrophy (increased myocardial cell mass) and increased energy expenditure
5
Q
What is Heart Failure Systolic Dysfunction? What are some causes?
(Systolic is when heart contracts)
A
This is impaired cardiac contractile function
Causes:
- Ischemic Heart disease (MI, Transient/persistent myocardial ischemia)
- Dilated Cardiomyopathy (Idiopathic, viral, genetic, alcohol, etc){over enlarged ventricles, not enough myocardium}
- Valvular Heart Disease (Aortic/Mitral valve stenosis or regurgitation)
6
Q
What is Heart Failure Diastolic Dysfunction? What are some causes?
(Diastolic is when heart fills)
A
Impaired filling of the left or right ventricle due to hypertrophy and/or changes in the composition of the myocardium
Causes:
- Left Ventricular Hypertorphy (e.g., as a result of chronically increased afterloads in HTN)
- Restrictive Cardiomyopathy
- Myocardial Fibrosis
- Pericardial Effusion or Tamponade
7
Q
With Hear Failure, what is the difference between HFrEF and HFpEF?
A
Due to significant overlap between systolic and diastolic dysfunction (i.e. many patients with HF suffer from both), it is common to categorize patients into having either:
- Heart Failure with reduced ejection fraction (HFrEF)
-< 40% EF
- Heart Failure with preserved ejection fraction (HFpEF)
-> 50% EF
This type of categorization is:
- useful, in part, because of the widespread availability of methods to measure LVEF (e.g., echocardiography)
- used as a variable in many clinical HF trials
- useful within medical management of individuals with HF
EF = Systolic / End-Diastolic volume (review)
8
Q
According to the ACC/AHA, what is Stage A of HF?
A
High risk for developing CHF
- No strucutral disorder of heart
9
Q
According to the ACC/AHA, what is Stage B of HF? What can this lead to?
A
Strucutral disorder of heart
- Never developed Sx of CHF
May lead to:
- NYHA Class 1: No limitations of physical activity
10
Q
According to the ACC/AHA, what is Stage C of HF? What can this lead to?
A
Past or current Sx of CHF
- Sx associated with underlying heart disease
May lead to NYHA:
11
Q
According to the ACC/AHA, what is Stage D of HF? What can this lead to?
A
End stage disease
- Requires specialized treatment strategies
May lead to NYHA:
12
Q
What increases Dyspnea/Increased work of Breathing?
A
- Increased pulmonary venous pressure can lead to a transudation of fluid into the alveoli (pulmonary edema) and pulmonary interstitium (making the lungs soggy and difficult to move) which both ultimately increase the work of breathing.
- The reduced blood flow to overworked respiratory muscles (i.e.., because of decreased cardiac output) and accumulation of lactic acid may also contribute to sensation of dyspnea.
13
Q
What do Pulmonary Crackles/rales result from?
A
- Results from elevated pulmonary venous and capillary pressures and transudation of fluid into alveolar spaces
- Frequently heard at both lung bases but may extend upward, depending on the patient’s position, the severity of CHF, or both
14
Q
What is Orthopnea?
A
Sensation of dyspnea or observation of labored breathing while lying flat which is relieved by sitting up
15
Q
What is Orthopnea caused by?
A
- Caused by the redistribution of blood from the gravity-dependent portions of the body (e.g. abdomen and LEs) towards the lungs that increases venous return and work on the heart.
- Can be described by number of pillows on which the patient sleep on to avoid breathlessness (e.g. 3-pillow orthopnea).
- In severe cases, individuals end up preferring to sleeping in sitting on a recliner.
16
Q
What is Paroxysmal Nocturnal Dyspnea?
A
Severe breathlessness that awakens the patient from sleep 1-3 hours after lying down
17
Q
What does Parixysmal Nocturnal Dyspnea result from?
A
- Results from the gradual reabsorption into the circulation of LE interstitial edema after lying down and increase in venous return/load on heart.
- A nocturnal cough may also occur for similar reasons
18
Q
Extra Heart Sounds
What does a S3 Heart Sound (aka Ventricular Gallop) indicate?
A
- Indicates a very compliant left ventricle. Thought to occur as blood passively fills a quickly distending left ventricle that makes contact with the chest wall during early diastole.
- May be normal (“physiologic S3”), particularly in young people, but in the presence of other indicators of heart disease, it is one of the most sensitive indicators of significant ventricular dysfunction
19
Q
Extra Heart Sounds
What does a S4 Heart Sound (aka Atrial Gallop) indicate?
A
- Represents “vibrations of the ventricular wall during the rapid influx of blood during atrial contraction” from an exaggerated atrial contraction. It is found in diseases with ventricles so thick to require a strong atrial contraction. As it is related to atrial systole, this sound is appreciated in late diastole.
- Unlike S3, this extra heart sound is almost always abnormal.
20
Q
Decreased Exertional Tolerance
Patients with cardiac muscle dysfunction, depending on the severity may display with what?
A
- A more rapid heart rate rise during any submax workload
- A flat, blunted, and occasionally hypotensive
(decrease) response in SBP during exercise - A lower max/peak oxygen consumption (VO2)
- ECG signs of myocardial ischemia
- More easily provoked dyspnea and fatigue
21
Q
What is Jugular Venous Pressure/Distension an indication of?
A
An indication of increased volume in the venous system and may be an early sign of right-sided heart failure
22
Q
What does Peripheral Edema reflect?
A
- Reflects increased venous pressures due to retrograde movement of fluid from heart chambers and fluid retention by kidneys after the pressoreceptors of the body sense a decrease in volume of blood (due to pump failure/drop in cardiac output).
- Mostly collects around ankles and feet.
23
Q
When evaluating for Pitting Edema, how long should you apply firm pressure?
A
Apply firm pressure to pretibial area for 10-20 seconds
24
Q
What is a 1+ on the Pitting Edema Scale?
A
Barely perceptible depression (pit)
25
What is a 2+ on the Pitting Edema Scale?
Easily identified depression; skin rebounds to its original contour within 15 seconds
26
What is a 3+ on the Pitting Edema Scale?
Easily identified depression; skin rebounds to its original contour within 15-30 seconds
27
What is a 4+ on the Pitting Edema Scale?
Easily identified depression; skin rebounds to its original contour within > 30 seconds
28
What are Sx of Left heart Failure?
*Breathing Signs*
- Dyspnea and increased WOB
- Orthopnea
- Paroxysmal Noctornal Dyspnea (PND)
29
What are the Physical Findins of Left Heart Failure?
- Diaphoresis
- Tachycardia/Tachypnea
- Pulmonary Rales
- S3/S3 (extra) heart sounds
30
What are Physical Findings of Right heart Failure?
- Jugular Venous Distension
- Peripheral Edema
31
What are Sx of Right heart Failure?
*systemic signs*
- Anorexia
- Right Upper Quadrant Discomfort (because of hepatic enlargement)
32
What is Heart Failure Exacerbation/Decompensation?
The presence of new or worsening signs/symptoms of dyspnea, fatigue, or edema that lead to hospitalization or unscheduled medical care (doctor visits or emergency department visits)
**- This Typically requires hospitalization**
33
With Heart Failure Exacerbation/Decompensation, what are the S/S?
* Dyspnea at rest
* Unrelieved Angina
* Wheezing or chest tightness at rest
* Paroxysmal nocturnal dyspnea: requiring to sit in chair to sleep
* Weight gain or loss of more than 5 lbs in 3 days
* Confusion
* Pulmonary Crackles
* S3 Heart Sound
* Jugular Venous Distention
34
With the Etiologies of Congestive Heart Failure, one of the causes is Coronary Artery Disease (Myocardial Ischemia). What is the Description of this?
Dysfunction of the Left or Right ventrical, or both as a result of injury. Scar formation and decreased contractility may occur as well as reduced relaxation
35
With the Etiologies of Congestive Heart Failure, one of the causes is Cardiac Dysrhythmias. What is the Description of this?
Extremely rapid or slow cardiac arrhythmias impair the functioning ventricles. Dysfunction may be reversible if arrhythmias controlled
36
With the Etiologies of Congestive Heart Failure, one of the causes is Cardiomyopathy. What is the Description of this?
Contraction and relaxation of myocardial muscle fibers are impaired. Primary causes: pathologic process in the heart muscle itself, which impairs the hearts ability to contract. Secondary causes: systemic disease process
37
With the Etiologies of Congestive Heart Failure, one of the causes is Heart Valve Abnormaility. What is the Description of this?
Valvular stenosis or imcompetent valves cause myocardial hypertrophy and cause a decrease in venticular distensibility with mild diastolic dysfunction
38
What is Absolute Stability?
Involves the appreciation of the absolute indicators of decompensation that need to be assessed and documented in their own right.
39
What is Relative Stability?
This considers whether the **patient is on a stable temporal trajectory**and the relative changes in hemodynamic parameters **over time**. In other words, relative stability considers alterations that occur on a day-to-day or visit-to-visit basis relative to the patient’s baseline.
40
The patient presents to the clinic with 78/40 mmHg, a heart rate of 110 bpm at rest, respiratory rate of 34 breaths per minute, oxygen saturation of 86% on room air, and bilateral
rales heard on auscultation. They report difficulty breathing even while sitting still. Is this an example of Absolute or Relative Stability at Rest?
Absolute Relative Stability
- This patient is not absolutely stable at rest, as their vital signs and symptoms at this visit show acute decompensation that is not evaluated based on previous sessions. **These signs and symptoms are serious on their own, regardless of his historical readings or conditions**. This patient's condition is critical, warranting immediate MD consultation and an emergency visit
to address acute decompensation and potential respiratory distress
41
The patient has a typical resting blood pressure in the 140s/80s mmHg and often reports fatigue. Today, the patients blood pressure is 102/68 mmHg and reports significantly more
fatigue than usual. Is this an example of Absolute or Relative Stability at rest?
Relative Stability at rest
- This patient appears relatively unstable at rest, as there is a **negative change over time from one visit to the next, relative to their individual baseline**, even though their BP is considered WNL. The patient may not require an emergency visit but likely benefits from an MD consult
42
The patient begins a supervised exercise program. During the initial session, they exhibits signs of exercise intolerance including severe shortness of breath, chest pain, and a drop in
blood pressure with minimal exertion. Is this an example of Absolute or Relative stability with exercise?
Absolute Stability with Exercise
- The patient's response to exercise is concerning **irrespective of his previous capacity or sessions**. Due to the acute and severe nature of the symptoms, the exercise should be stopped immediately, the intensity of future sessions should be reconsidered, and the patient may require an urgent medical consultation if their clinical status doesn’t improve
with rest
43
The patient has been participating in a cardiac rehabilitation program. Initially, they could tolerate 10 minutes on the treadmill at a moderate pace. Over the past few sessions,
they’ve only been able to manage 5 minutes before becoming excessively fatigued. Is this an example of Absolute or Relative stability with exercise?
Relative Stability with Exercise
Despite being stable in the short term, they **show a decline in exercise tolerance across sessions**, indicating they are not relatively stable with exercise. The exercise prescription
should be reassessed, potentially reduced, and the patient should consult with their physician to address the decline in her exercise capacity.
44
WIth the assessment of Stability, what will the patient Self-Assess with "Red"? What do we do?
Patient Self-Assesses:
- Difficulty breathing even at rest
- Unrelieved SOB
- Wheezing, chest pain or chest discomfort
- Feeling faint
- Confusion
What to do:
- Call physician immediately or immediate visit to the emergency department
45
WIth the assessment of Stability, what will the patient Self-Assess with "Yellow"? What do we do?
Patient Self-Assesses:
- Weight Gain > 2lbs in 1 day or 5lbs in one week
- Increase swelling
- Increase cough
- Increase in SOB with activity
- Increase in the number of pillows needed
What to do:
- Communicate with physician as the patient may need adjustment to medication
46
WIth the assessment of Stability, what will the patient Self-Assess with "Green"? What do we do?
Patient Self-Assesses:
- No SOB
- No weight gain
- No swelling
- No chest pain
- No decreased in ability to maintain activity level
What to do:
- Proceed with interventions, exercises, and activity as planned
47
With the Assessment of Stability, if the patient self-assesses as "Yellow" what should happen next?
A physical exam takes place,
-We assess Pulmonary Crackles, S3 auscultations, and JVD
- If the patient does not have any of these,
-This may indicate need for an adjustment in meds and therefore warrents communication with the physician
- If they do have these,
-Overt decompensation: an immediate visit to the ED or call physician office immediately
48
With the Assessment of Stability, if the patient self-assesses as "Red" what should happen next?
Overt decompensation: an immediate visit to the ED or call physician office immediately
49
# **MUST KNOW**
In the CPG, what is Action Statement 2?
**Educate on and Facilitate Components of Chronic disease management**
- PTs **MUST make appropriate nutrition referrals, perform medication reconciliation and provide appropriate education on preventative self-care behaviors to reduce risk of hospital readmissions**
- These include:
-Daily weight measurement to identify increases greater than 2 to 3 lbs in 24 hrs or 5 lbs over 3 days
-Recognition of S/S of an exacerbation
-Action plan with Red/Yellow/Green CHF tool
-Following nutrition plan
-Medication management/medication reconciliation
50
If you are doing an Assessment of Stability at Rest with a patient (vitals, Sx of decompensation {red, yellow, green zones}, signs of decompensation, what would happen if they DO have Absolute and Relative stability at Rest?
Continue and assess Stability with Exercise
-Vitals with exercise
-Recovery time
-S/S of Exercise tolerance
51
If you are doing an Assessment of Stability at Rest with a patient (vitals, Sx of decompensation {red, yellow, green zones}, signs of decompensation, what would happen if they DO NOT have Absolute and Relative stability at rest?
MD consult Emergency Visit
52
After you do the Assessment of Stability with Exercise, what would happen if they DO have Absolute and Relative Stability with Exercise?
Increase the intensity/Dose of Exercise
53
After you do the Assessment of Stability with Exercise, what would happen if they Do Not have Absolute and Relative Stability with Exercise?
Reduce intensity/Dose of exercise and/or MD consult Emergency Visit
54
What is Absolute Stability with Exercise?
The absolute degree of change in hemodynamic parameters including but not limitied to a drop in BP or rapid increase in HR that might occur with exercise
55
What is Relative Stability with Exercise?
The relative changes in exerices response that occur at the same intensity of exercise from one visit to the next
56
# **MUST KNOW**
In the CPG, what is Action Statement 3?
**Prescribe Aerobic Exercise Training**
PTs **MUST** prescribe aerobic exercise training for patients with Stable, NYHA class 2 to 3 HF using the following parameters:
- Time: 20-60 min
- **Intensity: 50-90% of Peak VO2 or Peak work**
- Frequency: 3 to 5 x a week
- Mode: Treadmill or cycle ergometer or dancing
## Footnote
Total energy expenditure during the program was the most important determinant of improvement in peak VO2
57
# **MUST KNOW**
In the CPG, what is Action Statement 4?
**Prescribe High-Intensity Interval Exercise Training in Selected Patients**
PTs **SHOULD** prescibe high intensity interval-based exercise (HIIT) for patients with stable, NYHA Class 2 to 3 HFrEF using the following parameters:
- Time: >35 total minutes of 1 to 5 minutes of high-intensity (>90%) alternating with 1 to 5 minutes at 40% to 70% active rest intervals, with rest intervals shorter than the work intervals
- **Intensity: >90 of peak VO2 or peak work.**
- Frequency: 2 to 3 times per week.
- Duration: at least 8 to 12 weeks.
- Mode: treadmill or cycle ergometer
## Footnote
Shorter HITT sessions may allow for the greatest long-term adherence
58
# **MUST KNOW**
In the CPG, what is Action Statement 5?
**Prescribe Resistance Training**
Physical therapists **SHOULD** prescribe resistance training for the upper and lower body major muscle groups for
patients with stable, NYHA Class I to III HFrEF using the
following parameters:
- Time: 45 to 60 minutes per session.
- **Intensity: 60% to 80% 1RM, 2 to 3 sets per muscle group.**
- Frequency: 3 times per week.
- Duration: at least 8 to 12 weeks
## Footnote
**Resistance training can be especially effective in patients that do not tolerate continuous or interval aerobic training or other therapeutic modalities.** Accommodating patient preference for mode of exercise may increase patient adherence, and thus resistance training should be offered as an option
59
# (FITT recommendations)
What is the ACSM guideline for Aerobic Exercise for Individuals with Heart Failure?
**F**: Minimally 3 days per week; preferably up to 5 days per week
**I**: **Start at 40 to 50% and progress to 70-80% VO2 reserve (HRR)**
**T**: Progressively increase to 20-60min a day
**T**: Aerobic exercise: focusing on treadmill or free-walking and stationary cycling as capable
60
# (FITT recommendations)
What is the ACSM guideline for Resistance Exercise for Individuals with Heart Failure?
**F**: 1-2 nonconsecutive days
**I**: **Begin at 40% 1RM for Upper Body and 50% 1RM for Lower Body**. Gradually increase to 70% 1RM over several weeks to months
**T**: 1-2 sets of 10-15 reps focusing on major muscles
**T**: Weight machines, dumbells, elastic bands and/or body weight can be used
61
Using Spirogram, a person with normal lungs, how long does it take them to reach 4 L (in volume) and what is the FEV1/FVC?
- Takes about 4 seconds
- FEV1/FVC = 75%
62
Using Spirogram, a person with obstructive lungs, how long does it take them to reach 4 L (in volume) and what is the FEV1/FVC?
- Takes about 7 seconds
- FEV1/FVC = 25%
63
What is the difference between normal and obstructive lungs in terms of Total Lung Capacity and Residual Volume?
Both are higher with the obstructive lungs
- Residual Volume is a **key characteristic** finding with obstructive lung disease
64
What is COPD?
A **progressive** disease which features chronic **airflow** limitations that are typically caused by a **mixture** of parenchymal alveolar disease (emphysema) and small-airway disease (obstructive bronchiolitis) which commonly occur in **combination**, with **proportions varying from individual to individual**. However, **in some cases**, either emphysema or chronic bronchitis is clearly dominant
## Footnote
Parenchymal: functional tissue of an organ (e.g. lung alveoli) as distinguished from the connective and supporting tissue
65
With the GOLD Staging of COPD, what is stage 2?
| COPD Severity, FEV1/FVC ratio, FEV range
- COPD Severity: Moderate
- FEV1/FVC Ratio: < 0.70
- FEV Range: 50 - 79% of normal
66
With the GOLD Staging of COPD, what is stage 1?
| COPD Severity, FEV1/FVC ratio, FEV range
- COPD Severity: Mild
- FEV1/FVC Ratio: < 0.70
- FEV Range: ≥ 80% of normal
67
With the GOLD Staging of COPD, what is stage 3?
| COPD Severity, FEV1/FVC ratio, FEV range
- COPD Severity: Severe
- FEV1/FVC Ratio: < 0.70
- FEV Range: 30 - 49% of normal
68
With the GOLD Staging of COPD, what is stage 4?
| COPD Severity, FEV1/FVC ratio, FEV range
- COPD Severity: Very Severe
- FEV1/FVC Ratio: < 0.70
- FEV Range: ≤ 30% of normal OR < 50% of normal with chronic respiratory failure present
69
What is Chronic Bronchitis Defined as?
The presence of a **chronic productive cough for 3 months in each of 2 successive years,** provided that other causes of chronic mucus production (CF, bronchiectasis, and tuberculosis [TB]) have been ruled out
70
What is the Pathophysiology of Emphysema "Pink Puffer"?
- There is **decreased Elastic recoil, which increases lung compliance and decreases ventilation** -> increases work of breathing
- There is destruction of capillary bed which decreases perfusion
*The **decrease** in perfusion **and** ventilation causes a Matched V:Q Defect (relatively well-oxygenated blood unit late stages)*
- There is **Alveolar detachment which causes air trapping on expiration** (we will see Pursed-lip breathing) -> we will see an increase in End-respiratory volume and an increase in RV and TLC and a decrease in VC -> **then causes barrel chest**
*Also with Emphysema, the people will breath in normally and then they will have an issue getting the air out. Air trapping happens.*
71
What is the Pathophysiology of Chronic Bronchitis "Blue Bloaters"?
- There is Airway obstruction, leads to Alveolar hypoxia. This then leads to V:Q Mismatch and/or Pulmonary Vasoconstriction
-With **V: Q Mismatch** we will see **Hypoexamia** (may also cause cyanosis) -> Polycythemia. Also we will see **Hypercarbia** leading to respiratory acidosis
-With **Pulmonary Vasoconstriction** we'll see Pulmonary Hypertension and this **leads to Decreased Left Ventricle output** leading to decreased circulating volume and Activation of RAAS, also we will see **Right Heart failure** leading to Cor pulmonale
- There is Mucus Hypersecretion, leads to productive cough with copious sputum
72
During the Physical Exam, what breath sounds may we hear with those patients with Chronic Bronchitis?
Vesicular, but likely diminished, prolonged expiration
73
During the Physical Exam, what Adventitous sounds may we hear with those patients with Chronic Bronchitis?
likely wheezing or rhonchi, possible crackles
74
During the Physical Exam, what Transmitted Voice sounds may we hear with those patients with Chronic Bronchitis?
None
75
During the Physical Exam, what Percussion Note may we hear with those with Chronic Bronchitis?
Resonant (Normal)
76
During the Physical Exam, where may we find the trachea when observing those patients with Chronic Bronchitis?
In midline
77
During the Physical Exam, what breath sounds may we hear with those patients with Emphysema?
Vesicular, but likely diminished, prolonged expiration
78
During the Physical Exam, what Adventitous sounds may we hear with those patients with Emphysema?
None, maybe wheezes during exacerbations (less than chronic Bronchitis)
79
During the Physical Exam, what Transmitted Voice sounds may we hear with those patients with Emphysema?
None
80
During the Physical Exam, what Percussion Note may we hear with those with Emphysema?
Diffusely Hyperresonant
81
During the Physical Exam, where may we find the trachea when observing those patients with Emphysema?
In Midline
82
What are Acute COPD Exacerbations?
An acute change in patient's baseline dyspnea, cough or sputum that is beyond normal variability and sufficient to warrent a change in therapy (ATS/ERS definition)
- Presentation may vary from a transient decline in functional to a fatal event
- Exacerbations contribute to high mortality rate associated with the disease
83
Those patients with COPD, what happens if they have an exacerbation?
- They rarely return fully to their baseline functional status; this results in a gradual progressive downhill course
84
Those with Lung Disease, what are other Examination Domains that we should assess?
- **Walking ability** (Endurance and speed): 2 or 6 MWT, ISWT, Incremental treadmill test, Seated or standing step test, 10 MWT, etc
- **Balanc/Fall Risk**: BBS, FGA, DGI, TUG, 5xSTS / 30 sec chair rise
- **Strength and Power**: Dynamometry, MMT, OMs like 5xSTS / 30 sec chair rise
- **QOL**: Chronic Respiratory Questionnaire (CRQ), COPD Assessment Test (CAT), Saint George Respiratory Questionnaire
(SGRQ), and Living with COPD questionnaire (LCOPD)
## Footnote
The exercise prescription for individuals with lung disease, particularly those with moderate to severe disease, should be based on exercise testing
85
# Considerations for Exercise Testing for Obstructive Lung Disease
Those with Obstructive Lung Disease should do Incremental Exercise Test to assess function. What is the difference in duration based on the severity of COPD? (Mild to Moderate compared to severe disease)
**A test duration of 8– 12 min is optimal in those with mild-to-moderate COPD, whereas a test duration of 5– 9 min is recommended for individuals with severe and very severe disease**.
86
# Considerations for Exercise Testing for Obstructive Lung Disease
Those with Obstructive Lung Disease, what is the purpose of Exercise Testing?
- Purposes of ET include **quantifying exercise capacity, establishing a baseline** for outcome documentation, **evaluating drug treatment efficacy**, assisting in the **development of the Ex Rx, evaluating unexplained dyspnea and exercise intolerance, and prognostic evaluation for individual risk stratification**.
87
# Considerations for Exercise Testing for Obstructive Lung Disease
For those with Moderate to Severe Obstructive Lung Disease (COPD), what may they experience with exercise?
**Individuals with moderate-to-severe COPD may exhibit oxyhemoglobin desaturation with exercise**
88
What is the **Aerobic** FITT Principle for Individuals with COPD?
**F**: Minimally 3 days/wk ; perferably up to 5 days/wk
**I**: Moderate to Vigorous Intensity (50-80% peak work rate or 4-6 on the Borg CR10 scale)
**T**: 20-60 min per day at moderate to high intensities as tolerated. *If the 20 to 60 min durations are not achievable accumulate ≥ 20 min of exercise rest periods of lower intensity work or rest*
**T**: Common Aerobic modes including walking (free or treadmill), stationary cycling and upper body ergometry
## Footnote
UE activity is associated with high metabolic and ventilatory demand, and activities involving the arms can lead to irregular or dyssynchronous breathing. This is because some arm muscles are also accessory muscles of inspiration.
89
What is the **Resistance** FITT Principle for Individuals with COPD?
**F**: At least 2 days/wk performed on non-consecutive days
**I**:
- **Strength**: 60-70% of 1RM for beginners; ≥80% for experienced weight trainers
- **Endurance**: < 50% of 1RM
**T**:
- **Strength**: 2-4 sets, 8-12 reps
- **Endurance**: ≤ 2 sets, 15-20 reps
**T**: Weight machines, free weights, or body weight exercise
90
From the ACSM, what are the Considerations for Exercis training (1) for those with Obstructive Lung Disease?
- **Interval training** may be an alternative to standard continuous endurance training **for those who have difficulty in achieving their target exercise intensity/volume due to dyspnea, fatigue, or other symptoms**. Several randomized, controlled trials and systematic reviews have found **no clinically important differences between interval or continuous training** protocols in exercise capacity, HRQOL, and skeletal muscle adaptations following training.
- **Intensity targets based on percentage of estimated HRmax may be inappropriate**, particularly in individuals with **severe** COPD where resting heart rate is often elevated and ventilatory limitations, as well as the effects of some medications, prohibit attainment of the predicted HRmax and thus its use in exercise intensity calculations. **Most individuals with COPD can accurately and reliably produce a dyspnea rating obtained from an incremental exercise test as a target to regulate/monitor exercise intensity**.
- The use of oximetry is recommended for the initial exercise training sessions to evaluate possible exercise-induced oxyhemoglobin desaturation and to identify the workload a which desaturation occurred
91
From the ACSM, what are the Considerations for Exercis training (2) for those with Obstructive Lung Disease?
- Maximizing pulmonary function using **bronchodilators** before exercise training in those with airflow limitation can reduce dyspnea and improve exercise tolerance.
- Inspiratory muscle weakness is a contributor to exercise intolerance and dyspnea in those with COPD. **Inspiratory muscle training (IMT) may prove useful in those unable to participate in exercise training** or can be used as an **adjunct** for those who participate in an exercise program. IMT improves inspiratory muscle strength and endurance, functional capacity, dyspnea, and QOL, which may lead to improvements in exercise tolerance in those with COPD and asthma.
- Individuals suffering from acute exacerbations of their pulmonary disease **should limit exercise until symptoms have subsided and rather focus on functional mobility**
