Pulmonary rehab

--Benefits of pulmonary rehab: increases arterial venous oxygen (AVO2) difference for improved oxygen extraction from arteries, improved exercise tolerance, reduced dyspnea, improved ambulation, decreased hospitalizations

--Moser classification of functional pulmonary disability:
1. Normal at rest, dyspnea with stenuous exertion
2. Normal ADLs, dyspnea on stairs
3. Dyspnea with some ADLs, able to walk 1 block
4. Dependent with some ADLs, dyspnea with minimal exertion
5. Housebound, dyspnea at rest

--Patients who would benefit most from pulmonary rehab:
• Respiratory limitation of exercise at 75% max O2 consumption
• Irreversible airway obstruction with FEV1 < 2000ml or FEV1/FCV < 60%
• Restrictive lung disease with CO diffusion capacity < 80% predicted

--Maximal oxygen consumption (VO2 max) = (HR x SV) x AVO2 diff (Fick’s equation)
*dependent on body weight, age, sex, natural endowment, pathological conditions, endurance exercise training

--Obstructive Pulmonary Disease:
• increased airway resistance due to bronchospasm
• air trapping
• increased compliance
• impaired blood oxygenation (hypoxia) 2/2 perfusion/ventilation mismatch
• Flattening of diaphragm
• Causes: chronic bronchitis, emphysema, cystic fibrosis, asthma
--Emphysema: distention of air spaces distal to terminal bronchioles with destruction of alveoli --> airway collapse on exhalation, decreased gas exchange --> severe mulmonary artery HTN and RV failure
--Cystic fibrosis: generalized disease of exocrine glands, respiratory failure due to inadequate removal of secretions from bronchioles
*aerobic exercise helps increase sputum expectoration, improves mucous transport, and reduces airway resistance
--Impairment develops when FEV1 falls below 3 L/sec
--Increased RV, TLC

--Restrictive lung disease: impaired lung ventilation as a result of mechanical dysfunction of the lungs or chest wall --> stiffness of the chest wall or lung tissue
--Causes of restrictive lung disease: neuromuscular disease, thoracic deformities (kyphoscoliosis), scoliosis > 90 deg, ank spond, cervical SCI, interstitial lung disease, pleural disease, surgical removal of lung
--Respiratory complications of Duchenne’s MD: atelectasis, pna, chronic alveolar hypoventilation, ventilatory failure
--Decreased VC, TLC, RV, but normal FEV1

--Aging --> decreased VC, FEV1 (rate of 30 cc/yr), PO2, increased RV and FRC
--In smokers, FEV1 decrease will be 2-3 times as fast

--Pulmonary changes in C5 quad: 60% inspiratory capacity, weak cough, difficulty clearing secretions, decreased VC, increased RV

--Duchenne’s MD: initiate vent support when pt has dyspnea at rest, VC 40% predicted, maximal inspiratory pressure < 30% predicted, hypercapnea

--ALS: monitor PFTs, functional VC is best prognostic indicator

--Asthma: for reversible bronchospasm, can try methylxanthines, beta-2 agonists, anticholincholinergics
*young patients with moderate asthma may benefit from theophylline
--O2 recommended for pts who desat below 90% during exercise
--Benefits of home O2: reduced polycythemia, improved pulm HTN, reduced perceived effort during exercise, prolonged life expectancy, improved cognition, reduced hospital needs
--Benefits of diaphragmatic breathing: incr TV, decr FRC, incr max oxygen uptake
--Benefits of pursed-lip breathing: prevents air trapping, greater gas exchange in alveoli, incr TV, reduced dyspnea and work of breathing in COPD
--Benefits of preoperative and postoperative chest therapy: decreased pna, decreases atelectasis
--Aerobic exercises for CF: trunk exercises (sit-ups), swimming, jogging

--Glossopharyngeal breathing: can be used in restrictive lung disease in the case of ventilator equipment failure for up to 4 hours, improves volume of voice and rhythm of speech, prevents micro-atelectasis, allows deeper breaths for better cough, improves pulmonary compliance

--Intermittent abdominal pressure ventilator (pneumobelt): abdominal corset which created forced expiration by moving diaphragm cephalad, works only in sitting position, liberates hands and mouth for other activities
*contraindicated in obesity, scoliosis, and patients with decreased pulmonary compliance or increased airway resistance
--Rocking bed: rocks patient along vertical axis, using gravity to assist ventilation --> useful in diaphragm paralysis
*benefits include preventing venous stasis, improved clearance of secretions, prevents decubs, benefits bowel motility
*disadvantages: not portable, not useful in patients with decreased pulmonary compliance or increased airway resistance

--Fenestrated trach tubes: used in pts who can speak and require only intermittent vent assist  when inner unfenestrated cannula is out and tube is plugged, pt may speak
--Nonfenestrated trach: for pts who require continueous vent or are unable to protect their airway during swallowing
*one-way talking valve may be installed
--Speaking trach tubes: used in alert pts who require inflated cuff for ventilation, and have intact vocal cords
*need to speak in short sentences, quality of speech altered
*manual dexterity and strength required to occlude external port
--One-way speaking valves (Passy-Muir): air directed through trachea and up through vocal cords
*requires less work
*cannot be used in COPD patients because lung has lost elasticity so air can’t be forced out

cardiac rehab

--Total oxygen consumption (VO2) = oxygen consumption of entire body
--Myocardial oxygen consumption (MVO2) = oxygen consumption by heart, can be measured by cardiac cath
--Rate Pressure Product (RPP) = SBP x HR = work required of heart
--Cardiac Output (CO) = HR x stroke volume
--MET: 1 met = 3.5 ml O2 consumed per kg wt per minute

--Benefits of cardiac rehab: improved exercise tolerance, symptoms, and cholesterol, reduction of smoking, stress reduction, reduced mortality

--Absolute contraindications to exercise training:
• Unstable angina
• Resting SBP > 200, DBP > 110
• Significant drop (20) in SBP
• Mod to severe aortic stenosis
• Acute illness
• Uncontrolled atrial or ventricular arrhythmia
• Uncontrolled tachycardia
• Symptomatic CHF
• 3rd degree heart block w/o pacemaker
• Active pericarditis/myocarditis
• Recent embolism
• Thrombophlebitis
• Resting ST displacement > 3mm
• Uncontrolled DM
• Orthopedic restrictions

--Activities to avoid during acute period of rehab (CCU): isometrics (increases HR), valsalva (causes arrhythmia), raising legs above heart (increases preload)

--Graded exercise stress tests (GXT) = assesses ability to tolerate increase stress  functional rather than diagnostic tool, can give risk stratification and limits for therapy
--For GXT, heart rate limit is 130-140 BPM
--Most ADLs in home require < 4 mets
--Benefits of cycle ergometer over treadmill: less space, less cost, minimized movement of arm and thorax for better recording, but treadmill is more physiological
--Arm ergometer used in LE amputees
--Bruce Protocol: exercise testing on treadmill with stages of 2-3 mets each

Cardiac Functional Classification:
--Class I: can do >= 7 mets
--Class II: can do >= 5 mets, < 7 mets
--Class III: can do >= 2 mets, < 5 mets
--Class IV: can do < 2 mets only

--Exercises for cardiovascular conditioning: isotonic, rhythmic, aerobic
--Small isometric component for cardiac patients
--Resistance exercises are safe and effective for improving strength and CV endurance in low risk patients  increases aerobic capacity of both Type I and Type II fibers
--Contraindications to resistance exercises: CHF, uncontrolled arrhythmia, severe vascular disease, uncontrolled HTN, SBP>160, DBP>100, aerobic capacity < 5 mets
--Optimum O2 consumption during exercise: 55-65% max VO2, 70% max HR  exercise 20-30 mins
--Borg scale: rating from 6-20 of perceived exertion

--Heart transplant: higher resting heart rate, lower peak exercise heart rate
*Monitor ECG changes during exercise testing b/c no angina

--Greatest % increase in energy for ambulation for amputees is for bilateral AK with prostheses (280%): 3 mets to 11.4 mets
--50% increase for no prosthesis with crutches
--50% increase for hemiplegic ambulation

--For >7 mets maximum work load, patient can do any job
--For >5 mets, patient can return to sedentary job and household chores

Dysphagia following stroke

1. What are the three phases of swallowing?
2. What is required for the pharyngeal phase of swallowing?
3. What is chin tuck?
4. What % of patients have silent aspiration not detected by bedside swallow? How can this be diagnosed?
5. When does recovery of swallowing function usually occur in brainstem strokes?
6. What is nasal speech?

Answers:
1. Oral, pharyngeal, esophageal.
2. Tongue elevation, soft palate elevation, laryngeal elevation, coordination of pharyngeal constriction and cricopharyngeal relaxation.
3. Compensatory technique that prevents entry of liquid into the larynx.
4. 40-60% have silent aspiration that can be diagnosed by video fluoro study.
5. First three weeks post-stroke.
6. Hypernasality caused by partial or complete failure of soft palate to close off the nasal cavity from the oral cavity.

Stroke rehabilitation

1. What are poor predictors of motor recovery in stroke?
2. What is the treatment of shoulder subluxation?
3. What is traction neuropathy?

Answers:
1. Severe arm weakness at onset, no return of hand function by 4 weeks, severe proximal spasticity, prolonged flaccidity period, later return of proprioceptive facilitation.
2. Sling not indicated but can be used for support during ambulation, FES, armboard, overhead slings.
3. Due to hemiparetic patient sustaining a brachial plexus injury due to traction.

Pediatric motor neuron disease

1. What is the pathophysiology behind spinal muscular atrophy?
2. What is another name for SMA I, when does it present, and what muscles are spared?
3. What weakness is characteristic of SMA type II?
4. What is another name for SMA III, what is the onset, and what is the prognosis?
5. What is the inheritance of Friedreich's ataxia and what protein is abnormal?
6. What is the most effective treatment of progressive scoliosis?

Answers:
1. Inherited disorders characterized by weakness and muscle wasting, secondary to degeneration of anterior horn cells and brain stem motor nuclei. There are three subtypes.
2. Severe SMA or Werdnig-Hoffman disease presents within first few months of life with severe hypotonia and weakness, with respiratory problems, sucking and swallowing difficulties. Extraocular and cardiac muscles are spared.
3. SMA II is intermediate and results in predominent leg weakness so that patient may sit unsupported but not stand.
4. Mild SMA or Kugelberg-Welander syndrome has onset >18 mo, with walking limitations, but good long-term survival depending on respiratory function.
5. Autosomal recessive, liked to chromosome 9q21, with abnormal Frataxin protein.
6. Spinal arthrodesis prior to curvature of 35 deg and prior to VC below 35%. Bracing can be used to improve sitting balance in nonambulatory patients.

Pediatric neuromuscular junction disorders

1. How does juvenile myasthenia present?
2. How is junenile myasthenia diagnosed?
3. What does repetitive nerve stim show in autoimmune myasthenia gravis?

Answers:
1. Often in adolescent girls, often severe, with ptosis and ophthalmoplegia, weakness in face, jaw, swallowing, speech, respiration, proximal muscles.
2. Fatigability of muscle after stim of nerve at 4-10 Hz, response to Tensilon, single fiber EMG.
3. Decrement in CMAP with slow stimulation greater than 12-15%.

Other pediatric muscle disorders

1. What is one of the cardinal clinical signs of fascioscapulohumeral dystrophy?
2. What are the presenting symptoms of myotonia congenita?

Answers:
1. Facial weakness --> inability to whistle.
2. Stiffness after rest and in cold weather, difficulty releasing grip, sustained eye closing in infants.