cardiopulm considerations

age related heart changes

degeneration heart muscle, accumulation lipofuscins, mild cardiac hypertrophy esp LV wall, dec coronary perfusion, stiff and thick valves, loss of pacing cells at SA node

age related vasculature changes

arteries thicken and become less elastic, slowed exchange of capillaries, increased peripheral resistance, rise in resting BP systolic > diastolic, decreased responsiveness baroreceptors, decreased blood volume and increased coagulability

cardiac clinical picture typical aging

resting HR/CO mildly affected, resting BP increases, CV response to exercise blunted (dec HR acceleration, VO2 max, HRmax, SV)

CV signs to watch for

orthostatic intolerance d/t reduced baroreceptor sensitivity and poor vascular elasticity
EKG changes: abnormal sinus rhythm, longer PR and QT intervals, wide QRS complex, increased arrhythmias

age related changes to pulm function

chest wall stiffness + decreased strength respiratory muscle leads to increased work to breathe
decreased lung elasticity leads to decreased recoil and increased compliance
lung parenchyma: alveoli enlarge and thin, fewer capillaries limit blood exchange and oxygen delivery
blood vessels thicken/lose elasticity, decline total lung capacity, FEV1 decreases, altered gas exchange, blunted ventilatory and homeostatic responses (risk for acidosis), inability to clear secretions + blunted immune response

pulm clinical picture

resp response at low and mod intensities similar
at higher intensities greater work cost, resp acidosis, increased SOB, increased perceived exertion

pulm signs to watch for

hypoxia (changes in mentation), impaired cough leading to infection risk, choking (change in sensation of mouth and decreased gag reflex inc risk aspiration), prolonged recovery from even mild resp illness, chronic smoking or exposure to environ toxins

s/s of heart disease

pain/numbness/tingling in shoulders/arms/neck/jaw/back, SOB (inability to tolerate supine), chest pain with activity, lightheadedness/dizziness, confusion, HA, cold sweats, N/V, fatigue, swelling in ankles/feet/legs/stomach/neck, reduced activity tolerance

CV disease

HTN or hypotension, aortic stenosis, CAD common OA, arrhythmias (afib - often asymptomatic until CVA), angina (concern when paired with SOB and/or ST segment depression), changes electrical conduction, MI, CHF, PVD, PAD, VTE

pulmonary disease

chronic bronchitis, emphysema, COPD, idiopathic pulm fibrosis, upper resp illness/infection, asthma, lung CA, pneumonia

assessment for pneumonia severity: CURB

confusion, uremia, resp rate > 30, BP < 90 SBP or < 60 DBP, age > 65
> 2 points reasonable referral to hospital

goals of cardiopulm rehab

maximize physiologic capacity to adapt to upright and move against gravity, maximize reserve capacity to exceed critical functional performance threshold

monitor before/during/after exercise

HR, BP, breathing frequency/pattern, RPE, breathlessness, color, perspiration, stability, facial expression, ability to talk

exercise intensity

warm up: 75% of intensity for steady state
steady state, warm down
recovery: monitor until within 10% of baseline and individual appears at baseline

barriers of tx

too low: not necessary to set low boundary unless pathologic, go by symptomatic presentation
too high: based on predetermined level of physiologic tolerance and pt response

exercise recommendations

frequency/duration: recovery in 30 min too infrequent, 30 min-3 hrs optimal, longer than 3 hrs too frequent
type: prioritize pt needs
progression: based on tolerance and response

estimated high functional capacity

someone who has been exercising at mod-vigorous intensity
type: based on goals, mode specific to desired outcomes
intensity: 70-85% perceived max intensity
duration: 20-40 min/session
frequencY: 3-5x/wk
time course: 3-6 mo with healthy active OA, 4-8 wks for sedentary OA

estimated intermediate functional capacity

type: treadmill, ergometer, walking, swimming, aquatic, etc, make sure mode is what pt will want still
intensity: 60-75% perceived max intensity
duration: 20 min or less
frequency: 1-2x/day
course: prolonged

estimated low functional capacity

type: walking, water exercise, light activity, ADLs
intensity: between 0.6-0.75 peak HR from submax + HRrest or use BP, RPE, talk test
duration: HIIT to tolerance, focus prolonged duration
frequency: several times daily
course: quick improvements if deconditioned, outcomes vary