Faculty Bibliography

Chronic obstructive pulmonary disease (COPD) is the most common form of primary pulmonary disability. Few effective treatment options exist for it, but recently, lung-volume reduction surgery (LVRS) has been shown to be effective in selected patients with emphysema. Pulmonary rehabilitation is an integral part of the preparation for and recovery from the procedure and has significant benefit in helping to improve the quality of life and conditioning of patients with COPD who undergo LVRS. Overall Article Objectives: (a) To describe the role of pulmonary rehabilitation in LVRS, (b) to understand the components of a comprehensive pulmonary rehabilitation program, and (c) to describe the effects of a pulmonary rehabilitation program

Screening athletes and advising them regarding exercise are parts of the practice of physical medicine and rehabilitation. Being able to recognize athletes at risk of coronary events is an important part of preparticipation screening. Good guidelines have been developed that let physicians proceed with confidence in screening and in recommending testing for athletes at risk. This review provides the recommended guidelines for physiatrists in practice. Overall Article Objectives: (a) To recognize risk of coronary disease in athletes, (b) to identify appropriate screening for people at risk, and (c) to interpret test results in people with coronary disease

Pulmonary rehabilitation includes the rehabilitation of not only patients with respiratory failure in need of ventilatory support but also patients with primary pulmonary disease. New advances in medical management now offer treatment to patients with end-stage emphysema, pulmonary hypertension, and interstitial disease, and the principles of rehabilitation can add both function and quality to the lives of these patients. New surgical approaches and better transplantation outcomes that restore pulmonary function have also been introduced. Rehabilitation professionals need to be aware of these advances and be able to incorporate this knowledge into the practice of rehabilitation medicine. Overall Article Objectives: (a) To identify major categories of pulmonary disease seen in pulmonary rehabilitation, (b) to know appropriate interventions and support for patients with respiratory failure, (c) to describe the new interventions available for end-stage lung disease, and (d) to describe the appropriate pulmonary rehabilitation for people with pulmonary disease

Cardiac rehabilitation includes not only the rehabilitation of people with ischemic heart disease but also those with congestive heart failure, heart transplantation, congenital heart disease, and other conditions. New advances in medical treatment have arisen, and there are new approaches in treatment, including alternative medicine and complementary care. New surgical approaches that help restore cardiac function have also been introduced, and rehabilitation professionals must be aware of these advances and be able to incorporate this knowledge into the practice of rehabilitation medicine. Overall Article Objectives: (a) To identify major categories of cardiac disease, (b) to elucidate appropriate interventions and support for patients with coronary artery disease, (c) to describe the new interventions available for the treatment of cardiac disease, and (d) to describe the appropriate role of cardiac rehabilitation for people with various forms of cardiac disease

OBJECTIVE: To evaluate in an inpatient cardiac rehabilitation program (a phase IB) whether length of stay (LOS), discharge to home, and improvement in physical function differed between patients with lower and higher degrees of functional independence on admission. DESIGN: A retrospective study. SETTING: A public acute long-term care hospital. PATIENTS: All cardiac rehabilitation patients (N = 143) admitted to the hospital from January 1998 through June 1999. Patients were divided into a higher- and a lower-functioning group by using the admission FIM instrument scores above and below the midpoint of 72. Comparisons in LOS, discharge disposition, and functional gains between these 2 groups were then performed. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: FIM scores, FIM change, FIM gains per week, LOS, and discharge disposition. RESULTS: Total FIM scores at discharge were significantly higher than those on admission (25%, P <.0001). The median value of total FIM gains per week was 7.78 with a stay of 17 days and a home discharge rate of 76%. The higher-functioning group (n = 106) differed from the lower group (n = 37) with shorter stay (15 vs 23d, P <.0001), greater FIM gains per week (8.6 vs 4.8, P =.002), and greater likelihood of discharge to home or community (84% vs 54%, P <.001). The average incremental FIM change in each group was the same. In multivariate analysis, both admission (P =.001) and discharge (P <.001) FIM scores were the best predictors of patients' discharge disposition to home. CONCLUSIONS: Admission FIM scores are important predictors for the clinical course and discharge outcomes of cardiac rehabilitation patients, with those with higher admission FIM scores having a shorter LOS and greater likelihood of discharge to home. The admission FIM scores can help to establish realistic goals

STUDY OBJECTIVE: Intermittent positive pressure ventilation (IPPV) can be delivered via various oral, nasal, or oronasal interfaces as an alternative to tracheostomy for up to 24 h of ventilatory support. Nocturnal nasal IPPV is often associated with frequent transient but at times severe oxyhemoglobin desaturations (dSaO2s) and sleep fragmentation. The purpose of this study was to determine if nocturnal mouthpiece IPPV is also associated with dSaO2s and sleep disruption. DESIGN: Twenty-seven postpolio ventilator-assisted individuals (VAIs) using mouthpiece IPPV with little or no ventilator-free breathing time (VFBT) underwent nocturnal oxyhemoglobin saturation (SaO2) monitoring. In addition, 15 underwent nocturnal capnography and 13 underwent polysomnography. RESULTS: Mean nocturnal SaO2 was normal in 22 of 27 and maximum end-tidal PCO2 was normal in 12 of 15 VAIs. Use of lipseal retention for nocturnal mouthpiece IPPV significantly improved blood gas values during sleep. The polysomnography results demonstrated relatively normal sleep efficiency. CONCLUSIONS: Nocturnal mouthpiece IPPV is most effective with lipseal retention. It can provide normal alveolar ventilation and SaO2 during sleep for VAIs with little or no measurable vital capacity or VFBT. Because transient dSaO2s can be eliminated with lipseal retention, it may disrupt sleep less than nasal IPPV

Osteogenesis imperfecta, a rare connective tissue disorder, is known to be associated sometimes with the invagination of the basilar skull. This deformity may disturb respiratory function secondary to brain stem compression and hydrocephalus. In addition, the deformed thoracic cage and fragile ribs make pulmonary care more complicated. A case of 24-year-old man is presented with brain stem compression syndrome secondary to osteogenesis imperfecta congenita with basilar impression. He developed respiratory failure and became tracheostomy positive-pressure ventilator dependent at the age of 21 years. He also suffered multiple skeletal abnormalities and mental retardation, and following the brain stem compression, severe quadriparesis. The patient's condition is stable since he has been using the ventilator and he is currently living in the community

Six ventilator-assisted individuals (VAIs) with spinal muscular atrophy (SMA) are described. All six survived by using intermittent positive pressure ventilation via an indwelling tracheostomy for a mean of 11.7 +/- 17.7 yr despite frequent episodes of mucus plugging and pneumonia. Four of the VAIs also received all nutrition via indwelling gastrostomy tubes because of severe bulbar muscle weakness. Four VAIs used tracheostomy intermittent positive pressure ventilation with their tracheostomy cuffs deflated and could communicate verbally. Five of the six VAIs remained institutionalized from the onset of ventilatory use. Two SMA VAIs survived for 15 and 4 yr, respectively, despite need for ventilatory support since early infancy. All four SMA VAIs who could communicate remained socially active and one, gainfully employed. We conclude that for patients with advanced SMA markedly prolonged survival is possible with ventilatory assistance despite severe respiratory and bulbar muscle dysfunction

Pulmonary complications from impaired airway secretion clearance mechanisms are major causes of morbidity and mortality for post-poliomyelitis individuals. The purpose of this study was to review the long-term use of manually assisted coughing and mechanical insufflation-exsufflation (MI-E) by post-poliomyelitis ventilator-assisted individuals (PVAIs) and to compare the peak cough expiratory flows (PCEF) created during unassisted and assisted coughing. Twenty-four PVAIs who have used noninvasive methods of ventilatory support for an average of 27 years, relied on methods of manually assisted coughing and/or MI-E without complications during intercurrent respiratory tract infections (RTIs). Nine of the 24 individuals were studied for PCEF. They had a mean forced vital capacity (FVC) of 0.54 +/- 0.47L and a mean maximum insufflation capacity achieved by air stacking of ventilator insufflations and glossopharyngeal breathing of 1.7L. The PCEF were as follows: unassisted, 1.78 +/- 1.16L/sec; following a maximum assisted insufflation, 3.75 +/- 0.73L/sec; with manual assistance by abdominal compression following a maximum assisted insufflation, 4.64 +/- 1.42L/sec; and with MI-E, 6.97 +/- 0.89L/sec. We conclude that manually assisted coughing and MI-E are effective and safe methods of airway secretion clearance for PVAIs with impaired expiratory muscle function who would otherwise be managed by endotracheal suctioning. Severely decreased maximum insufflation capacity but not vital capacity indicate need for a tracheostomy

Despite wider application of the use of nocturnal intermittent positive pressure ventilation (IPPV) via nasal access for the management of nocturnal hypoventilation, there continues to be a lack of familiarity with the use of IPPV via the mouth for ventilatory support. Unlike nasal IPPV, which is generally practical only for nocturnal use, up to 24-h mouth IPPV was the key method of noninvasive ventilatory support that permitted the avoidance or elimination of tracheostomy for 257 individuals with acute or chronic ventilatory failure. Mouth IPPV was delivered via commercially available mouthpieces for daytime aid and mouthpiece with lip seal or custom orthodontic interfaces for nocturnal support. The use of mouth IPPV alone or in a regimen with other noninvasive ventilatory aids was reviewed for these 257 individuals. Mouth IPPV was used for nocturnal aid by 163 individuals, 61 of whom had little or no measurable vital capacity or significant ventilator-free breathing time, for more than 1,560 patient-years with few complications. It was also the predominant method of daytime ventilatory support for 228 individuals for more than 2,350 patient-years. We conclude that for individuals with adequate bulbar muscle function but chronic respiratory muscle insufficiency, mouth IPPV can be an effective alternative to tracheostomy. It can significantly prolong survival while optimizing convenience, safety, and communication