Week 7 Flashcards

Question

What kills most patients after a lung transplant?

Answer 1

- Graft failure (within 1st 30 days) | - Infection (within the 1st year)

Answer 2

• 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

Answer 3

* Muscle weakness * Prolonged hospitalization * Fatigue * Prolonged bedrest or confinement to home * Decreased mobility * Poor breathing mechanics * Inability to clear pulmonary secretions

Answer 4

``` • 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 ```

Answer 5

* Early Mobility in ICU | * Gait, balance, ADLs, Functional Mobility etc

Answer 6

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

Answer 7

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

Answer 8

• 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

Answer 9

• 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

Answer 10

• 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

Answer 11

• 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

Answer 12

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

Answer 13

Exercise training, education on heart healthy living, and | counseling to reduce stress and help you return to an active life

Answer 14

``` • 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 ```

Answer 15

• 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

Answer 16

* 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

Answer 17

• 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

Answer 18

• 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

Answer 19

- Smoking - DM - HTN - ApoB/A1

Answer 20

* Only 14% to 35% of heart attack survivors | * Only 31% of patients after CABG participate

Answer 21

* 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

Answer 22

* 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

Answer 23

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

Answer 24

``` • 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 ```

Answer 25

* Prevent skin breakdown, deconditioning and DVT/VTE, early mobilization * Direct gradual return to activity

Answer 26

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

Answer 27

* Intensity <5METs for 6-8 post-MI | * HR <120bpm OR no more than +20bpm from resting

Answer 28

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

Answer 29

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).*

Answer 30

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).

Answer 31

* 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

Answer 32

``` 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 ```

Answer 33

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

Answer 34

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

Answer 35

* Consider increasing Intensity 1 MET every 2 weeks | * Multiple Modes

Answer 36

* 70% to 85% of the HR at the onset of ischemia | * Consider RPP

Answer 37

Consider RPE (12-15), or Karnoven Equation

Answer 38

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

Answer 39

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

Answer 40

* 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

Answer 41

Minimum 5wks post including 4wks of cardiac rehab

Answer 42

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

Answer 43

Minimum 2wks post including 2wks of cardiac rehab

Answer 44

• 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

Answer 45

``` • Yoga • Tai Chi Chuan • Waltz Dancing - Stable HF • Meditation ```

Answer 46

• 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

Answer 47

``` • 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 ```

Answer 48

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

Answer 49

* 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

Answer 50

* Initial assessment of Respiratory disease process * Underlying medical disorder * General medical condition * Functional status * Patient’s goals * Select treatment goals

Answer 51

``` • 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 ```

Answer 52

* Patient * Medical Team * Physical Therapist * Respiratory Therapists * Nurses * Occupational therapists * Social workers * Nutritionist * Psychology or psychiatry services

Answer 53

``` • 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 ```

Answer 54

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

Answer 55

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

Answer 56

• 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.

Answer 57

• 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

Answer 58

Limitations to compliance and referral • Lack of PFT • Readmission

Answer 59

• 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.

Answer 60

• 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

Answer 61

• 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%

Answer 62

• 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.

Answer 63

• 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.

Answer 64

• 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

Answer 65

• 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.

Answer 66

• 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.

Answer 67

• 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

Answer 68

• 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.

Answer 69

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.

Answer 70

* 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

Answer 71

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

Answer 72

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

Answer 73

- Endurance exercise - Resistance exercise - Upper limb exercise - Flexibility exercise

Answer 74

• 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.

Answer 75

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

Answer 76

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

Answer 77

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

Answer 78

• 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

Answer 79

• 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)

Answer 80

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

Answer 81

• 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

Answer 82

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

Answer 83

• 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

Answer 84

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

Answer 85

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

Answer 86

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)

Answer 87

*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.

Answer 88

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.*

Answer 89

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

Answer 90

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.