• Heart disease is the leading cause of death in the United States.

Chapter 47

Cardiac and Pulmonary Diseases

Incidence of Cardiac and Pulmonary Disease Incidence of Cardiac and Pulmonary Disease

• Heart disease is the leading cause of death in the United States.

Ch i b t ti l di i

• Chronic obstructive pulmonary disease is

the fourth leading killer of Americans.

Cardiac Diseases Cardiac Diseases

1. Myocardial Infarction

2. Congestive Heart Failure (鬱血性心衰竭 ) g (鬱血性心衰竭 ) 3. Cardiomyopathy

4 A i P t i

4. Angina Pectoris

1 Myocardial Infarction (MI) 1. Myocardial Infarction (MI)

• MI

• MI

– Heart attack (MI) is death of the heart muscle caused by lack of blood flow due to an obstruction of a coronary artery by plaque or spasm

• Acute Coronary syndrome (ACS)

– Indicate acute MI – Symptoms Symptoms

• Chest pain/ pressure radiate to teeth, jaw, ear, arm, midback

• Diaphoresis(冒汗), short of breath (SOB), nausea(噁心), vomiting(嘔吐)/

fatigue fatigue

• A drug called thrombolytic agent (抗凝劑）must be given quickly and are most effective within 1 hr post symptoms

Left ventricle is usually the first area to suffer from perfusion deficiency

– Left ventricle is usually the first area to suffer from perfusion deficiency

2 Congestive Heart Failure

2. Congestive Heart Failure

CHF 鬱血性心衰竭

• CHF, 鬱血性心衰竭

– Inability of the heart to function as an effective pump – Caused by…

• Hypertension

• Hypertension

• Multiple MIs

• Incompetent valves

• Cardiomyopathy

• Cardiomyopathy – Signs and symptoms

• Increase in weight of 2-5 pounds or more over several days

• Inability to sleep

• Persistent dry hacking cough

• Shortness of breath with normal activity

• Shortness of breath with normal activity

• Swelling in ankles and feet

• fatigue

Cont.

3. Cardiomyopathy – CM, 心肌症 CM, 心肌症

• Disease of cardiac muscle

– Three main types

• 擴張型心肌症(Dilated Cardiomyopathy)(較嚴重,最常見）

• 肥厚性心肌症(Hypertrophic Cardiomyopathy)

• 窄縮性心肌症(Restrictive Cardiomyopathy)，較少見的 窄縮性心肌症( y p y) 較少見的

http://w3.csmu.edu.tw/~lcs/a2.htm

4. Angina Pectoris

– Heart pain caused by temporary inadequate supply of blood to heart muscle – Heart pain caused by temporary inadequate supply of blood to heart muscle – Angina is relieved with rest

– Nitroglycerin, taken by pill or spray under tongue relives angina quickly

– An indication of coronary a. disease

Cardiac rehabilitation Cardiac rehabilitation

1. Controllable risk factors for heart disease 2. Inpatient Cardiac Rehabilitation -- Phase I p 3. Outpatient Cardiac Rehabilitation -- Phase II 4 Community-Based Cardiac Rehabilitation -- 4. Community-Based Cardiac Rehabilitation --

Phase III

1 Controllable risk factors for heart disease 1. Controllable risk factors for heart disease

• 10 Factors that increase risk for heart disease:

• 10 Factors that increase risk for heart disease:

1) Age

2) Family History 2) Family History

3) Gender………..↑ uncontrollable 4) Smoking ) g

5) Hyperlipidemia (高脂血症) 6) Hypertension

7) Sedentary Lifestyle 8) Obesity

9) Diabetes

10) Psychological Stress ………..↑ controllable

2. Inpatient Cardiac Rehabilitation -- Phase I p

• 當個案狀況穩定時，即可介入，一般約入院後24- 48hr

48hr

• Goals:

– Prevent muscle loss from bedrest

– Monitor and assess patient’s ability to function – Instruct in appropriate home activities Instruct in appropriate home activities

– Education about risk factors and methods to reduce them

them

I t ti

• Intervention

– During exercise, occupational therapist monitors heart rate , blood pressure, and EKG responses

– Individual and Group Treatment

¾ Program

¾ Program

¾ 2-minute bouts with 1-munite rest (total 4-8 minutes, depending on the patient’s tolerance)

¾ Gradually progress to 8 10 minutes in total

¾ Gradually progress to 8-10 minutes in total

• Modalities

c Calisthenics (體操) d Stair climbing

e Treadmill

¾ at 1-1.5 mph or less than 3-5 minutes, with progression p p g based on patient’s tolerance

f Bicycle ergometer

g Hall walking

Meas ring Blood Press re

• Measuring Blood Pressure

– To be considered normal, blood pressure must be under 140/90 at rest. (140-收 縮壓, 90-舒張壓)

– Systolic blood pressure (收縮壓) should rise with exercise Systolic blood pressure (收縮壓) should rise with exercise.

– With exercise, diastolic blood pressure (舒張壓) should not increase more than 10 mm of mercury compared with resting.

• Pulse Taking g

– A normal heart rate (HR) range at rest is between 60-100 beats per minute (bpm).

– After open heart surgery, a patient often has a heart rate in the low 100s.

i i i h fi k f l (恢復期) h h

– During exercise in the first 2 weeks of convalescence(恢復期), the heart rate should not increase more than

• 20 bpm above resting for a patient with an MI and

• about 30 bpm for a patient after surgery about 30 bpm for a patient after surgery (ACSM, 2000). (ACSM, 2000).

– If the patient’s HR is uncontrolled and is 120 bpm or higher at rest, exercise is

contraindicated.

• Signs and Symptoms of Exercise Intolerance

– Chest pain or pain referred to the teeth, jaw, ear, or arm

– Excessive fatigue – Shortness of breath

– Lightheadedness or dizziness – Nausea or vomiting

– Unusual weight gain of 3-5 lbs in a 1- to 3-day period

H

• Home program

– 每一位個案在出院前，治療師都應該提供一份 individualized home program

individualized home program

– General component in Individualized home program

• Activity and exercise guideline Activity and exercise guideline

• Work simplification

• Pacing

S i l i i

• Social activity

• Signs and symptoms of exercise intolerance

• Discussion of risk factors

– 提供建議時，需同時考量個案的lifestyle, favorite

activities, work, hobbies…

2 METs (Metabolic equivalent) 2. METs (Metabolic equivalent)

METs, ^{運動代謝當量}

– a unit of measure used to describe the amount of oxygen the body

d f i i i

needs for a given activity

– One MET = oxygen consumption at rest or 3.5ml of O

/kg/weight/min

– Table 4-7 MET Values for Various Activities Table 4 7 MET Values for Various Activities

MET Values for Various Activities

Home Leisure and Vocational Exercise and Sports

1.0-2.5 METS

Sweeping floors Power boating Walking at slow pace

Sweeping floors Dusting

Straightening up Serving food

Power boating Fishing from boat Pumping gas

Changing light bulbs

Walking at slow pace Playing catch with a baseball or football

Horseback riding walking Serving food

Table setting

Knitting and crocheting Putting away groceries

Changing light bulbs Typing, computer

Sitting for light office work Card playing sitting

Horseback riding, walking

Putting away groceries Making bed

Standing quietly in line

M i l ith idi

Card playing, sitting Board games

Playing piano or organ D i i t t

Mowing lawn with a riding mower Casino gambling-standing

Sexual activity

D i d d i

Driving tractor

Sewing with a machine Driving an auto or truck

Sitti t t d d it

Dressing and undressing Sleeping

Watching TV

Sitting to study, read, or write

Home Leisure and Vocational Exercise and Sports Home Leisure and Vocational Exercise and Sports 2.6-4.0 METS

Child care bathing and Pitching horseshoes Very light stationary Child care, bathing, and

grooming

Walk, run, and play with

hild ( d )

Pitching horseshoes Home auto repair

Planting seedlings and

Very light stationary biking

Weight lifting of light

d ff

children (moderate)

General house cleaning Walking downstairs

shrubs

Playing the drums Home wiring or

to moderate effort Stretching, yoga Golf using a cart Walking downstairs

Sweeping garage or sidewalk

Home wiring or plumbing

Feeding small farm

Golf using a cart Snowmobiling

Walking at moderate Raking lawn

Walking and carrying load of 15 lbs

animals

Standing to pack light to moderate boxes

speed

Water aerobics

of 15 lbs moderate boxes

Bartending-standing

Walking and picking up

Home Leisure and Vocational Exercise and Sports

>4.0-6.0 METS

Major house cleaning, such as washing

windows vigorous effort

Laying carpet or tile Slow wood chopping

F i f di ttl

General calisthenics, moderate effort

Shooting hoops windows, vigorous effort

Moving furniture

Scrubbing floors on

Farming, feeding cattle Carpentry on outside of house

Shooting hoops Golf, carrying clubs Softball, fast or slow hands and knees

Cleaning gutters

Painting the outside of

Carpentry, refinishing surfaces

H ti l

, pitch

Low-impact or dance aerobics

Painting the outside of house

Painting and wallpapering

Hunting-general

Road building, carrying heavy loads

aerobics

Dodgeball or hopscotch inside of house

Weeding or cultivating

y

Roofing Bicycling at 10-11.9

mph

Home Leisure and Vocational Exercise and Sports

<6.0-10 METS

C i i F i b lli h Hi h i t

Carrying groceries upstairs

Moving household

Farming, balling hay Concrete masonry

Moving heavy objects such

High-impact

aerobicsRunning 10- 12 min/mileBasketball g

items in boxes

Shoveling more than 16 lbs per minute

Moving heavy objects such as furniture

Firefighter carrying hoses

gameJump ropingRace

walkingSwimming 16 lbs per minute

(heavy)

Walking or standing

laps at a moderate paceBicycling at moderate pace >12 with objects weighing

50-74 lbs

moderate pace 12

mph

3 Home Program 3. Home Program

HP i l di

• HP including

– Activity & exercise guidelines – Work simplification

– Work simplification – Pacing

– Temperature precautions p p – Social activity

– Sexuality

Si & t f i i t l

– Signs & symptoms of exercise intolerance – Discussion of risk factors

• Clinical pathway 專科診療途徑

• Clinical pathway 專科診療途徑

– MI pathway, CHF pathway….

• Home programs for MI Home programs for MI

– Healing of heart muscle takes about 4-8 weeks depending on the amount of damage sustained

Restrict patient’s activities to the 2 4 MET range during 4 8 – Restrict patient s activities to the 2-4 MET range during 4-8

weeks

– walking or biking exercise schedule

W lki d d

• Walking at moderate speed

• Walking at moderate speed – Home activities

• Child care, bathing, and grooming

• Walk, run, and play with child

• Walking downstairs g

• Sweeping garage or sidewalk

• Walking and carrying load of 15 lbs

O H t S H P

• Open Heart Surgery Home Program

– Given information on stretches and mild exercise to assist in incision pain management

assist in incision pain management

– Surgical patients are avoid lifting, pushing, or pulling, especially one-sided lifting or pulling, of greater than p y g p g, g 10lbs for 6-12 weeks

• Example

P lling open a hea door it is desirable to se t o hands – Pulling open a heavy door, it is desirable to use two hands – Picking up a heavy coffeepot, put one hand & the other hand

on the handle

P ti t h l i f f li t l hifti li ki

• Patient who complain of feeling sternal shifting or clicking, should avoid activity that causes it

• Walking schedule per patient tolerance are given

CHF h

• CHF home program

– inability: limit in endurance – Intervention: Intervention:

• Pacing

• work simplification

• Mild exercise program

• Mild exercise program

• Angioplasty (動脈氣球擴張術) Home Program

– Goal: to teach risk factor recognition, the ways to modify these risk

– Aerobic exercise program, walking…

– How to assess their physical response to exercise using Borg How to assess their physical response to exercise using Borg Rating of Perceived Exertion Scale (RPE) (ACSM, 2000)

– Review signs and symptoms of exercise intolerance

B R f P i d

• Borg Rate of Perceived Exertion (RPE) Scale

（ ）

7 極之輕鬆（extremely light）

8

‧ RPE 評量表

‧ 讓參與者藉運動時的自身感覺

（心跳 呼吸 排汗 肌肉疲

9 非常輕鬆（very light）

10

11 輕鬆（light）

（心跳、呼吸、排汗、肌肉疲 勞等），來估計運動時的強度

‧ RPE評量表的數值範圍: 6 至

12

13 有點辛苦（somewhat hard）

20

16

17 非常辛苦（very hard）

17 非常辛苦（very hard）

18

19 極之辛苦（extremely hard）

盡最大努力（ ）

20 盡最大努力（maximal exertion）

Outpatient Cardiac Rehabilitation Phase II Outpatient Cardiac Rehabilitation --Phase II

• Goals:

c Continued medical surveillance (監督) and c Continued medical surveillance (監督) and

assessment of an individual’s cardiovascular response to exercise

d Limit the physiological and psychological effects of heart disease.

e Instruct on risk factors for heart disease and how to reduce their impact.

f Maximize psychological and vocational status.

T d t i th i t i i t it

• To determine the appropriate exercise intensity

– Reach 50 ~ 85% of maximum age-adjusted heart rate (MAHR)

• MARA= 220- age g

• 50 ~ 85% of MAHR for the 50-year-old patient

= 0.5 x MAHR ~ 0.85 x MAHR

» (220-50)x0.5~(220-50)x0.85 ( ) ( )

» 85~149 (bpm)

– Borg RPE Scale

• For patient is on a beta blocker medication For patient is on a beta blocker medication

• Initial stage: Scale 11 ~ 13

• Rehabilitation stage: Æ Scale 12 ~ 15

Final exercise tolerance goal:

• Final exercise tolerance goal:

– 5 ~ 6 METs

– Home activities ~ major house cleansing (washing windows) j g ( g )

8. Intervention---Phase II

(Outpatient Rehabilitation) (Cont’d)

Two methods

• Two methods

1) Continuous exercise

• Short bouts of exercise on one pieces of equipment followed by a short rest 1 2 minutes

short rest 1-2 minutes

• 20-40 minute (total duration of exercise)

• Increasing intensity gradually

• Advantage: mimics home exercise

• Advantage: mimics home exercise

• Disadvantage: only certain muscle groups are targeted 2) Discontinuous exercise

• Amount of time staying on a piece of equipment remains the same

• Amount of time staying on a piece of equipment remains the same, but intensity gradually increases

• After finishing allotted time on one equipment, then switch to another

• This process is repeated several times

• Advantage: multiple muscle groups are used/ boredom is minimized

Disadvantage: takes a lot of space & equipment/ does not reflect

• Disadvantage: takes a lot of space & equipment/ does not reflect

Community Based Rehabilitation Phase III Community-Based Rehabilitation -- Phase III

• Cardiac rehabilitation with larger groups of patients

• Cardiac rehabilitation with larger groups of patients and fewer staff members per participant

• Often located in community centres, school gyms, and y , gy , YMCAs.

• Generally not covered by insurance

• Requires physician referral

• Trained personnel monitor the following:

– Blood pressure response – Heart rate

– EKG once per month

– Goal setting for risk management

Pulmonary Diseases

1. Chronic Obstructive Pulmonary Disease (COPD) y ( )

• Combination of

• Combination of

emphysema (肺氣腫)

and bronchitis (支氣管

炎)

Emphysema

• Emphysema

– Progressive and irreversible destruction of alveoli walls El ti fibb f l li ll d t d

– Elastic fibbers of alveoli wall are destroyed

– Lungs lose elasticity Æ air trapped in lung ÆÈ lung shrink during exhalation Æ decreased air inhaled with next breath g

• Chronic bronchitis

– excessive sputum production and cough of at least 3 months

• Disease Process:

Dyspnea (呼吸困難), Fatigue, Cough, Sputum Production

z Without enough energy to do their daily tasks (ADL,

leisure, vocation..)

• Pulmonary function tests

(1)FEV1(1秒鐘的空氣呼出量 ) 氣

To exhale forcefully as much air as possible in 1 second into a

肺 y 計 p

spirometer (肺量計 ).

高榮

(2) Arterial blood gases (動脈血液 (2) Arterial blood gases (動脈血液

氣體分析)

– to determine the lungs' ability to oxygenate blood

www.letcoinc.com ability to oxygenate blood,

remove CO

, and maintain the body's acid-base status – It is helpful to draw blood p

gases before and after exercise

(3) Pulse oximeter (脈動式血氧計) – non-invasive test to

determine the amount of i th bl d

oxygen in the blood.

– Oxygen saturation (O

Sat)

2. Pulmonary Rehabilitation y

• Goals and interventions of the occupational therapist:

therapist:

a) ADL evaluation and training to increase functional endurance

endurance

b) Instruction and training in appropriate breathing techniques with ADLs

techniques with ADLs

c) Evaluation and strengthening of the upper extremities d) Work simplification and energy conservation

d) Work simplification and energy conservation e) Evaluation of the need for adaptive equipment f) A i t i d ti l i ti iti

f) Assistance in adapting leisure activities

g) Education in stress management and relaxation techniques

techniques

• ADL evaluation and training to increase functional endurance

– Dyspnea Æ Limited activity Æ Disuse Æ Muscle wasting – 評估患者執行日常生活時的呼吸型態，不當的呼吸型

態 態：

• 憋氣、淺而快的呼吸、聳肩呼吸

U l i l O S （血氧飽和度）

– Use pulse oximetry to evaluate O ₂ Sat （血氧飽和度）

– O2 Sat < 90%

f i h i i

• Use of oxygen with activity

• Breathing techniques

(1) Pursed Lip Breathing (噘嘴呼吸) (1) Pursed Lip Breathing (噘嘴呼吸)

• Breathe in through your nose.

• With lips pursed exhale air slowly With lips pursed, exhale air slowly.

• Try to take twice as much time to exhale as it did to inhale (呼1吸2)

to a e (呼 吸 )

(2) diaphragmatic breathing (腹式呼吸) 腹式呼吸

– Sit in a relaxed position preferable with feet elevated – Place your hand on your abdomen.

– As you inhale through your nose, try to feel your stomach push out as your lungs fill with oxygen. (鼻子吸氣，感覺胃部向外)

– Next, feel your stomach go down as you slowly breathe out through pursed lips. (噘嘴吐氣，感覺胃部向下)

– Continue to repeat this process until you become comfortable doing it p p y g

– Stop the diaphragmatic breathing if you become lightheaded or fatigued.

B thi T h i

• Breathing Techniques

– sitting in a relaxed position preferably with feet elevated

elevated

– try using techniques while doing pleasant activities, after well practice

fi ll t i f th t h i hil d i

– finally try using one of these techniques while doing a task that is difficult, such as stair climbing

• 職能治療師的工作： 職能治療師的工作

– 教導COPD個案執行日常生活時，能應用正確的呼吸方 式

使用吸塵器 推出時 氣 拉入時 氣

– 使用吸塵器，推出時____氣，拉入時____氣

– 舉重物時，要____氣

• Upper extremity function

– COPD個案，往往會用聳肩動作以代 常 償呼吸，因此執行上肢活動時，經常 出現困難。

U/E t th i – U/E strengthening

• 有助於：

– Improve QOL Improve QOL

– reducing requirement of U/E activity

• Theraband, arm ergometer, strengthening t h i

technique

T f l t ti

• Type of muscle contraction

– Concentric

• Muscle shortens to move a limb section in the direction of the muscle pull

– Eccentric

• Contracted muscle lengthens to act as Contracted muscle lengthens to act as brake against an external force to allow for a smooth controlled movement

– Isometric

• The length of a contracted muscle remains the same

• Hypertension cardiovascular Hypertension, cardiovascular problems

– Isometric contraction should be avoided

• Work simplification and energy conservation

– Avoid hot humid bathing

• Use shower chair, terry robe

– Powered equipments

• Electric toothbrush

– Avoid bending

B di t ti h l ti h l

• Bending over to tie shoes ~ elastic shoe laces

• Put on pants ~ long-handled shoe horn

– U/E supported in ADLs – U/E supported in ADLs

• Support arm during hair combing or shaving