HSC 551 Exam 4

Intermittent claudication

pain, cramping, or aches in the hips, thighs, or buttocks

Biggest Risk Factors of PAD

smoking, diabetes, previous diagnosis of CVD

ABI Diagnostic Criteria

>1.40 , noncompressible vessels, TBI test recommended
1.00 - 1.40 , normal
.91 - .99 , borderline, indeterminate need exercise ABI test
< .90 , abnormal, DIAGNOSTIC FOR PAD

How to calculate ABI

higher Right ankle BP / higher Right brachial BP

higher Left ankle BP / higher Left ankle BP

** lower of these answers is ABI

What post-exercise ABI confirms PAD?

< .99 confirms PAD

Primary assessments of treadmill walking test

1. claudication onset time / distance
2. peak walking time / distance

Structured Exercise for PAD

1. set walking speed
2. patient walks until they experience moderate claudication (3 or 4/5) - should happen within 5 - 10 mins
3. when patient reaches target level leg discomfort they should stop
4. after pain subsides, they begin walking again
5. initial goal is to complete 30 mins of intermittent walking

Progression of PAD

- once patient achieves 30 mins, then increase workload (increase grade first)
- Goal: 30 - 45 mins of walking

Effects of exercise training - PAD patients

- improved biomechanics of walking
- increased collateral angiogenesis
- increased extraction of oxygen (avO2diff)
- increased pain tolerance

Pharmacologic Therapy for PAD

- Pentoxifylline - not great results
- Cilostazol - only FDA approved med for PAD, should not be used for patients with heart failure

COPD - chronic obstructive pulmonary disease

- airflow obstruction that is due to chronic bronchitis or emphysema
- productive cough most days during 3 consecutive months
- 2 successive years in a row
- hypersecretion of mucus

Emphysema

- abnormal enlargement of the respiratory bronchioles and alveoli

Asthma

- airway hyperresponsiveness and airway limitations
- sensitivity to allergens

Chronic Lung Disease

- get air into the lungs, but struggle to expire
-diagnoses based on:
1. FEV1 / FVC < .70%
2. FEV1% predicted 30-80%

CAD patients with COPD

- follow standard exercise rx regimens (RPE 11 - 14)
- perform baseline assessment to determine any exercise-induced symptoms

Exercise Considerations for COPD patients

- expiratory volume decreases by 200 - 400 mL with moderate intensity exercise
- COPD patients have increase in expiratory volume during exercise
- HR is not a reliable indicator
- intensity is monitored by dyspnea rating and RPE
- may need to give supplemental O2 if oxygen saturation falls below 90%
- focus on lower extremity exercises (walking, cycling) for aerobic exercise
- need proper warm-up and cool-down
- monitor dyspnea (have rescue inhaler available)

What is heart failure

the inability of the heart to deliver blood to meet the metabolic demands of the boyd's organs and tissues, characterized by reduction in CO

Systolic Heart Failure

- the inability of the left ventricular myocytes to contract against a load
- results in reduced EF
- HFrEF < 40% (normal is >55%)
- due to hypertension and ischemic heart disease

Diastolic Heart Failure

- the inability of the left ventricle to fill with blood
- results in preserved EF (HFpEF) (EF >50%)

Paroxysmal Nocturnal Dyspnea

sudden awakening during the night to catch breath

Orthopnea

difficulty breathing while laying flat

Clinical Characteristics of HF

1. exercise intolerance as manifested by fatigue or SOB upon exertion
2. fluid retention, evident by pulmonary/peripheral edema and/or recent weight gain

HF Patient Considerations

1. changes in body weight over 1-3 day time period >4 lbs, weigh pts before every CR session
2. monitor med compliance
3. evaluate changes in exercise intolerance
4. be aware of arrythmias
5. compliance is key to improvement in QoL
6. educational components
7. recommend 64oz fluid per day (8 cups)
8. all HF patients are high risk

HF Exercise Prescription

Duration: initially 10 min bouts with rest in between
Frequency: target 3 days/wk
Intensity: RPE 11-14, +20-30 bpm
Progression recommendation: reach duration goal before increased ex intensity

Exercise Considerations for Heart Transplant pts

1. lower resting SV
2. heart does not respond to immediate exertion by HR acceleration
3. anginal symptoms eliminated... no chest pain, cannot rely on angina
4. pay attention to dyspnea, lightheadedness, arrythmias, ST segment

Ex Rx for Heart Transplant pts

1. use RPE of 11-14
2. use dyspnea scale

LVAD- left ventricular assisted device

- always high risk, 100% ecg monitoring
- heavy medication regiment
- continuous flow device or pulsate flow device
- check power source

LVAD exercise considerations

-exercise intensity: set initial training at or below 2 METs, RPE 11-14, HRR 60-80% with baseline GXT
-mode: mild walking, NuStep
-terminate exercise if patient does not tolerate a small change in workload
-terminate if O2sat drops below 90%
-occasionally check VAD monitor

Pre-exercise check for LVAD patients

- review vital signs and change in symptoms
- use Doppler for BP
** do not exercise if > 90 mmHg or if < 66 mmHg

Routine Patient Assessment

- recent medical history since last visit
- resting ECG and HR
- BP
- Body Weight
- Medication compliance
- must document

FVC and FEV1

FVC (forced vital capacity) = volume of air that can be expired after full inhalation

FEV1(forced expiratory reserve volume in 1 sec) = amount of air forcibly expired in one second after full inhalation

**normal values = 75-80%

Compensatory Response to HFrEF

- maintains CO
- vasoconstriction, fluid retention, rate response, blood pressure

Medications for Compensatory Response to HF

- ACE Inhibitors / Ang receptor blocker - manage RAAS, lower DBP and BP
- Beta Blocker - manage SNS, lower resting HR and BP
- Diuretics - lower volume overload