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213 Cards in this Set
- Front
- Back
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Elastase and emphysema
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used by neutrophils to break down cell wall of bacteria
elastase can break down lung tissue In Emphysema, there is too much elastase, which breaks down lung tissue |
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Pulmonary fibrosis
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cause increased recoil (restrictive lung disease) = lung hard to blow up
Fibroblasts make too much fibers (collagen) Hard to suck air in |
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restrictive lung diseases
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pulmonary fibrosis
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Emphysema
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decreased recoil, lungs don't collapse
have trouble breathing air out Elastic tissue and some alveolar areas eaten away Pure form: genetic defect; don't have LIVER ENZYME to mop up elastase (breaks stuff down) from neutrophils |
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Respiratory distress syndrome
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premature babies don't have surfactant
have difficulty breathing, atelectasis, alveolar edema surfactant system develops later in fetal life |
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atelectasis
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collapsed alveoli
results from lack of surfactant and not breathing deep enough (fear of pain w/ breathing after surgery) makes you more susceptible to pneumonia infant respiratory distress syndrome is a distinct type of atelectasis |
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FRC
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2500mL
ERV + RV functional residual capacity air in lungs at end of resting expiration volume of air in lungs between breaths Dr. Martin: the amount of gas remaining in the lungs after a normal quiet tidal expiration |
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Vt
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500mL
tidal volume volume of air that moves into and out of lungs during a normal breath 500mL in, 500mL out Dr. Martin: volume of gas inspired or expired during unforced respiratory cycle |
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spirometry - upward reflection
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inhalation
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spirometry - downward reflection
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exhalation
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IRV
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3000mL
inspiratory reserve volume max air that can be breathed in, from end of normal inspiration breath in normal (Vt), then breath as much as you can in(IRV) Dr. Martin: the volume of gas that can be inspired at the end of a tidal inspiration |
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ERV
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1200mL
expiratory reserve volume max air blown out from End of normal expiration blow out normally (Vt=500), then breath out as much as you can (ERV= 1200mL) Dr. Martin: the volume of gas that can be expired at the end of a tidal expiration |
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RV
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1200mL
residual volume air left in lungs after max expiration negative intrapleural pressure prevents complete collapse of lungs. can measure RV with spirometer Dr. Martin: the volume of gas left in the lungs after a maximal expiration |
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IC
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3500mL
Vt(500mL) + IRV(3000mL) = 3500mL inspiratory capacity max air breathed in at end of resting expiration breath out normally, then breath in as much as you can (Vt + IRV) Dr. Martin: the maximum amount of gas that can be inspired at the end of a tidal expiration |
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VC
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5000ml
vital capacity max air blown out after max inspiration IRV + Vt + ERV Dr. Martin: the maximum amount of gas that can be expired after a maximum inspiration |
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TLC
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6000mL
air in lungs at end of max inspiration VC + RV Dr. Martin: the total amount of gas in the lungs at the end of a maximal inspiration |
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obstructive pulmonary disease
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increase in airway resistance
RV increases b/c cant breath air out FRC (air in lungs between breaths) increases normal TLC |
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what is normal in obstructive pulmonary disease?
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TLC = total lung capacity
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restrictive pulmonary disorders
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cant expand lungs, have trouble breathing air in
TLC decreases |
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what stays normal or decreases with restrictive lung disease?
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RV and FRC
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FVC
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patient takes max inspiration then forcefully breaths out as quickly as possible
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a low FVC is indicative of what?
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restrictive pulmonary disease
have trouble expanding lungs so VC is low |
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FEV1/FVC
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normal is 80%
percentage of FVC that can be blown out in one second below 80% is obstructive |
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obstructive lung disease:
TLC? FVC? FRC, RV? FEV1/FVC? |
TLC = normal
FVC = decreased FRC,RV = increased FEV1/FVC = less than 80% |
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restrictive lung disease:
TLC? FVC? FRC, RV? FEV1/FVC? |
TLC = decreased
FVC = decreased FRC,RV = normal or decreased FEV1/FVC = greater than 80% |
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Restrictive lung disease means you have no trouble breathing air out, so
FEV1/FVC = ? |
greater than 80%
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3 examples of obstructive lung disease (hard to blow out)
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1. chronic bronchitis
2. asthma 3. emphysema (b/c of decreased recoil) |
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chronic bronchitis
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obstructive - hard to blow out
inflammation b/c of smoking obstruction in airway (mucus) Inspiration: airways expand and air goes around obstruction Expiration: airways close, increasing closing due to obstruction, hard to blow out |
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asthma
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obstructive - hard to blow out
constriction of airway smooth muscle narrowing the airway inflammation constriction due to allergy, cold, exercise inspiration: airways helped to open expiration: airways stay constricted |
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emphysema
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obstructive - hard to breath out b/c LOST ELASTIC recoil
Pure: alveolar regions destroyed, holes in lungs; floppy airways, alveoli not there to hold airway open Exhale: airways slam shut Smoking: do not have pure form, have partial emphysema and bronchitis |
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which lung disease has pursed lip breathing?
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obstructive lung diseases
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restrictive lung diseases (hard to breath in)
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1. pulmonary fibrosis
2. sarcoidosis 3. pulmonary edema 4. pneumonia 5. neuromuscular disease - polio, scoliosis (anything that causes musculature changes) |
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pulmonary fibrosis
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restrictive (hard to breath in)
increase in elastic fibers, lung harder to blow up. elastic recoil is high you can breath out perfectly well b/c of increased recoil dust, idiopathic |
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Sarcoidosis
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restrictive (hard to breath in)
autoimmune disease lesions in alveolar area = hard to inflate alveoli = increased recoil |
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pulmonary edema
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restrictive (hard to breath in)
lungs heavy from fluid, harder to blow up |
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pneumonia
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restrictive (hard to breath in)
inflammation, fluid in lungs, lungs harder to blow up |
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definition of pulmonary edema
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fluid accumulates outside the pulmonary capillaries causing a bigger distance between air and blood, hard for gas exchange
restrictive lung disease |
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causes of pulmonary edema
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1. CHF - blood backs up in veins, back up in pulmonary capillaries, increases pressure, force plasma out of capillaries into ISF
2. destruction of barrier of capillary - fluid leaks out; b/c of radicals from chronic infection, dust, radiation treatment 3. lymphatic blockage - cant dry up lungs 4. unknown causes - people that move to high altitude quickly, heroin users |
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carbon monoxide is used clinically for what?
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to measure diffusion of lungs
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definition of diffusing capacity (measured clinically for CO)
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Increase DLCO = increase area, decreased thickness, diffusion increases
Decrease DLCO = decrease area, increase thickness, diffusion decreases With exercise DLCO is up With disease DLCO is down DLCO = 25mL/min/torr DLCO decreases for both restrictive and obstructive lung disease |
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Diseases which affect diffusion of gases
associated with increase in diffusion distance |
of course this decreases DLCO(oxygen does not diffuse as well)
Restrictive lung disease increases diffusing distance. example: Pulmonary fibrosis -increase distance by laying down extra fibers Sarcoidosis - lesions Pulmonary edema - fluid build-up |
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simple definition for DLCO
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measure of how well gases diffuse in lungs
measures how well oxygen passes from lungs to the blood use CO |
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Diseases which affect diffusion of gases
associated with decreased surface area for diffusion |
this of course decreases DLCO (oxygen does not diffuse as well from lungs to blood)
1. emphysema - destroy lung tissue, surface area reduced 2. pneumonectomy |
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effects on exercise on diffusing capacity
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increases DLCO (oxygen diffuses better from lungs to blood)
diffusion capacity of CO will increase by 2 to 3x lungs diffuses gases 2-3x better during exercise than during rest 1. Recruitment: of capillaries at top of lungs = increase area 2. Distension: capillaries that are open become larger,increase area and decreased thickness 3. alveolar stretching: alveoli are more open = increased area and decreased thickness |
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Components of an Exercise Prescription for Cardiac Rehab
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warm-up
type of training activity intensity duration frequency cool-down special considerations |
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Cardiovascular Complications Rate
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1 major (fatal and non fatal) CV complications per 16,566 person hours of exercise
Range: 1 event 4,600 hours to 1 event 25,000 hours 80% of cardiac events were successfully resuscitated |
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Warm-up
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Cardiovascular
-increased blood and muscle temperature -decrease vascular resistance -decrease incidence of ischemic ECG changes Musculoskeletal -stretching |
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how long should Warm-up duration be?
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5-15 minutes
evenly divided between musculoskeletal / stretching activities and cardiovascular / very low level aerobic exercise may not be needed for very deconditioned pt’s |
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End Points for Safe Maximal Heart Rate (4)
when to stop exercise |
1. clinical signs
2. physical signs 3. ECG changes 4. symptoms |
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End Points for Safe Maximal Heart Rate:
Clinical Signs |
pallor (pale color) / cyanosis (blue skin)
CNS dysfunction -staggering -confusion -dizziness -ataxia |
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End Points for Safe Maximal Heart Rate: when to stop exercise
Physical Signs |
-failure to increase heart rate = bad
-failure to increase systolic blood pressure = bad -falling systolic blood pressure (>20 mm Hg) = bad -increasing diastolic blood pressure (>20 mm Hg) = bad -inability to continue (a max test) |
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End Points for Safe Maximal Heart Rate: when to stop exercise
ECG Findings |
-atrial arrhythmia
-2° or 3° Atrioventricular block -bundle branch blocks -ST segment displacement >1 mm 80 msec --> "J" point -PVC's (frequent, more than 1, coupled, multifocal) |
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End Points for Safe Maximal Heart Rate: when to stop exercise
Symptoms |
anginal pain
claudication (cramping pains in the legs) undue dyspnea (Difficult or labored breathing; shortness of breath) orthopedic problems sternotomy pain |
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What are 2 methods of calculating target heart rates?
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1. Karvonen or heart rate reserve method (preferred for CAD patients and others with very low maximal heart rates)
2. Straight method (70-85% of maximal heart rate) |
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Patient example
Drugs: Norpace 400 mg q day, Lanoxin 0.25 mg q day, Inderal 160 mg q day Max test - generalized fatigue maximal heart rate = 140 resting heart rate = 90 What is heart rate reserve? What is the target HR using the Karvonen method? |
HRR = max HR - resting HR = 140-90= 50
60% (HRR) = 60%(50) = 30 80% (HRR) = 80%(50) = 40 Target HR: Resting HR + 60%(HRR) --> Resting HR + 80%(HRR) 90 + 30 = 120 bpm 90 + 40 = 130 bpm target HR = 120 - 130 bpm round off to 120 - 128 (nearest multiple of 4) |
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Why use 60 - 80% of the heart rate reserve?
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-training effect is optimal at 60-80% of VO2max, and 60-80% of heart rate reserve is ~ = to 60-80% of VO2max
-70 - 85% of maximal heart is also ~ = to 60-80% of VO2max |
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training effect is optimal at ____% of VO2max, and ____% of heart rate reserve is ~ = to ____% of VO2max
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60-80%
60-80% 60-80% |
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_____% of maximal heart is also ~ = to 60-80% of VO2max
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70 - 85%
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Straight method (70-85% of maximal safe HR) of target HR calculations
max safe HR = 140 70% of 140 = 98 85% of 140 = 119 (70-85% THR 98 - 119) PROBLEM: resting HR = 90 & 70% THR =98; in some cases 70% THR < resting HR. ____ method works better with CAD patients and others with extremely ____ resting HR's and/or very low maximal HRs. |
Karvonen
extremely HIGH resting HR's |
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Intensity Considerations
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some patients are limited by local muscle fatigue
THR not as important- use RPE scale OBSERVE the patient use interval training- exercise 1-3 minutes, rest and repeat & gradually increase duration of exercise bouts & reduce rest periods |
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Once you go past (increase intensity) 70-85% HR max, or 60-80% VO2max, you increase what?
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Increase risk of cardiovascular complication
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What is the optimal intensity range?
____% HR max ____% VO2 max |
70-85% HR max
60-80% VO2 max |
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phasic flow of blood through the coronary capillaries of the left and right ventricles
during systole, coronary blood flow in R coronary artery does what? L coronary artery? how about diastole? |
Systole
-R coronary artery blood flow is 50 ml/min -L coronary artery blood flow dips down to 100 ml/min Diastole -R coronary artery blood flow remains at 50 ml/min -L coronary artery blood flow increases a lot to almost 300 ml/min take home message: during systole, coronary blood flow is low in the R and L coronary arteries (<100 ml/min for both). During diastole, coronary blood flow remains low in the R coronary artery (50 ml/min), but coronary blood flow shoots up in the L coronary artery during diastole (300 ml/min) |
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double product, a measure of the work load of the heart is = SBP x HR
There is an "anginal threshold", meaning if you reach a certain amount of double product, you will get angina. what happens with exercise training? |
Angina occurs at the same double product (same HR x SBP), but...
it takes much more intensity and duration of exertion to reach that double product (slope is less) after exercise training. "the major mechanism of beneficial action of exercise is REDUCTION of myocardial OXYGEN DEMAND ie with exercise training, at a given intensity and duration, people that work out have a lower double product (HR x SBP) than those who don't work out. |
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what is the relationship between coronary flow and the product of systolic pressure and HR (double product)?
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as double product increases, coronary flow (ml/100g min) also increases.
linear relationship of course, healthy controls have higher coronary blood flow at a given double product compared to a patient w/ CAD |
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Angina vs. Musculoskeletal pain
what kind of pain is this? -dull, pressure, squeezing, ache -not altered by pressure or movement -very reproducible -tends to be constant or increase over time |
Angina
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Angina vs. Musculoskeletal pain
what kind of pain is this? -sharp, jabbing, knifelike -may be altered by pressure or movement -waxes and wanes -tends to decrease over time |
Musculoskeletal pain
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Types of Activities (3)
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1. stretching
2. aerobic / endurance 3. muscular strength |
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define Aerobic activities
give some examples what is a bad activity for CAD patients? |
definition: sustained rhythmical movements (>3 min) using the large muscle groups
ex: walking, jogging, walk/jog, cycles, stair master, arm ergometer, swimming rope skipping is not a wise activity for CAD pts- skipping at 80-100 jumps/ min = ~ 8 METs (average CAD patient has max of ~ 6-7 METs) |
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Does the Type of Aerobic Activity Matter?
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you can improve overall cardiovascular function with any type of aerobic activity, but subjects tend to achieve the best test results if they are tested and trained with the same activity.
to get good at walking, you have to walk |
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Muscular Strength
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a neglected aspect of cardio-pul rehab
primarily shoulders and arm musculature, barbells, dumbbells, arm ergometer, etc avoid Valsalva maneuver - breathe when lifting especially during isometric work |
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blood pressure and heart rates are ____ with arm work than with leg work at a given fixed workload
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higher
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arm VO2max is ~ _____ of leg value
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60%-70%
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Duration
warm-up + training period + cool-down should not > ___ min. Poorly conditioned pt's; ____ minutes of intermittent work as conditioning improves, reduce rest periods and gradually increase training period at THR. duration, intensity and frequency are inter-related decreased intensity can be largely counterbalanced by increases in ____ and _____ |
not be > 60 minutes
10-20 minutes of intermittent work duration and frequency |
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relationship (graph) of % change in VO2max and duration (minutes at 75% VO2max).
exercise duration of _____ minutes at 75% VO2max is the optimal duration range, and past that (>___) increases the risk of _____ complication |
20-30 minutes at 75% VO2max, the % change in VO2 max levels levels out at this range, and past 30 minutes at 75% VO2 max, the risk of
Orthopedic complication increases. |
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Frequency I
optimal frequency is ~ ____sessions per week at a duration of ____ min at THR < ___ sessions per week is ineffective more than ___ training sessions per week increases the incidence of orthopedic complications and decreases _____ |
optimal frequency is ~ 3-4 sessions per week at a duration of 30-40 min at THR
< 2.5 sessions per week is ineffective more than 5 training sessions per week increases the incidence of orthopedic complications and decreases compliance |
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Frequency II
As conditioning level improves, sessions may be increased to ___ sessions per week for up to 30-40 min at intensities not to > ____VO2max |
4-5 sessions per week
80% VO2max |
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Frequency II
Minimal effective exercise dose = ___ sessions per week for ___ min at ___% of VO2max |
3 sessions per week
30 minutes 60% of VO2max |
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Frequency II
poorly conditioned patients will improve with initial training bouts on a M/W/F schedule for ____ minutes at THR |
10-20 minutes
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relationship (graph) of % change VO2max and frequency (sessions/week)
the optimal frequency range is ___ sessions per week, and > than that will increase risk of orthopedic complication the % change in VO2max levels out (plateaus) at this frequency range |
3-4 sessions per week
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what is the purpose of Cool down?
prevent _____ in lower extremities - post exercise _____ allow gradual ____ adaptation to near resting state (reduce HR & BP) cool-down period is a good time to incorporate ____ exercises duration of cool-down period (_____ minutes - the higher the intensity of the training sessions, the ___ the cool-down period) |
prevent blood pooling; post exercise hypotension
cardiovascular adaptation flexibility exercises 5 - 15 minutes; the longer the cool-down period |
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Special Considerations
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hot weather
cold weather failure to respond to training exercise Rx modifiers |
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Importance of Cool-down Period
Approximately ____% of cardiac events in cardiac rehab programs occur during the cool-down period. Patients must not be allowed to cut the cool-down period time |
50% of cardiac events
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Hot Weather Considerations I
Use THRZ to modify workload maintain ____ balance light weight (preferably cotton) and color clothing avoid temperature and humidity extremes if possible (use malls, churches, etc) |
WATER balance
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Hot Weather Considerations II
NO RUBBER SUITS TO SPEED "WEIGHT LOSS" electrolyte imbalance; diuretics + high sweat & K+ loss = ____ which leads to increasing ____ be aware of symptoms of heat-related problems |
hypokalemia ----> increases arrhythmias
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Cold Weather Considerations
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Use THRZ to modify workload
dress in layers hat, gloves, scarf warm-up inside and increase warm-up duration start training period slowly be aware of symptoms of frostbite use indoor facilities if available |
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Failure to Respond to Training examples:
no change or decrease in ___ or ___, or subjective feelings of strain despite adequate training appearance of ____ or symptoms at previously symptom-free HR _____ fatigue |
no change or decrease in HR or SBP
appearance of arrhythmias constant fatigue |
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Exercise Rx Modifiers
no meals ____ hours prior to exercise _____ is a contraindication no tobacco prior to exercise decrease intensity, duration and frequency of exercise after ____ (vacations, injury, illness, poor adherence) adapt to special problems (sciatica, back pains, amputations, diabetes) good supporting shoes for joggers |
1.5 - 2 hours
alcohol intoxication is a contraindication after layoff |
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Lung ____ are the four Non overlapping components of the total lung capacity
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lung volumes
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lung ____ are the sum of two or more lung ___
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lung capacities are the sum of two or more lung volumes
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Pulmonary Function Testing
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Volumes & capacity
Gas flow rates Diffusion |
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lung volumes in health and in disease
early emphysema |
residual volume increases
expiratory reserve volume increases inspiratory capacity increases TLC is greater (110%) than young and elderly normal |
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lung volumes in health and in disease
severe emphysema |
residual volume increases a lot (lots of gas left in the lungs after a maximal expiration)
ERV is same as young and elderly normal (able to breath out as much gas after tidal expiration as normals) IC increases, about the same as early emphysema, but higher than normals over 150% of total lung capacity compared to normal (lots of air in the lungs, but hard to breath it out) |
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lung volumes in health and in disease
pulmonary fibrosis |
about 60% of TLC (less air in the lungs)
RV, ERV, and IC all are about equal, and all are less than normal |
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lung volumes in health and in disease
neuromuscular disease |
about 60% of TLC (less air in the lungs)
RV is the greatest (more than normals), ERV is extremely small (not able to breath much air out after normal tidal expiration) IC is also smaller than normals |
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lung volumes in health and in disease
severe obesity |
about 60% of TLC (not as much air in the lungs
RV is about the same as elderly normals (higher than young normals) IC is less than normals like neuromuscular disease, ERV is extremely small (not able to breath out much air after normal tidal expiration) |
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Obstructive disease effect on:
Vt - tidal volume |
none or Increase
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Obstructive disease effect on:
IC - inspiratory capacity |
none or Decrease
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Obstructive disease effect on:
ERV - expiratory reserve volume |
none or Decrease
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Obstructive disease effect on:
VC - vital capacity |
none or Decrease
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Obstructive disease effect on:
FVC - forced vital capacity |
none or Decrease
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Obstructive disease effect on:
RV - residual volume |
none or Increase
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Obstructive disease effect on:
FRC, TLC |
none or Increase
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Obstructive disease effect on:
FEV1 |
DECREASE
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Restrictive disease effect on:
Vt - tidal volume |
none or Decrease
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Restrictive disease effect on:
IC - inspiratory capacity |
none or Decrease
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Restrictive disease effect on:
ERV - expiratory reserve volume |
none or Decrease
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Restrictive disease effect on:
VC - vital capacity |
DECREASE
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Restrictive disease effect on:
FVC - forced vital capacity |
DECREASE
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Restrictive disease effect on:
RV - residual volume |
none or Decrease
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Restrictive disease effect on:
FRC - functional residual capacity |
none or Decrease
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Restrictive disease effect on:
TLC - total lung capacity |
DECREASE
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Restrictive disease effect on:
FEV1 |
NOTHING!
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spirograms in healthy and disease states:
normal: FEV1 = ___L FVC = ___L FEV1/FVC = ___% |
Normal:
FEV1 = 3.0 L FVC = 4.0L FEV1/FVC = 75% |
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spirograms in healthy and disease states:
obstructive: FEV1 = ___L FVC = ___L FEV1/FVC = ___% |
FEV1 = 1.0 L (hard to breath out)
FVC = 4.0 L (can breath out all the air in your lungs, but just takes longer than usual. notice that you can still get 4 L of air in the lungs) FEV1/FVC = 25% |
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spirograms in healthy and disease states:
restrictive: FEV1 = ___L FVC = ___L FEV1/FVC = ___% |
FEV1 = 2.5 L (can breath out air fairly quickly)
FVC = 3.0 L (you don't breath out as much air, ie there's not as much air in your lungs as usual) FEV1/FVC = 83% |
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flow volume loops
graph of flow and volume during forced inspiration and expiration whats the dealio w/ obstructive? restrictive? |
obstructive (emphysema) - severe = "scooped" expiratory flow
restrictive - small area |
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Tests of lung volume & capacity
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Tidal volume (Vt) - air moved per minute
Inspiratory reserve volume (IRV) Expiratory reserve volume (ERV) Vital capacity (VC) Inspiratory capacity (IC) Residual volume (RV) |
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Tests of gas flow
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Forced vital capacity (FVC)
Forced expired volume in 1 sec (FEV1.0) Forced mid-expiratory flow (FEF25-75) Maximum voluntary ventilation (MVV) Peak expired flow (PEF) Airway resistance (Raw) Compliance (C) |
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severity of reductions in the FVC and/or the FEV1
Normal - > ___% Mild - ____% of predicted Moderate - ____% of predicted Moderately severe - _____% Severe - ____% of predicted Very severe - Less than ___% of predicted |
normal 80%
mild 70-79% of predicted moderate 60-69% moderately severe 50-59% severe 35-49% very severe less than 35% |
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Tests of Diffusion
Diffusing capacity of lung aka ____ Normal value _____ Reasons for low ____ 1. Low ____ 2. _____ alveolar-capillary membrane 3. _____ alveolar surface area |
(Dlco)
25-30 mL/min/ mm Hg reasons for low Dlco: 1. low Hct 2. Thickened 3. Decreased |
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PFT interpretation
A reduced FVC on spirometry in the absence of a reduced FEV1-to-FVC ratio suggests a ____ ventilatory problem. |
restrictive
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PFT interpretation
Disproportionate reduction in the FEV1 as compared to the FVC (and therefore the FEV1-to-FVC ratio, also called FEV1%) is the hallmark of ______ lung diseases (asthma, acute and chronic bronchitis, emphysema, bronchiectasis, cystic fibrosis, pneumonia, alpha1-antitrypsin deficiency, and bronchiolitis) |
obstructive
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These are examples of ____ diseases:
asthma acute and chronic bronchitis emphysema bronchiectasis cystic fibrosis pneumonia alpha1-antitrypsin deficiency bronchiolitis |
obstructive
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ASSESSMENT OF RESPIRATORY MUSCLE STRENGTH
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Synonyms -Maximum inspiratory pressures (MIP), maximum expiratory pressures (MEP), negative inspiratory force (NIF), respiratory pressures, maximum respiratory pressures
Indications -Assessing respiratory muscle strength allows for assessment ventilatory failure, restrictive lung disease, and respiratory muscle strength. |
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This is an example of ___
Patients breathe through a flanged mouthpiece with nose clips in place Patients are instructed to exhale to RV At RV, a valve or shutter is closed and the patient is coached to inhale as forcefully as possible. Maximum pull should be maintained for 1-2 seconds. A standardized leak must be present in the measurement system to eliminate significant overstatement of MIP by allowing the cheek muscles to contribute to the measured pressures. Initial maximum negative pressures that cannot be maintained for 1 full second are ignored. |
MIP
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this is an example of ___
Patients breathe through a flanged mouthpiece with nose clips in place. Patients are instructed to inhale to TLC. At TLC, a valve or shutter is closed and the patient is coached to exhale as forcefully as possible. Maximum push should be maintained for 1-2 seconds. Initial maximum positive pressures that cannot be maintained for 1 full second are ignored |
MEP
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Results
Maximal inspiratory mouth pressure (PImax), maximal expiratory mouth pressure (PEmax) are reported in ____. Multiple attempts usually needed to obtain stable results the range of normal values is broad, suggesting wide variations in respiratory muscle strength among normal values. This makes interpretation of low values difficult. Initial values should be compared to the lower limit of normal values for the patient's age |
centimeters of water pressure
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In general, a PImax of less than -___ cm water pressure and a PEmax of greater than +___ cm water pressure excludes important weakness of the respiratory muscles.
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-80
80 |
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Patients with a PEmax less than ___ cm water pressure may have difficulty generating sufficient cough to clear respiratory secretions
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50
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In patients with ALS, a MIP pressure less than ___ cmH2O was associated with a hazard risk for death of 9.1 ([CI], 4-20.8) and the median mortality was 6 ± 0.3 months (95% CI, 2.5-8.5 mo)
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40
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VE - minute ventilation
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volume of air exhaled per unit of time
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VCO2 - carbon dioxide output
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volume of carbon dioxide exhaled per unit of time
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VO2- oxygen uptake
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volume of oxygen consumed per unit of time
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R - gas exchange ratio
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VCO2/VO2
volume of carbon dioxide exhaled per unit of time/ volume of oxygen consumed per unit of time |
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Pulse Oximetry:
Synonyms |
Synonyms - Oximetry, oxygen saturation check, oxygen sat check, exercise oximetry, oxygen titration by oximetry, oxygen saturation measured using pulse oxymetry (SpO2), oxygen desaturation test
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Pulse Oximetry:
Patient care/preparations |
Patient care/preparations - Standard pulse oximeter probes may be placed on fingers or earlobes of ambulatory patients. Some oximeters offer reflectance probes that can be placed on the forehead. Fingernail polish should be removed, and peripheral circulation should be maximized by warming or by applying vasodilating cream, if necessary.
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Although widely used, the practice of assessing oxygen desaturation by pulse oximetry is poorly standardized.
The principle of oximetry measurement by ____, although improving, is not as reliable as many practitioners believe. One side of the oximeter probe acts as a light-emitting source, and the other side acts as a ____. The probe is placed on a finger or earlobe. A forehead reflectance probe may also be used. The relative absorption of red (absorbed by oxygenated blood) and infrared (absorbed by deoxygenated blood) light of the ___(___) component of the absorption waveform correlates to _____. |
spectrophotometry
photodetector pulsatile (systolic) arterial blood oxygen saturation |
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When obtaining pulse oximetry readings during exercise, the type and intensity of exercise (eg, walking speed, duration of activity) along with the heart rate and SpO2 at the end of the activity should be reported.
When ____ is detected, the activity should be repeated with supplemental oxygen in place to demonstrate improvement in SpO2 values. |
desaturation
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Pulse oximetry is often performed (though optional) in the setting of the ____ test, a standardized measure of functional exercise capacity.
This test is a measure of the maximum distance the patient is able to walk in a hallway with a minimum of 100 feet marked in 5-foot increments. The patient is permitted to slow down or even stop, if required; however, the elapsed time counter continues during rest periods. This test should be performed while exercise oxygen needs are being adequately met with ____. ____ and fatigue scores are collected immediately after completion of the walk. |
6-minute walk test
portable oxygen delivery Borg dyspnea |
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While SpO2 readings greater than ___% make the probability of clinically significant hypoxemia unlikely, clinical suspicion of hypoxemia should initiate the examination of ABGs.
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95%
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The goal of titration of supplemental oxygen should be a stable SpO2 reading of ___% or higher.
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93%
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Arterial desaturation can be considered present when the pulse oximeter saturation falls more than ___% below the baseline reading.
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3%
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The role of pulse oximetry in the Medicare guidelines for reimbursement for continuous supplemental oxygen therapy are demonstration of one of the following while at rest and breathing room air:
1. PaO2 less than or equal to ___ mm Hg 2. SaO2 less than or equal to __% 3. SpO2 less than or equal to __%. |
55 mm Hg
88% 88% |
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Patients may qualify for supplemental oxygen therapy reimbursement even if the PaO2 is greater than 55 mm Hg and the SaO2 or SpO2 is greater than 88% if one of the following conditions is met:
(1) _____due to congestive heart failure; (2) _____ documented by P pulmonale on an ECG or by an echocardiogram, gated blood pool scan, or direct pulmonary artery pressure measurement, and (3) hematocrit greater than ___%. |
1. dependent edema
2. cor pulmonale 3. 56% |
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generally accepted normal ranges for arterial blood gas values:
PCO2 |
normal value: 40
normal range: 35-45 |
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generally accepted normal ranges for arterial blood gas values:
PO2 |
normal value: 97
normal range: >80 |
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generally accepted normal ranges for arterial blood gas values:
HCO3- |
normal value: 24
normal range: 22-28 |
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generally accepted normal ranges for arterial blood gas values:
BE |
normal value: 0
normal range: +/- 2 |
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generally accepted normal ranges for arterial blood gas values:
%Sat |
normal value:
normal range: >95% |
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Acute alveolar hyperventilation
pH = PaCO2 = |
pH > 7.50
PaCO2 < 30 mm Hg |
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Chronic alveolar hyperventilation
pH = PaCO2 = |
pH = 7.40 - 7.50
PaCO2 < 30 mm Hg |
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Compensated metabolic acidosis
pH = PaCO2 = |
pH = 7.30 - 7.40
PaCO2 < 30 mm Hg |
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Partially compensated metabolic acidosis
pH = PaCO2 = |
pH < 7.30
PaCO2 < 30 mm Hg |
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Metabolic alkalosis
pH = PaCO2 = |
pH > 7.50
PaCO2 = 35-45 mm Hg |
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Normal
pH = PaCO2 = |
pH = 7.35 - 7.45
PaCO2 = 35-45 mm Hg |
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Metabolic acidosis
pH = PaCO2 = |
pH < 7.30
PaCO2 = 35-45 mm Hg |
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Partially compensated metabolic alkalosis
pH = PaCO2 = |
pH > 7.50
PaCO2 > 50 mm Hg |
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Chronic ventilatory failure
pH = PaCO2 = |
pH 7.30 - 7.50
PaCO2 > 50 mm Hg |
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Acute ventilatory failure
pH = PaCO2 = |
pH < 7.30
PaCO2 > 50 mm Hg |
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ARDS
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Acute respiratory distress syndrome (ARDS) is a life-threatening lung condition that prevents enough oxygen from getting into the blood.
* Labored, rapid breathing * Low blood pressure and organ failure * Shortness of breath |
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Bronchiectasis
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destruction and widening of the large airways
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___ is defined as abnormal permanent enlargement of air spaces distal to the terminal bronchioles, accompanied by the destruction of the walls and without obvious fibrosis.
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emphysema
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The 3 described morphological types of ____ are:
1. centriacinar 2. panacinar 3. paraseptal |
emphysema
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Pathophysiology of emphysema:
presents with ______, and the pathological changes occur not only in the lung parenchyma but also in the ____ airways |
chronic bronchitis
large and small |
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Pathophysiology of emphysema:
characterized by ___ destruction limited to the airspaces distal to the ___ Both emphysematous destruction and ____ inflammation often are found in combination in individual patients |
focal
respiratory bronchioles small airway inflammation |
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When emphysema is moderate or severe, loss of ___, rather than bronchiolar disease, is the mechanism of airflow limitation
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elastic recoil
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when emphysema is mild, ___ are most responsible for the airflow limitation
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bronchiolar abnormalities
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Although air flow obstruction in emphysema is virtually ___, ___ due to inflammation accounts for a limited amount of reversibility
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irreversible
bronchoconstriction |
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Pathogenesis
various lesions may be found in the airways of ___ lungs Cigarette smoking-leads to ___ activation and retention in the lung parenchyma A number of neutrophil-derived and macrophage-derived enzymes known as ___ can destroy various components of the extracellular matrix of the lung and cause ___ |
emphysematous
neutrophil proteinases and elastases (ie, proteolytic enzymes) emphysema |
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Pathogenesis of emphysema
Lung destruction results from an excess of ___ release in the lungs, a reduction in the anti-proteinase defense within the lung, or a combination of both increased proteinase burden and decreased proteinase inhibitor capacity |
proteinase
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____ is the product of an imbalance between the proteinases and anti-proteinases in favor of proteinases.
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emphysema
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pathogenesis of emphysema
the cellular composition of the airway inflammation in COPD is predominantly mediated by the ___ Cigarette smoking induces macrophages to release ___, thus unleashing tissue destruction |
neutrophils
neutrophil chemotactic factors and elastases |
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Alpha1-antitrypsin deficiency
___ is a ___ that is synthesized in the ___ and is secreted into the blood stream The main purpose of this amino acid is to neutralize ___ in the lung interstitium and to protect the lung parenchyma from elastolytic breakdown |
AAT
glycoprotein liver neutrophil elastase |
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Severe ___ deficiency predisposes to unopposed elastolysis with clinical sequela of early onset of ___.
Deficiency of ___ is inherited as an ___ condition |
alpha1-antitrypsin (AAT)
panacinar emphysema AAT autosomal codominant |
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In the US: ___% of male adults and ___% of female adults are estimated to have emphysema
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4-6% male adults
1-3% female adults |
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___ Americans have severe AAT deficiency, but only ___% have been identified
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60,000-100,000
4% |
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The major risk factor for developing AAT- related emphysema is ___, which accelerates the onset of dyspnea by ~19 years
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cigarette smoking
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___ is now the fourth most common cause of death, accounting for nearly ___% of all deaths
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COPD
4.5% |
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Sex- ___% of white male adults and ___% of white female adults have ___ or ___. ___ have a higher mortality rate than women
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4-6%
1-3% emphysema or COPD Men |
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Most patients with ___ have smoked at least 20 cigarettes per day for 20 or more years before the common symptoms of cough and dyspnea develop (20pk * yr history)
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emphysema
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emphysema
Typical patients present in their fifth decade of life with productive cough or acute chest illness cough usually is worse in the morning and produces small amounts of colorless sputum from concomitant ___ ___ is the most significant symptom By the time FEV1 has fallen to ___% of predicted, the patient is breathless on minimal exertion |
chronic bronchitis
Breathlessness 30% |
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emphysema
___ may occur in some patients, particularly during exertion and exacerbations With disease progression, the intervals between acute exacerbations become shorter; ___ and ___ may develop |
Wheezing
cyanosis and right heart failure |
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Physical findings for ___
sensitivity of the physical evaluation in mild-to-moderate disease is relatively poor physical signs are quite sensitive and specific for severe disease. Patients with severe disease experience tachypnea and respiratory distress with simple activities. respiratory rate increases in proportion to disease severity. Use of accessory respiratory muscles and paradoxical indrawing of lower intercostal spaces are evident. Thoracic examination reveals hyperinflation (ie, barrel chest), wheezing, diffusely decreased breath sounds, hyperresonance on percussion, and prolonged expiration. |
emphysema
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___ is by far the single most clearly established environmental risk factor for emphysema
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Cigarette smoking
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prevalence and incidence of emphysema are increased in relation to smoking by ___ times
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2.8
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Mortality rates from emphysema are increased substantially in people who smoke for more than ___ pack years
Emphysema also develops in patients who have ___ |
20
AAT deficiency syndrome |
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Alpha1-antitrypsin level-serum levels below the protective threshold of ___ mmol/L
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11 mmol/L
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Measure the AAT level in all patients younger than __ years or with a family history of emphysema at an early age
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40 years
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___ may develop in severe COPD or in patients who smoke excessively
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Polycythemia
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A hematocrit > ___% in men and > ___% in women is indicative of polycythemia
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> 52% in men
> 47% in women |
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Patients should be evaluated for ___ at rest, with exertion, or during sleep
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hypoxemia
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Sputum evaluation- ___ and ___ are pathogens that are cultured frequently during exacerbations
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treptococcus pneumoniae and Haemophilus influenzae
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Chest radiograph- Frontal and lateral chest radiographs reveal signs of ___, which involves flattening of diaphragms, increased retrosternal air space, and a long narrow ___
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hyperinflation
heart shadow |
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Rapid tapering vascular shadows accompanied by ___ of the lungs are signs of emphysema.
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hyperlucency
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Chest radiograph shows hyperinflation, flattened
diaphragms, increased retrosternal space, vertical heart and hyperlucency of the lung parenchyma in ___ |
emphysema
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___ is more sensitive than a standard chest radiograph.
___ scan is highly specific for diagnosing emphysema and outlines bullae that are not always observed on radiographs |
CT scan- A high-resolution CT (HRCT) scan
HRCT |
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A ___ scan shows emphysematous
bullae in upper lobes. |
CT
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localized, ___ = enlarged air space >1 cm in diameter).
The emphysema is located at the top of the lung. Note that the tissue not involved in the emphysema appears almost normal in this case. |
bullous emphysema
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PFT
These measurements are necessary for the diagnosis of ___ airway disease and assessment of its severity. In addition, spirometry is helpful for assessing response to treatment and disease progression |
obstructive
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PFT
___ is a reproducible test and is the most common index of ___. Lung volume measurements show an increase in total lung capacity (TLC), functional residual capacity, and residual volume. The vital capacity is decreased. |
FEV1
airflow obstruction |
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___ is decreased in proportion to the severity of emphysema.
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DLCO
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Arterial blood gases reveal mild-to-moderate hypoxemia (decreased partial pressure of oxygen in blood) without hypercapnia (too much carbon dioxide in the blood) in the early stages. As the disease progresses, hypoxemia becomes more severe and hypercapnia supervenes.
Hypercapnia is observed commonly as the FEV1 falls below ___ |
1 L/s or 30% of predicted
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Lung mechanics and gas exchange worsen during acute exacerbations
As many as ___% of patients have an increase in FEV1 of ___% after inhalation of a ___. |
30%
15% or more bronchodilator |
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Treatment
|
Smoking cessation
Alpha1-antitrypsin deficiency Available augmentation strategies include pharmacologic attempts to increase endogenous production of AAT by the liver (eg, danazol, tamoxifen) or administration of purified AAT by periodic IV infusion or by inhalation. Pharmacologic therapy of emphysema Bronchodilators Anti-inflammatory therapy The use of corticosteroids requires a careful evaluation in patients on adequate bronchodilator therapy who do not improve sufficiently or who develop an exacerbation. Most studies suggest that 20-30% of patients with COPD improve if administered long-term oral steroid therapy. Carefully document the effectiveness of such therapy (>20% improvement in FEV1) before administering prolonged daily or alternate-day treatment. Corticosteroids have side effects: myopathy, easily bruised skin, glucose control, increased appetite,osteoporosis, behavorial changes |
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Most studies suggest that ___% of patients with COPD improve if administered long-term oral steroid therapy.
Carefully document the effectiveness of such therapy (___% improvement in FEV1) before administering prolonged daily or alternate-day treatment |
20-30%
>20% improvement in FEV1 |
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these are side effects of ___:
myopathy, easily bruised skin, glucose control, increased appetite,osteoporosis, behavorial changes |
Corticosteroids
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___ have been used with success to treat outpatients with acute exacerbations; however, after stabilization, oral corticosteroids should be weaned gradually because of the potential for adverse effects.
|
Oral steroids
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Despite a lack of conclusive evidence to support the role of ___ in the management of COPD, the use of these agents is widespread
|
inhaled corticosteroids
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Three large placebo-controlled trials investigating the use of these agents in severe, mild, and very mild disease have been completed. Based on the rate of decline in FEV1, results from these 3 trials suggest that ___ do not slow the decline in lung function but decrease the frequency of exacerbations and improve disease-specific, health-related quality of life.
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inhaled corticosteroids
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more treatments for emphysema
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Antibiotics
Mucolytic agents Surgical Care -Bullectomy for giant bullae -Lung volume reduction surgery -Lung transplantation |
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Diet- Inadequate nutritional status associated with low body weight in patients with COPD is associated with impaired pulmonary status, reduced diaphragmatic mass, lower exercise capacity, and higher mortality rates. Nutritional support is an important part of their comprehensive care.
When you can’t breathe, eating interferes with breathing! |
another treatment for emphysema
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Acute exacerbation of COPD
Acute exacerbation of COPD is a major reason for hospital admission in the United States Causes of acute exacerbations include upper respiratory infection, myocardial ischemia, congestive heart failure, thromboembolism, and recurrent aspiration. Significant loss of muscle strength and endurance often accompanies COPD exacerbations |
another treatment for emphysema
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