ExRx - Pulmonary Disease

Pulmonary System Review

1. Nasal Passage

2. Oral Cavity

3. Pharynx

4. Epiglottis

5. Larynx

6. Trachea

7. Lungs

8. Bronchi

9. Bronchioles

10. Alveolar Sac

11. Alveolar Ducts

12. Alveolar Pores

Accessory Muscles of Inspiration

• Sternocleidomastoid (Elevates sternum)

• Scalenes (Elevates ribs)

• Pectoralis Major

Principal Muscles of Inspiration

• External Intercostals

  • Part of the Internal Intercostals

  • Also elevates ribs

• Diaphragm

  • Dome descends increasing vertical dimension of thoracic cavity

  • Also elevates lower ribs

Accessory Muscles of Expiration

• Quiet Breathing

• Expiration is from passive elastic recoil of the lungs, rib cage, and diaphragm

Principal Muscles of Expiration

• Active Breathing

• Internal Intercostals (except for interchondral part, pulls ribs down)

• Abdominalis (pulls ribs down, compress abdominal contents and push diaphragm up)

• Quadratus Lumborum (pulls ribs down)

Static Lung Volume

Volume in the lungs when no air is flowing in or out of the lungs

Tidal Volume (TV)

Volume of inspired or expired air per breath

Inspiratory Reserve Volume (IRV)

• Maximum inspiration at the end of tidal inspiration

Expiratory Reserve Volume (ERV)

Maximum expiration at the end of tidal expiration

Total Lung Capacity (TLC)

Volume in lungs after maximum inspiration

Residual Lungs Volume (RLV)

Volume in lungs after maximum expiration

Forced Vital Capacity (FVC)

Maximum volume expired after maximum inspiration

Inspiratory Capacity (IC)

Maximum volume inspired following tidal expiration

Functional Residual Capacity (FRC)

Volume in lungs after tidal expiration

Variations from Normal Breathing Patterns

• Hyperventilations

• Dyspnea

• Valsalva Maneuver

Hyperventilation

Increase in pulmonary ventilation that exceeds O₂ consumption & CO₂ elimination needs of metabolism

Hyperventilation

Increase in pulmonary ventilation that exceeds O₂ and CO₂ elimination needs of metabolism

Dyspnea

Inordinate shortness of breath or subjective breathing distress

Valsalva Maneuver

• Closing of glottis after a full inspiration and maximally activating expiratory muscles

• Creates a compressive force that increases intrathoracic pressure above atmospheric pressure

Asthma

• Results in bronchospasm

  • Increased work of breathing

  • Shortness of breath (dyspnea)

Exercise Induced Asthma

• Bronchospasm during or immediately following exercise

• May impair exercise performance

Chronic Obstructive Pulmonary Disease

Compromises respiratory tract diseases that obstruct airflow (emphysema, asthma, and chronic bronchitis)

Restrictive Lunch Dysfunction

Abnormal reduction in pulmonary ventilations with:

• Diminished lung expression

• Decreased TV

• Loss of functioning alveolar capillary units

Pulmonary Function: Restrictive

• Pulmonary Fibrosis

• FEV = 2.8L

• FVC = 3.1L

• Percent = 90%

Pulmonary Fibrosis

• Lung disease caused by damage and scarred lung tissue

• Damaged tissues between and around alveoli make it difficult for oxygen to pass through to the bloodstream and becomes more difficult to breath

• Damaged tissue causes include long-term exposure to environmental toxins, medical conditions, radiation therapy, and some medications

• Caused by many factors, cannot always be determined

Pulmonary Function: Obstructive

• Bronchial Asthma

• FEV= 1.3L

• FVC = 3.1L

• Percent: 42%

Pulmonary Function: Normal

• FEV = 4.0L

• FVC = 5.0L

• Percent = 80%

Pulmonary Diseases: COPD

• 4th leading cause of death

• Major cause of chronic morbidity

• Preventable and treatable

• Results in chronic airway inflammation due to exposure to noxious gases and particles

• Based on severity of disease can be identified as chronic bronchitis and/or emphysema

Effects of COPD on Physiological Responses

• Added expiratory resistances triples normal cost of breathing at rest and severely limits exercise capacity

• Severe cases energy cost of breathing attains 40% of total exercise VO2

• Intense exercise causes a competition between O₂ blood flow needs of locomotor and respiratory muscles eventually encroaches on O₂ available to active non-respiratory skeletal muscles

Characteristics of COPD

• Increased airway resistance

  • Due to constant airway narrowing

  • Decreased expiratory airflow

• Includes two lung diseases

  • Chronic bronchitis

  • Emphysema

• Increased work of breathing

  • Leads to SOB

  • May interfere with exercise and activities of daily living

Chronic Bronchitis

• Condition where lungs are inflamed triggering immune system to form excessive mucus blocking the airway

• Symptoms

  • Dyspnea or SOB

  • Whistling sound while breathing

  • Tachycardia

  • Fatigue

  • Frequent cough with mucus for 3 months of year for 2 years

Emphysema

• Condition where airway collapses and there is increased resistance causing damage to the alveoli

• Causes

  • Smoking

  • Pollution

  • 2nd Hand Smoke

• Symptoms

  • Finger clubbing (Low levels of O₂ in blood)

  • Barrel chested (trapped air caused by blockage in alveoli leading to overinflated lungs)

Diagnostic Tests of PD

• X-ray (Most popular)

• Computed Tomography (CT Scan)

• Spirometry

• Pulmonary Diffusion Capacity (How well O₂ moves from lungs to blood)

• Blood gas analyses (measures levels of O₂ and CO₂ in blood and pH)

Treatment/Management of PD

• Quit smoking

• Pulmonary rehab

• Medications

  • Bronchodilators, anti-inflammatories, antibiotics

• Vaccinations

• Supplemental O₂

• Exercise

Exercise Benefits for PD

• ACSM

  • Reduce risk of comorbidities

  • Manage weight

  • Reduce anxiety and sleep

  • Improve muscle endurance

  • Enhance heart health

  • Improve circulation

  • Lowers stress of exercise on breathing

• ALA Improves

  • Body’s use of O₂

  • Energy levels

  • Anxiety, stress, depression, sleep

  • Self-esteem

  • Cardiovascular fitness

  • Muscle Strength

  • SOB

Ex Rx Aims for PD

• Improve health status

• Improve respiratory symptoms

• Recognize signs needing medical attention

• Maximize arterial O₂ saturation and CO₂ elimination

• Enhance daily functional capacity

• Modify body composition to help functional capacity

• Optimize nutritional status

GXT: Basic

• Pretraining and spirometric analyses form basis of Ex Rx

• Determine:

  • Test termination points

  • Pre and post exercise pulmonary function

  • Supplemental O₂ needs

Asthma and GXT Protocol

• Evaluate:

  • Cardiorespiratory capacity

  • Pre/post pulmonary function

  • Oxyhemoglobin saturation

• Administer inhaled bronchodilator

• Supervised treadmill or cycle ergometer

• Monitor and record degree of exercise induced bronchoconstriction

• Pre/post FEV_1.0 measurement

• Post exercise bronchodilator administration

Benefits of Warm-Up and Medication for PD

• 15-30 min

• Light to moderate

• Initiates refractory period

• Pre exercise meds

• Potentiates bronchodilation

• Higher airflow

FITT Aerobic: Asthma

• F: min 3 d/w, preferably up to 5 d/w

• I: begin with moderate intensity of 40-59% HRR, progressed to 60-70% HRR

• T: progressively increase to at least 30-40 min/d

• T: aerobic activities using large muscle groups such as walking, running, cycling, swimming, or pool exercises

FITT Resistance: Asthma

• F: at least 2 d/w with non-consecutive days

• I: Strength: 60-70% 1-RM for beginners, ≥80% for experience weight trainers, Endurance: ≤50% of 1-RM

• T: Strength: 2-4 sets of 8-12 reps, Endurance: ≤2 sets of 15-20 reps

• T: Weight machines, free weight, or body weight exercises

FITT Flexibility: Asthma

• F: ≥3-4 d/w, daily most effective

• I: Stretch to point of feeling tightness or slight discomfort

• T: 10-30s static stretching, 2-4 repetitions of each exercise

• T: Static, dynamic, or PNF stretching

Asthma and Special Considerations

• Caution using HR for intensity measurement

• Symptoms present = postpone exercise

• Use inhaler pre-exercise

• Avoid cold, dry environments

• Avoid locations with allergens or pollutants

• Swimmers use non chlorinated pools

• Be prepared for symptoms

GXT: COPD Protocol

• Objective measures of:

  • Exercise capacity

  • Mechanisms of exercise intolerance

  • Disease progression

  • Treatment response

• Modifications of traditional protocols

  • Test duration of 8-12 min is optimal in those with mild to moderate COPD

  • Test duration of 5-9 min is recommended for individuals with severe and very severe disease

GXT for COPD

• 6MWT

• Incremental and endurance shuttle walk tests

• CWR tests

• Exertional dyspnea is common

• Modified Borg Category Ratio

• Follow standard termination criteria

  • Severe atrial oxyhemoglobin desaturation (≤80% = termination)

FITT Aerobic: COPD

• F: min 3 d/w, preferably up to 5 d/w

• I: moderate to vigorous intensity 50-80% of peak work rate or 4-6 on Borg scale

• T: 20-60 min/d at moderate to high intensity, if not achievable accumulate ≥20 min of exercise interspersed with intermittent exercise rest periods of lower intensity work or rest

• T: Common aerobic modes of walking, stationary cycling, and upper body ergometry

FITT Resistance: COPD

• F: at least 2 d/w on non-consecutive days

• I: Strength: 60-70% 1-RM for beginners, ≥80% for experienced weight trainers, Endurance: <50% of 1-RM

• T: Strength: 2-4 sets of 8-12 reps, Endurance: ≤2 sets of 15-20 repetitions

• T: Weight machines, free weight or body weight exercises

FITT Flexibility: COPD

• F: ≥ 2-3 d/w, daily most effective

• I: Stretch to point of discomfort or tightness

• T: 10-30s hold for static stretching with 2-4 reps of each exercise

• T: Static, dynamic, PNF

COPD Special Considerations

• Supervised is highly recommended

• Encourage high intensities as tolerated

• Mild COPD: intensity guidelines for healthy older adults are appropriate

• Mod-Severe COPD: Light intensity aerobic, increasing as tolerated

COPD Special Considerations: Monitoring

• Peak Work Rate or Dyspnea Rating

• HR_MAX deemed inappropriate

• Oximetry for Hb saturation monitoring

• Flexibility training focused on postural impairments (Kyphosis)

• Resistance training (upper body work)

• Be prepared to adjust intensity and/or duration

• Supplemental O₂ may be needed