Chronic Disease: Emphysema Pathophysiology - Case Study Example

Emphysema case study: Name: Subject: Course: Supervisor: Date of submission: Introduction Emphysema pathophysiology Hutchinson (1994) & Contran, Kumar & Collins (1999) Emphysema (Chronic Obstructive Pulmonary Disease; COPD) is a disease of the respiratory system. It affects the alveoli; causing them to permanently enlarge forcing the capillaries to rupture narrowing the airways leading inhaling difficulties. Consequently, airflow is decreased and there is increase in airway resistance This disease does not have a known cure Copstead & Banasik, 2000, Porth, 2005 and Sundararajan, Balani & packhan, 2010. In this case study, Anthony zdrilic 56 years old suffers from moderate emphysema, hypertension, osteoarthritis and hyperlipidemia with a normal BMI of 24. Literature Review and Discussion COPD test COPD chronic symptoms include exercise intolerance, dyspnoea, wheezing, expectoration and cough which alter quality of life and health. A Health-Related Quality of Life (HRQoL) test is used to find the best exercises for COPD victim although HRQoL test vary significantly. For Anthony, dyspnea grading system will be used. The level of dyspnoea is used to indicate how severe the disease is Rabe, Hurd, Anzueto, Barnes, Buist, Calverley, et al., (2007). Dyspnea scale of the modified medical research council (mMRC) assesses the activities which the client can perform according to Anthony’s subjective information is experiencing dyspnea Grade 1. For Anthony who has moderate emphysema, shortness of breathe which is making the body tire easily; it is advisable to start with less demanding exercises and upgrade as time progresses Hutchinson, 1994. It should be noted that pulmonary rehabilitation in Anthony does not aim at replacing chest physiotherapy; rather it will allow a reduction in the time spent on conventional physiotherapy treatment. (Reid, Geddes, O,Brien, Brooks & Crowe, 2008). Types of exercises A pulmonary rehabilitation meta-analysis training COPD on exercise should only take four weeks (Lacasse, Goldstein, Lasserson & Martin, 2006) hence a good plan has been set for Anthony for four weeks. Anthony will benefit in exercise because; Exercise improves functional ability, exercise tolerance, quality of life and improves breathlessness which Anthony is experiencing (Lacasse, Goldstein, Lasserson & Martin 2006). In addition, Anthony will benefit from raised activity level and learn coping methodologies. Physiotherapeutic intervention for emphysema client like Anthony goes through different treatment phases which involve the breathing excises, respiratory and peripheral muscle training and physical exercise training Langer, Hendriks, Burtin, Probst, Van der schans, Paterson et al., (2009).. Inspiratory Muscle Training There is no clear role played by IMT on COPD patient who are generally strong. However, generally, the COPD patients just like it is with Anthony suffer from weak respiratory muscles. A systematic review conducted by (Shoemaker, Donker & Lapoe, 2009) had very little evidence supporting IMT among the COPD. However, in COPD management plan, the Thoracic Society Recommended incorporation of IMT (O’Donnell, Hernandez, Kaplan, Aaron, Bourbeau, Marciniuk, et al, (2008) this is because based on observational studies and non-randomized trials general exercise training combined with IMT is essential. In addition, IMT has been used in COPD patient, and has been found to improve tolerance in exercise and reduce breathlessness severity, and therefore, will be used in Anthony’s case as well for the same purpose. In the same study, IMT 5 days a week for four weeks was beneficial to the participants (O’Donell et al, 2008). Enhanced aerobic and strength capabilities of extrafusal muscle fibres can only be attributed to trained inspiratory muscles. Therefore, we decided to include inspiratory muscle training within our program, in addition to other aerobic and resistances training due to the hypothesised benefits at a low stress level to Anthony’s body. Hypertension IMT has been found to strengthen the circulatory system as well; the myocardiac muscles and arterial walls exert pressure during IMT due to oxygen and carbon dioxide gas exchanges. Hence, IMT will not only benefit the respiratory system affected with emphysema in Anthony, but also regulate the heart beat Lacasse et al., 2006. Aerobic exercise This is the main exercise in the non-pharmacological treatment excellent tolerated by COPD patients. The training program involves duration, frequency and intensity guidelines (Martin-Valero, Cuesta-Vargas & Labajos-Manzanares, 2010 and Lacasse et al., 2006. Kuys et al., (2011) reported higher adherences to a training program through gaming consoles such as Wii over traditional forms of exercise such as cycling or running. Exercises advised include swimming, stationary cycling and running more than a 200m*3 times per week. Swimming will be applied in Anthony training program because it has been proven to be an effective exercise to clear mucus in the lungs and improve ventilatory function (Zach, Purrer & Oberwaldner, 1981). The remaining aerobic exercises, treadmill and cycling were both chosen as alternative exercises to avoid monotony in swimming adherence (Celli1995), Aerobics short-term physiological alterations on pulmonary function. Ramirez-Sarmiento, 2002 states exercise will block the amiloride-sensitive sodium channels, within the respiratory epithelium of emphysema sufferers. Consequently, in Anthony this could lead to decreased sputum viscosity (mucus which blocks airways), due to reduced sodium production across the epithelium. Long Term physiological alterations of aerobic exercise on pulmonary function Ramirez-Sarmiento, 2002 Patients, who undergo exercise, have reported a decreased level of breathlessness. This is significant because it will improve Anthony’s quality of life which has been affected by emphysema. Resistance training O’shea, Taylor & Paratz, 2004 found that for patients whose peripheral muscles are weak and have dyspnea which is pronounced the best intervention is resistance training. Anthony falls short of breath after little physical activity. Getting tired easily is also a good indicator of low oxygen supply. This exercise was chosen also because it can accompany other pulmonary rehabilitation exercises like aerobics which Anthony will be practicing as well O’shea, Taylor & Paratz, 2004. Arm exercises do increase forces of arm muscles among COPD patients (Epstein, Celli, Martinez, Couser, Roa, Pollock et al., 1997) as well as reducing fatigue and dyspnea which present in Anthony’s case. Osteoarthritis In addition, due to a lot of joint movement patients suffering from osteoarthritis like Anthony will improve on the joint contraction and relaxation. This body movement cause a lot of calories breakdown therefore, Anthony will benefit burning the cholesterol levels. However, hypertensive patients like Anthony have to be monitored as they carry out these exercises to ensure BP remains in the recommended levels (O’Donell et al, 2008). Medication Smoking cessation In Anthony, will be encouraged to quit smoking because, smoking cessation is the only COPD management that reduces lung deterioration McKenzie, Firth, Burdon & Town, (2003) & Talley & O’Connor 2001). Bronchodilator therapy: Celli (1995) is best drug for lung muscle relaxation especially pulmonary rehabilitation training program although does not affect lung deterioration. Acetylcysteine agents: to lower amount of sputum in lungs. Osteoarthritis Vitamin D, K and calcium In addition to micronutrient supplementation, Anthony should Hutchinson (1994), Sambrook & Eisman (2000) & Mckenzie et al., (2003), to replenish bone tone. Although Crimmins (2004), prolonged Vitamin D supplement causes other condition such as diabetes, cataract, and hypertension and weakens bones. Acetaminophen; as pain killer, Hyperlipidemia; Grundy, Cleeman, Merz et al, (2004) Exercise will burn calories and fats hence lowering the raised bad fats in Anthony and lontesin as antihypertensive drug Hutchinson, (1994). Goals Throughout this pulmonary rehabilitation program we have established both longterm and short term goals Short-term goals in Anthony include: Reduce infections Improve nutritional status. Reduce dyspnea in everyday activities. Improve their attitude towards resistance training. Decrease sputum production within the lungs Improve stamina, raise activity level and resume work Reduce pain in the knee joint Long-term goals in Anthony include: Increase responsibility of the patient towards drug compliance and self-care Reduce premature mortality Improve muscle mass to limit deconditioning. Improve bone tone Improve connective muscle strength Lower cholesterol level and increase lean mass Improve functioning of cardiopulmonary Improve inspiratory muscle strength. Improve respiratory functioning. Reduce disease progression Conclusion Emphysema is a chronic illness whose management when followed keenly improves and prolongs the patient’s life quality. Management varies from exercise to drugs and to operation in severe and extreme cases Hutchinson (1994). Anthony will be involved in pulmonary rehabilitation program on diverse set of exercise to improve quality of life in general and reduce monotony. He will also be put on prescribed drugs to reduce symptoms of emphysema. References Celli B.R. (1995) pulmonary rehabilitation in patinets with COPD. Am J Respir crit care med 152: 861-864 Contran R., Kumar V. & Collins (1999). Pathological basis of disease sixth ed. Saunders company; Saunders, Copstead C.L. & Banasik L.J. (2000). Pathophysiology biological and behavioral perspectives. 2nd ed Elsevier: Philadelphia: Crimmins E (2004) Trends in the health of elderly. Annu Rev Public Health 25:79–98 Epstein S.K., Celli B.R., Martinez F.J.,Couser J.I., Roa J.,Pollock M. et al.,(1997). Arm training reduces VO2 and VE cost of unsupported arm exercise and elevation in chronic obstructive pulmonary disease. Journal of Cardiopulmonary Rehabilitation 17(3): 171-177 Grundy S.M., Cleeman J.I., Merz C.N. et al, (2004) Implications of recent clinical trials for the national cholesterol education program adult treatment panel III guidelines. Circulation 110:227 Hutchinson D. (1994). Pulmonary emphysema, BMJ 309: 1244-1245 Kuys, S., Hall, K., Peasey, M., Wood, M., Cobb, R., Bell, S. (2011). Gaming console exercise and cycle or treadmill exercise provide similar cardiovascular demand in adults with cystic fibrosis: a randomised cross-over trial. Journal of physiotherapy, 57, 35-40. Lacasse Y., Goldstein R., Lasserson T.J. & Martin S. (2006). Pulmonary rehabilitation for chronic obstructive pulmonary disease. Conchraine Database of Systematic Reviews 4:4 Langer D., Hendriks, E., Burtin C.,Probst V., Van der schans C.,Paterson W et al., (2009). A clinical practice guideline for physiotherapists treating patients with chronic obstructive pulmonary disease based on a systematic review of available evidence. Clinical Rehabilitation 23(5) 445-62 Martin-valero R., Cuesta_Vargas A.I. & Labajos-Manzanares M.T. (2010). Revision de ensayos clinicos sobre rehabilitation respiratoria en enfermos pulmonares obstructivos cronicos. Rehabilitacion 44(2) 158-166 McKenzie D., Firth P., Burdon J. & Town G. (2003). The COPDX plan: Australian and New Zealand guidelines for management of chronic obstructive pulmonary disease O’Donnell D.E., Hernandez P., Kaplan A., Aaron S., Bourbeau J., Marciniuk D., et al, (2008). Canadian thoracic society recommendations for management of chronic obstructive pulmonary disease. Canadian Respiratory Journal: Journal of The Canadian Thoracic Society 15 Suppl A, 1A-8A O’Shea S.D., Taylor N.F.& Paratz J. (2004). Peripheral muscle strength training in COPD: A Systematic Review. Chest, 126(3), 903-914 Porth M.C. (2005). Pathophysiology concepts of altered health states 7th ed. Lippincott Williams & Wilkins: New York Rabe K.F., Hurd S., Anzueto A., Barnes P.J., Buist S.A.,Calverley P., et al., (2007). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD Executive summary. American Journal of Respiratory and Critical Care Medicine 176(6), 532-555 Ramirez-Sarmiento, A., Orozco-levi, M., Guell, R., Barreiro, E., Hernandez, N., Mota, S., et al., (2002). Inspiratory Muscle Training in Patients with Chronic Obstructive Pulmonary Disease. American journal of respiratory and critical care medicine, 166, 1491-1497. Sambrook P.N. & Eisman J.A (2000). Osteoarthritis prevention and treatment. Med J Aust; 172:226-229 Sundararajan L., Balani J. & packhan S. (2010). Effectiveness of outpatient pulmonary rehabilitation in elderly patient with chronic obstructive pulmonary disease. J Cardiopulm Rehabil Prev. 30:121-125 Shoemaker M.J., Donker S.& Lapoe A. (2009). Inspiratory muscle training in patients with chronic obstructive pulmonary disease: the state of the evidence. Cardiopulmonary Physical Therapy Journal 20(3), 5-15 Talley N.J. & O’Connor S.(2001). Clinical examination- a systematic guide to physical diagnoses, 4th edition. Sydney Zach, M, S., Purrer, B. & Oberwaldner, B. (1981). Effect of swimming on forced expiration and sputum clearance in cystic fibrosis. The Lancet, 318 (8257), 1210 – 1203. Client Details Name: Anthony zdrilic Age: 62 years old Gender: Male Assessment Advice planned actions Resources History Quitline: 131 848 Smoking Yes Stop Heartline: 1300 36 27 87 Diet/nutrition High Fibre, Fruit and Vegetables Balanced diet with poly unsaturated fats like olive oil. High consumption of uncooked vegetable juices and fruit juices, vitamin D,E,C,K and calcium rich sources Directline: 1800 888 236 A 24 hour telephone counselling, information and referral services for drug and alcohol related issues Alcohol Yes Stop Heartline: 1300 36 27 87 Go For Your Life info Line: 1300 73 98 99 Physical Activity minimal Physical Activity 2*15 mins a week Need to perform planned exercise routine with a higher intensity. Depression No osteoarthritis Yes Take diets rich in vitamin D, K and Calcium; expose to low temperature sunlight and acetaminophen Asthma Yes (7-20 years old) Osteoporosis No Examination Bodyweight/BMI weight 71kg, height 172cm, Waist circumference = 86 cm BMI 24 Blood pressure 143/91mmHg Antihypertensive drugs Diabetes None Skin cancer None Moderate emphysema Yes Bronchodilator, Acetylcysteine, broad spectrum antibiotics, oxygen concentrators Tests Lipids LDL 4.2mmol/L , HDL – 1.1mmol/L, Total cholesterol = 6.3mmol/L (high), Avoid saturated fats and do exercise Diabetes Fasting Glucose = 4.1 Mmol/L Cervical Cancer N/A Prostate None Other as appropriate (e.g. colorectal, cancer, breast cancer) None Medical History For emphysema : Bronchodilators although not effective in emphysema as it is in asthma Vitamin D, K and Calcium- prevent or slow arthritis and on general vitamin supplementation to improve the disease condition On hypertensive drugs Pain killers-acetaminophen, myalgia and hyaluronan to relieve knee pain Family History Social History Mother: died at 86 years Smoking: yes Father: Died at 71years of age due to heart attack Smoking: yes General Recommendations (if appropriate): Due to Anthony’s chronic disease (emphysema) it is recommended that he undertake an exercise program under the supervision of an exercise scientist to improve quality of life, reduce symptoms associated with this disease and to increase life expectancy. Summary of 4 week Training Program – in order from left to right Initial phase Central phase Final phase Inspiratory muscle training Warm Up (5 mins) Resistance Training (10 mins) Aerobic Training (30 mins) Cooldown Inspiratory muscle training Nintendo Wii Sunday Rest day Monday A-D* Wk 2, 400m walk Wk4, 400m run Wk 1,3 Star jumps Refer to 'resistance training program' section Treadmill Light jog E-G Wii Sports Tuesday All Exercises Wk 2, 400m walk Wk4, 400m run Wk 1,3,: Star jumps No training Swimming Light jog All exercises Wii Sports Wednesday E-G Wk 2, 400m walk Wk4, 400m run Wk 1,3 Star jumps Refer to 'resistance training program' section Cycling Light jog A-D Wii Sports Thursday Rest day Friday A-D Wk 2, 400m walk Wk4, 400m run Wk 1,3,5,7: Star jumps Refer to 'resistance training program' section Outdoor Run Light jog E-G Wii Sports Saturday All Exercises Wk 2, 400m walk Wk4, 400m run Wk 1,3 Star jumps No training skipping Light jog All Exercises Wii Sports Warm Up Weeks 1, 3 Star Jumps for 5 minutes/ motivational music at the background. Week 2 400m walk at own pace Week 4 400m run at own pace Cooldown for all weeks 5 minute light jog Inspiratory Muscle Training Exercises A: Stretching the muscles of the chest wall 1. Starting Position: Stand up, hands by your sides, palms facing inwards 2. Rotate palms facing forwards 3. Extend arms, and bring arms above the head so hands touch 4. inhale through the nose when rising the hands 5. turn palms outwards, and exhale through mouth as arms move down to starting position 6. Repeat 10 times B: pursed-lip breathing 1. The exercise is performed when lying down with bent knee or sitting on a firm chair. 2. Place one hand on your abdomen and the other on your chest. The hand on the abdomen should be seen rising when breathing and that on the chest remain still. 3. Inhale for 2 seconds through the nose and breathe out for 4 seconds through the mouth as though blowing a candle. 4. Repeat this for 10 times. C: Sniffles (good workout for diaphragm) 1. With mouth closed 2. Breath in and out through nose as quickly as possible 3. Repeat for 10 seconds D: Elbow Circles 1. place hands on shoulders, with elbow pointing laterally, fingertips touching shoulders 2. Rotate elbows in backwards circular motion, keeping the fingers on the shoulders 3. Inhale as elbows are brought up 4. Exhale as elbows are brought down E: Shoulder Shrug 1. Place arms by your side, palms facing forwards 2. Inhale, as shoulders are lifted in front of body, moving towards ears 3. Exhale as shoulders roll back down, towards the back of the body 4. Repeat 10 times, and then do 10 repetitions in opposite direction. F: Bicep curls 1. Using dumbbells sit on a chair which is firm. 2. Slowly lift up the weights with elbows facing your body to above your shoulder as you inhale through the nose and exhale through the mouth. 3. Repeat breathing as you bring down the weights. Remember to breathe in as you relax and out when applying effort. 4. Do this 10 times G: Shoulder press 1. Hold the weights still seated on your shoulder. 2. Take a deep breathe and lift the weight above your head and breathe out through the mouth. 3. Repeat 10 times daily. Resistance training Training for Strength Recommendations Load:≥ 85% Sets: 2-6 Reps: ≤ 6 Rest: 3-5mins Perform a 1RM Submax test RM Testing 1. Select a warm-up load the subject can perform easily for ~8 repetitions without failure Relax for 2-3 minutes 1 Increase the load and let the client perform ~5 repetitions without fail Relax for 2-3 minutes Increase the load and let the client perform ~3 repetitions without fail Relax for 2-3 minutes Repeat with small increments until you are certain that it is a maximal performance. 1. Estimate the subjects 1RM based on the table below Weeks 1-2 Exercise Muscles Load (% 1RM) Sets Reps Rest (mins) Week 1 2 1 2 1 2 Monday Dumbbell Standing Calf Raise Gastrocnemius 85 2 3 3 4 5 5 Dumbbell Reverse Calf Raise Tibialis Anterior 85 2 3 3 4 5 5 Wednesday Lunges Quadriceps 2 3 3 4 5 5 Dumbbell Straight Leg Deadlift Hamstrings 85 2 3 3 4 5 5 Friday Chin ups Biceps 3 3 4 4 5 5 Pull ups Triceps 3 3 4 4 5 5 Weeks 3-4 Exercise Muscles Load (% 1RM) Sets Reps Rest (mins) Week 3 4 3 4 3 4 Monday Inverted Row Back muscles 85 2 3 3 4 5 5 Barbell Shrug Upper Trapzius 85 2 3 3 4 5 5 Wednesday Bench Press Pectoralis Major 85 2 3 3 4 5 5 Sumo deadlift Gluteus Maximus 85 2 3 3 4 5 5 Friday Crunches Rectus Abdominis 2 3 3 4 5 5 Dumbbell One Arm Straight Leg Deadlift Erector Spinea 2 3 3 4 5 5 Aerobic Training Monday: (30 mins). Week Type Location Intensity 1,2,3& 4 Treadmill Gym 50% - 60% HRmax Tuesday: Swimming (30 mins) Week Distance Rest (s) Stroke 1 200m 60 Freestyle swim. 2 250m 60 Butterfly. 3 300m 60 backstroke 4 350m 60 any stroke you want Wednesday: Cycling (30 mins) Week Type Location Intensity 1 Outdoor Bike Riding local park 50% - 60% HRmax 2 Indoor Bike Gym 50% - 60% HRmax 3 Outdoor Bike Riding Near shopping centre 50% - 60% HRmax 4 Indoor Bike Gym 50% - 60% HRmax Friday: Running (30 mins) week Type Venue Intensity 1 Outdoor Run shore of the beach 50% - 60% HRmax 2 Outdoor Run local park 50% - 60% HRmax 3 Outdoor Run To the near shopping centre 60% - 70% HRmax 4 Outdoor Run To the near college/ or high school 60% - 70% HRmax Saturday: Skipping (30 mins). 15 minutes each variation Week 1: Standard Skip Week 2: Standard + feet together Week 3: Running Jumps+ Feet apart Week 4: Double jumps + High knee jumps Nintendo Wii Play 'Wii: Sports' video game according to client’s wish Accredited Exercise Physiologist (ESSA) PhD (ACU) Email: drad.aarons@medical-practice.com Phone: 0473 691325 Medicare provider number: 8275903 B Date: 26/03/2013 Appointment: 23/04/2013 Referring Doctor: ………………. Name: Anthony zdrilic DOB: (04/03/1951) Age 62 years Gender: M Dear Dr. ……………………., Thank you for getting Mr. zdrilic into contact with physiotherapy department for exercise prescription to aid and improve airway capacity and increase life expectancy as well as quality of life related to emphysema. Initial consultation with Mr. zdrilic revealed that he smokes, drink alcohol and has a diet high in fibre and plant foods. Mr. zdrilic takes Bronchodilators drugs, although not effective in emphysema as it is in asthma. Vitamin D, K and Calcium- prevent or slow arthritis and in general he is on vitamin supplementation to improve the disease condition and is on hypertensive drugs. He is also on pain killers-acetaminophen, myalgia and hyaluronan to relive knee pain. He has expressed that these medications helps improve breathing and relieve pain as well as strengthening bone tone of which research has justified his comment. However, due to disease multimordality he is quite unwell for now. As on the date of 26/03/2013 Mr. zdrilic is: Height- 172cm Weight- 71kg BMI- 24kg/m2 Waist circumference- 86cm Resting BP- 143/93mmhg Lipids LDL 4.2mmol/L, HDL 1.1mmol/L Total cholesterol = 6.3mmol/L (high), Fasting blood sugar4.1mmol/L Mr zdrilic was taken through a Health-Related Quality of Life (HRQoL) test which proven that his emphysema condition is now at dyspnea grade 1: This means appropriate exercise will improve his quality of life significantly and be able to resume his normal duties. Mr. zdrilic body measurements shows that he is hypertensive and has hyperlipidemia so the aims of the training program will be targeting aspects of quality of life health for Mr. zdrilic, lower choletsrol level and ensure blood pressure remains at normal level. Desired Outcomes of Exercise Physiology Intervention: Improve inspiratory muscle strength via inspiratory muscle training Increased muscle mass via breathing exercises, lower and upper limb exercise Improve bone health via lower limb exercises and upper limb work outs Reduction in infection frequency and severity via enhanced immune system Decrease dyspnea via aerobic training Improved quality of life through combination of all benefits of intervention. Mr. Zdrilic has received appropriate guidelines for the exercise intervention regarding adequate hydration, especially in regards to salt intake for sweat replacement. Mr Zdrilic has been advised to exercise in immediate access to oxygen supplementation and Mr. Zdrilic’s gym has been advised as to the needs of Mr. Zdrilic. A follow up session was made for the 23/04/2013 to address any issues Mr. Zdrilic has with the training program as well as providing a fully supervised training environment where measurements can be accurately obtained. Exercise program consists of different varieties of moderate intensity aerobic training, respirational training exercise and resistance training exercise. This is complimented by inspiratory training and sessions using an at home interactive workout. A copy of Mr. Zdrilic training program is attached for you to review. If you have any questions feel free to contact the physiotherapy department staff. Signed …………………….. Accredited Exercise Physiologist (ESSA) PhD (ACU) Email: drad.aarons@medical-practice.com Phone: 0473 691325 Medicare provider number: 8275903 B Date: 26/03/2013 Appointment: 23/04/2013 Referring Doctor: ………………….. Name: Anthony zdrilic DOB: (04/03/1951) Age 62 years Gender: M Dear Mr zdrilic, Thank you for your visit and managing to undertake consultation and fitness level evaluation. The measurements that were taken during the session will be used in the formation aims as well as the formation of your exercise plan. This is so you will experience the greatest possible adaptations to help with your immune system, functional capacity, reduce disease progression and quality of life. Below is your measurements versus body composition and physical capacity to have a look at with a comparison to the normal values. Body Composition Measurement Anthony zdrilic Healthy Range Height 175cm n/a Weight 71kg 55-73kg BMI 24kg/m2 18.5-25kg/m2 Waist Circumference 86cm Read More