PULMONARY REHABILITATION CLINIC PROTOCOLObjectives :1.To improve exercise capacity2. To reduce perceived intensity of breathlessness3. To improve health-related quality of life3. To reduce number of hospitalizations and durations of hospitalizations.4. To reduce anxiety and depression associated with COPD5. To improve arms function by strength and endurance training of upper limbs6. To improve survival7. To enable respiratory muscle training for optimal utilizationParticipants : SKN Medical College, Narhe, Pune1.Department of Respiratory Diseases2.Department of Psychiatry3.Department of Physiotherapy4.Department of Nutrition & DieteticsThe Components:1. The S G Respiratory Questionnaire2. History & Clinical examination3. Laboratory investigation4. Six minute walk test5. Spirometry6. Radiological investigation7. Morbidity assessment8. Medical management9. Psychiatry guidance for smoking cessation10.Physiotherapy11.Nutritional guidanceThe S G Respiratory QuestionnaireIt is in two parts. Part I produces the Symptoms score, and Part 2 the Activity andImpacts scores. A Total score is also produced.Part 1 (Questions 1-7 to assess the patient’s perception of his/her recent respiratoryproblems.Part 2 (Questions 8-14) addresses the patient’s current state (i.e. how they arethese days). The Activity score measures disturbances to daily physical activity.The Impacts score covers a range of disturbances of psycho-social function.Administration of Questionnaire
he questionnaire should be completed in a quiet area, free from distraction and thepatient should ideally be sitting at a desk or table.Explain to the patient why they are completing it, and how important it is forclinicians and researchers to understand how their illness affects them and theirdaily life. Ask him or her to complete the questionnaire as honestly as they can and stressthat there are no right or wrong answers, simply the answer that they feel bestapplies to them.Explain that they must answer every question and that someone will be close athand to answer any queries about how to complete the questionnaire.It is designed for supervised self-administration. This means that the patientsshould complete the questionnaire themselves so family, friends or members ofstaff should not influence the patient’s responses.Once the patient has finished, it is very important that you check the questionnaireto make sure a response has been given to every question, before he/she leaves.If a patient gives an answer you disagree with it is not appropriate to challengetheir response . It is their view of their condition we are interested in – no matterhow strange the response!The following are notes that may help you explain to patients what is required1. In Part 1 of the questionnaire, emphasise to patients that you are interested inhow much chest trouble they have recently. The exact period is not important.We are looking for an impression or perception of health.2. An attack of chest trouble (Part 1, Question 5) is any episode of worsesymptoms that constitutes an attack in the patient’s own judgement. Not just severeattacks as judged by medical staff.3. COPD can vary day-to-day. Part 2 is concerned with the patient’s current state(i.e. on average over ‘these days’), not necessarily just today.4. For Part 1 Question 6, emphasise that you are interested in the number of gooddays that they have had.5. In Part 2, Questions 8 and 14 require a single response, but Questions 9 to 13require a response to every question. It may be worth emphasising this to thepatient.6. Many patients do not engage in physical activity. It is important to determinewhether this is because they do not wish to (in which case the answer would be‘False’) or cannot engage in these activities because of their chest trouble (inwhich case the answer would be ‘True’).7. Responses to Questions 12 and 13 concern limitations due to breathingdifficulties and not any other problems. If the patient does not engage in an activityfor another reason, they should tick ‘False’.ST GEORGE’S RESPIRATORY QUESTIONNAIRE FORCOPD PATIENTS
PART 1 (exact duration/period is not important )Question 1: You have cough on:a. Most daysb. Several daysc. With chest infectionsd. Not at allQuestion 2: You bring up phlegm (sputum) on:a. Most daysb. Several daysc. With chest infectionsd. Not at allQuestion 3: You have shortness of breath on:a. Most daysb. Several daysc. Not at allQuestion 4: You have attacks of wheezing on:a. Most daysb. Several daysc. A few daysd. With chest infectione. Not at allQuestion 5: How many attacks ( in the patient’s own perception, not as judged byany medical personnel )of chest trouble have you had?a. 3 or moreb. 1 or 2 attacksc. NoneQuestion 6: How often ( number ) do you have good days (with little chesttrouble)?a. Noneb. A fewc. Most are goodd. Every dayQuestion 7: If you have a wheeze, is it worse in the morning?a. Nob. YesPART 2 ( overall current condition, not necessarily today )Question 8: How would you describe your chest condition? ( a single response is tobe selected )a. The most important problem I haveb. Causes me a few problemsc. Causes no problemQuestion 9: Questions about what activities usually make you feel breathless.( response necessary to every question )
a. Getting washed or dressedb. Walking around the homec. Walking outside on the leveld. Walking up a flight of stairse. Walking up hillsQuestion 10: More questions about your cough and breathlessness. .( responsenecessary to every question )a. My cough hurtsb. My cough makes me tiredc. I get breathless when I talkd. I get breathless when I bend overe. My cough or breathing disturbs my sleepf. I get exhausted easilyQuestion 11: Questions about other effects your chest trouble may have on you. .( response necessary to every question )a. My cough or breathing is embarrassing in publicb. My chest trouble is a nuisance to my family, friends or neighborsc. I get afraid or I panic when I cannot get my breathd. I feel that I am not in control of my chest probleme. I have become frail or an invalid because of my chestf. Exercise is not safe for meg. Everything seems too much of an effortQuestion 12: Questions about how activities may be affected by your breathing. .( response necessary to every question ; If patient is unable to do the activity due toany other reason than breathing difficulties , the response should be ‘false’ )a. I take a long time to get washed or dressedb. I cannot take a bath, or I take a long timec. I walk more slowly than other people, or I stop for restsd. Jobs such as housework take a long time, or I have to stop for restse. If I walk up one flight of stairs, I have to go slowly or stopf. If I hurry or walk fast, I have to stop or slow downg. My breathing makes it difficult to do things such as walk up hills, carry thingsup stairs, light gardening such as weeding,etc.h. My breathing makes it difficult to do things such as carry heavy loads, dig thegarden, jog or walk at 5 miles per hour, etc.Question 13: We would like to know how your chest trouble usually affects yourdaily life. .( response necessary to every question ;If patient is unable to do theactivity due to any other reason than breathing difficulties , the response should be‘false’ )a. I cannot play sports or gamesb. I cannot go out for entertainment or recreationc. I cannot go out of the house to do the shoppingd. I cannot do houseworke. I cannot move far from my bed or chair
Question 14: Tick the statement which you think best describes how your chestaffects you.( single response is to be selected )a. It does not stop me doing anything I would like to dob. It stops me doing one or two things I would like to doc. It stops me doing most of the things I would like to dod. It stops me doing everything I would like to doThe entire questionnaire has been translated into Marathi by the department ofRespiratory Diseases and then validated by the department of CommunityMedicine.Item weights :Each questionnaire response has a unique empirically derivedweight(Note: the wording is abbreviated from that used in the questionnaire.)PART 1Question 1: I cough:Most days 80.6Several days 46.3With chest infections 28.1Not at all 0.0Question 2: I bring up phlegm (sputum):Most days 76.8Several days 47.0With chest infections 30.2Not at all 0.0Question 3: I have shortness of breath:Most days 87.2Several days 50.3Not at all 0.0Question 4: I have attacks of wheezing:Most days 86.2Several days 71.0A few days 45.6With chest infection 36.4Not at all 0.0Question 5:How many attacks of chest trouble have you had3 or more 80.11 or 2 attacks 52.3None 0.0Question 6: How often do you have good days (with little chest trouble)?None 93.3A few 76.6Most are good 38.5Every day 0.0
Question 7: If you have a wheeze, is it worse in the morning?No 0.0Yes 62.0PART 2Question 8: How would you describe your chest condition?The most important problem I have 82.9Causes me a few problems 34.6Causes no problem 0.0Question 9: Questions about what activities usually make you feel breathless.Getting washed or dressed 82.8Walking around the home 80.2Walking outside on the level 81.4Walking up a flight of stairs 76.1Walking up hills 75.1Question 10: More questions about your cough and breathlessness.My cough hurts 81.1My cough makes me tired 79.1I get breathless when I talk 84.5I get breathless when I bend over 76.8My cough or breathing disturbs my sleep 87.9I get exhausted easily 84.0Question 11: Questions about other effects your chest trouble may have on you.My cough or breathing is embarrassing in public 74.1My chest trouble is a nuisance to my family, friends or neighbours 79.1I get afraid or panic when I cannot get my breath 87.7I feel that I am not in control of my chest problem 90.1I have become frail or an invalid because of my chest 89.9Exercise is not safe for me 75.7Everything seems too much of an effort 84.5Question 12: Questions about how activities may be affected by your breathing.I take a long time to get washed or dressed 74.2I cannot take a bath or shower, or I take a long time 81.0I walk more slowly than other people, or I stop for rests 71.7Jobs such as housework take a long time, or I have to stop for rests 70.6If I walk up one flight of stairs, I have to go slowly or stop 71.6If I hurry or walk fast, I have to stop or slow down 72.3My breathing makes it difficult to do things such as walk up hills, carry things upstairs, light gardening such as weeding, 74.5My breathing makes it difficult to do things such as carry heavy loads, dig thegarden, jog or walk at 5 miles per hour, 71.4Question 13: We would like to know how your chest trouble usually affects yourdaily life.I cannot play sports or games 64.8
I cannot go out for entertainment or recreation 79.8I cannot go out of the house to do the shopping 81.0I cannot do housework 79.1I cannot move far from my bed or chair 94.0Question 14: Tick the statement which you think best describes how your chestaffects you.It does not stop me doing anything I would like to do 0.0It stops me doing one or two things I would like to do 42.0It stops me doing most of the things I would like to do 84.2It stops me doing everything I would like to do 96.7Scoring Algorithm :A Total and three component scores are calculated: Symptoms;Activity; Impacts.Each component of the questionnaire is scored separately.Sum the weights for all items with a positive response.Symptoms component:This consists of all the questions in Part 1. The weights for Questions 1-7 aresummed. A single response is required to each item. If multiple responses aregiven to an item, the weights for the multiple positive responses should beaveraged then added to the sum. This is a better approach than losing the data setand thistechnique was for calculating scores used in the original validation studies forpatients who gave multiple responses. (Clearly a better approach is to prevent suchmultiple responses occurring).Activity component :This is calculated from the summed weights for the positiveresponses to items Questions 9 and 12 in Part 2 of the questionnaire.Impacts component :This is calculated from Questions 8, 10, 11, 13, 14 in Part 2 of the questionnaire.The weights for all positive responses to items in Questions 10, 11, 13 are summedtogether with the responses to the single item that should have been checked(ticked) in Questions 8 and 14. In the case of multiple responses to either of theseitems, the average weight for the item should be calculated.Total score :The Total score is calculated by summing the weights to all thepositive responses in each component.Calculate the scoreThe score for each component is calculated separately by dividing the summedweights by the maximum possible weight for that component and expressing theresult as a percentage:Score = 100 x ( Summed weights from all positive items in that component ÷ Sumof weights for all items in that component)The Total score is calculated in similar way:Score = 100 x (Summed weights from all positive items in the questionnaire ÷ Sumof weights for all items in the questionnaire)
Sum of maximum possible weights for each component and Total:Symptoms 566.2Activity 982.9Impacts 1652.8Total (sum of maximum for all three components) 3201.9 (Note: these are the maximum possible weights that could be obtained for theworst possible state of the patient).CLINICALLY SIGNIFICANT DIFFERENCE IN SGRQ SCOREThe threshold for a clinically significant difference between groups of patients andfor changes within groups of patients is four units. Note this is an indicative value(the threshold is not 4.0). As with all measurements there is biological variation,sampling error and measurement error. Four units is an average value obtained indifferent groups of patients.The following is the Protocol form for patient record –Evaluation as well asManagement.
Patient Record OPD No. : Study Sr No. Name : Age : years Sex : Male Female Address : Contact no. : Occupation : Occupation type : Sedentary □ Moderate □ Heavy □ Social History : No. of family members : No. of earning members : Monthly income of entire family : Chief Complaints Duration in days 1. 2. 3. 4. 5. CHEST SYMPTOMS :COUGH Onset : Sudden / Gradual Duration : Days / Month / year Progression (change in severity of cough since onset ) : increased / decreased/ constant/ fluctuating Nature : Hacking / Barking /Whooping / Bubbling Pattern : Occasional / Regular / paroxysmal
Related to : - Time of day : Morning / Night /throughout the day - Weather : Winter / Summer / Rainy / Change of seasons - Exertion : - Activities : Talking/ Laughing/Deep breathing - Eating: Post Meal - Specific food Items Severity: Not causing any distress/Tiring / interfering with day-to- day activities Sleep disturbed Causing Chest pain Postural relation : (increases in which posture) : Associated Symptoms: Dyspnoea/ Chest Pain / Headache/ Choking / Vomiting/ Syncope SPUTUM Onset: Duration: Days /Month / year Diurnal variation ( more at what time of day) : Mornings/ Evenings/ night/ throughout the day Consistency: Viscous/Watery/ Salivary Amount: Teaspoon/ Table Spoon / Cup / katori Postural relation : (increases in which posture) : Sitting/ supine/prone/ Rt lateral decubitus/ Lt lateral decubitus Appearance: Mucoid / Mucoprulent/ Purulent / Greenish / Black / Rusty Presence of Thick Plugs & Threads : yes / no Presence of foul odor : Yes/ NoWHEEZE: Onset: sudden /insidious
Duration: in days/Month / year Timings( heard when ): Inhaling / Exhaling/ Continuous) Frequency: Throughout the day / Intermittent / Morning/ Night Aggravating factors : With Exercise/ Food / Emotional upsetsBREATHLESSNESS Onset: Sudden / insidious Duration: in days/Month / year Progression:(change in severity of breathlessness since onset ) : increased / decreased/constant/ fluctuating Posture(increases in which): Sitting/ supine/prone/ Rt lateral decubitus/ Lt lateral decubitus Severity of breathlessness: Grade (according to the Medical Research Council Scale)
CHEST PAIN Onset : sudden/insidious Duration: in days/ Month / year Nature : Pleuritic / Muscular/ Nonspecific) Location: Localized / Diffuse; presence of radiation Aggravating factors: With Exercise/ Food / Emotional upsets Relieving factors:HAEMOPTYSIS Onset ( first episode ) Duration : in Days/ Month / year Appearance of blood : Fully Bloody / blood-streaked / Bright red / brown Amount in ml.(Approx): each episode / over 24 hours No. of episodes over last 1 week : Associated symptoms: Vomiting Cough FEVER Onset: Duration: in days / Month / year Nature : Continuous/ Intermittent/ Remittent) Grade: Low /Mod. /High
11. OSA/HS12. Surgery (if yes, which)13. Drug reactions14. AllergiesFamily History: 1.YES 2.NO If yes, Maternal / Paternal1. Diabetes2. Hypertension3. Asthma / Allergic rhinitis4. Tuberculosis5. Malignancy6. Connective tissue diseasePersonal History: 1.YES ; Duration in years. 2.NOSmoking:Alcohol:Tobacco chewing:Other addictions:History of drug intake including current treatment: Drug Dosage Duration188.8.131.52.5.
6.`Physical Examination: Build (Frame) : Small □ Medium □ Large□ Height (cms): Ideal body weight Weight (Kgs): Weight loss(Kgs): In what duration Waist (cms) Hip (cms)BMI : Waist-hip ratioMid-Arm Circumference (cms) Skin fold thickness (mm)Temperature: Pulse: R.R: Blood Pressure: SpO2: PEFR (L/min) :AP diameter (cms) Transverse diameter(cms):AP:Transverse ratio : Chest expansion (cms)Icterus ClubbingCyanosis Pedal edema Skin Spine JVP LymphadenopathySystemic examination:Respiratory System: yes/noAccessory muscles working :Intercostal bulging and ribs horizontals:Widening of subcostal angleLength of extra-thoracic tracheaType of breathingRhythm/patternAuscultation :Cardiovascular System:
Abdomen:Central Nervous System:Laboratory Investigations:Complete Haemogram: Hb (gm %) TLC (cu.mm) DLC P (%) L (%) E (%) M (%) ESR (mm/hr) Platelets (cu.mm)RBS (mg/dl): Serum Calcium Serum proteins Serum albuminRenal function test : B.Urea (mg/dl) S. Creatinine (mg/dl)
Serum C-Reactive proteins Lipid Profile: Sr cholesterol Sr triglycerides Sr LDL Sr HDL Sr VLDL Chest X Ray PA view: Hyperinflation: Collapse: Bulla : Localized air- trapping : Other SPIROMETRY (PRE AND POST BRONCHODILATOR): Pre % pred. Post %pred. %change FVC FEV1 FEV1/FVC PEFR REVERSIBILTY 6 MINUTE WALK TEST DISTANCE (metres) BORG SCALEBorg Scale for perceived dyspnoea after exertion : 0 nothing at all 0.5 very very slight 1 very slight 2 slight 3 moderate 4 somewhat severe 5 severe 6
7 very severe89 very very severe ( almost maximal )10 maximal PRE POST AT HALT PULSE BP RR SpO2 ABG: PH PO2 PCO2 HCO3 ECG: 2D ECHO: Other Investigations : SpO2 Morbidity Grade : 1. Patient symptomatology 2. Spirometric abnormalities 3. Presence of complications The BODE index, 1. FEV1 2. Six-Minute Walk Test 3. MRC Dyspnea Index
4. Body Mass Index (BMI) Total score :Medical Management now advised i. Inhaled medications ii. Oral medications iii. Vaccines to prevent infective exacerbations iv. Anabolic steroids v. Anti-oxidants vi. Domiciliary Oxygen vii. NIV support vi. Others
Psychiatry Guidance for Smoking CessationFagerstrom’s Test for Nicotine dependence1. How soon after you wake up do you smoke your first cigarette ? After 60 minutes (0) 31-60 minutes (1) 6-30 minutes (2) Within 5 minutes (3)2. Do you find it difficult to refrain from smoking in places where it isforbidden ? No (0) Yes (1)3. Which cigarette would you hate most to give up ? The first in the morning (1) Any other (0)4. How many cigarettes per day do you smoke ? 10 or less (0) 11-20 (1) 21-30 (2) 31 or more (3)5. Do you smoke more frequently during the first hours after awakening thanduring the rest of the day ? No (0) Yes (1)6. Do you smoke even if you are so ill that you are in bed most of the day ? No (0) Yes (1)
INTERPRETATION GUIDELINES :SpirometryObstruction is defined as e/o increase in FEV1 by >200 ml as well as 12% abovepre-bronchodilator levels.Staging is on the basis of post-bronchodilator valuesStage 1 : Mild : FEV1/FVC % < 70 FEV1 > 80% predictedStage 2 : Moderate : FEV1/FVC % < 70 50% < FEV1 < 80% predictedStage 3 : Severe : FEV1/FVC % < 70 30% < FEV1 < 50% predictedStage 4 : Very Severe : FEV1/FVC % < 70 FEV1 < 30% predicted or FEV1 < 50% pred. with chronic respiratory failureNormal FEV1/FVC is always above 70 %.Six Minute Walk TestStandardisation of the six-minute walk test (6MWT) is very important.At the commencement of pulmonary rehabilitation, the 6MWT must be performedon two occasions to account for a learning effect. Please note that:• The best distance walked in metres is recorded.• If the two tests are performed on the same day, at least 30 minutes rest should be allowed between tests. Debilitated individuals may require tests to be performed on separate days, preferably less than one week apart.• The walking track should be the same layout for all tests for a patient: o The track may be a continuous track (oval or rectangular) or a point-to-point (stop, turn around, go) track. o The track should be flat, with minimal blind turns or obstacles. o The minimum recommended length for a centre-based walking track is 25m and could be marked in metre increments. Note: If you do not have access to a 25m track, make sure you use the same track for all tests and be aware that the distance walked may be less due to the patient having to slow down and turn more often in the six minutes.Before the 6MWT
• Ensure that you have already obtained a medical history for the patient and have taken into account any precautions or contraindications to exercise testing.• Instruct the patient to dress comfortably, wear appropriate footwear and to avoid eating for at least two hours before the test (where possible or appropriate).• Any prescribed inhaled bronchodilator medication should be taken within one hour of testing or when the patient arrives for testing.• The patient should rest for at least 15 minutes before beginning the 6MWT.• Record: o Blood pressure. o Heart rate. o Oxygen saturation. o Dyspnoea score.* o * Note: Show the patient the dyspnoea scale (i.e. Borg scale) and give standardised instructions on how to obtain a score.Instructions for the 6MWTInstructions and encouragement must be standardised. Tip: Put the instructions on a laminated card and read them out to each patient.Before the TestDescribe the walking track to the patient and then give the patient the followinginstructions:"You are now going to do a six-minute walking test. The object of this test is towalk as quickly as you can for six minutes (around the track; up and down thecorridor etc… depending on your track set up) so that you cover as much ground aspossible.You may slow down if necessary. If you stop, I want you to continue to walkagain as soon as possible. You will be regularly informed of the time and you will
be encouraged to do your best. Your goal is to walk as far as possible in sixminutes.Please do not talk during the test unless you have a problem or I ask you aquestion. You must let me know if you have any chest pain or dizziness.When the six minutes is up I will ask you to stop where you are. Do you have anyquestions?"Begin the test by instructing the patient to:“Start walking now.”During the TestMonitor the patient for untoward signs and symptoms.At the End of the 6MWT• Put a marker on the distance walked.• Seat the patient or, if the patient prefers, allow to the patient to stand. Note: The measurements taken before and after the test should be taken with the patient in the same position.• Immediately record oxygen saturation (SpO2)%, heart rate and dyspnoea rating on the 6MWT recording sheet.• Measure the excess distance with a tape measure and tally up the total distance.The patient should remain in a clinical area for at least 15 minutes following anuncomplicated test.Normally the clinician does not walk with the patient during the test to avoid theproblem of setting the walking pace. The pulse oximeter should be appliedimmediately if the patient chooses to rest, and at completion of the six-minutewalking period. Any delay may result in readings being recorded that are notrepresentative of maximum exercise response.If the Patient Stops During the Six Minutes• Allow the patient to sit in a chair if they wish.
• Measure the SpO2% and heart rate.• Ask patient why they stopped.• Record the time the patient stopped (but keep the stop watch running).• Give the following encouragement (repeat this encouragement every 15 seconds if necessary): “Begin walking as soon as you feel able.”• Monitor the patient for untoward signs and symptoms.Stop the Test in the Event of Any of the Following• Chest pain suspicious for angina.• Evolving mental confusion or lack of coordination.• Evolving light-headedness.• Intolerable dyspnoea.• Leg cramps or extreme leg muscle fatigue.• Persistent SpO2 < 85%.• Any other clinically warranted reason.Predicted Normal Values for the 6MWT• Predictive equation for males: 6MWD(m) = 867 – (5.71 age, yrs) + (1.03 height, cm)• Predictive equation for females: 6MWD(m) = 525 – (2.86 age, yrs) + (2.71 height, cm) – (6.22 BMI).6MWT as an Outcome MeasureThe change in the distance walked in the 6MWT can be used to evaluate theefficacy of an exercise training program or to trace the natural history of change inexercise capacity over time.The minimum important difference (i.e. improvement) in the distance walked in a6MWT has traditionally been estimated as 54 metres (Smaller improvements in 6MWT distance may occur in patients who walk a veryshort distance (eg less than 200 metres) in their 6MWT before pulmonaryrehabilitation. For these patients, it may be more reasonable to evaluate efficacybased on the percent change rather than a change in a set number of metres. Achange of 10% has been suggested as clinically important in COPD.
Laboratory ParametersHaematocrit : <35% bad survival prognosis 35-55% Moderate survival prognosis >55% good survival prognosisSpO2Arterial Blood Gases : ( by Definition, PaO2 < 60mm Hg with or without PaCO2 >50mm Hg when breathing room air is respiratory failure )Serum Erythropoietin levelsGrading of morbidity :1. Patient symptomatology2. Spirometric abnormalities3. Laboratory & Radiological Parameters4. Presence of complications5. Presence of Co-morbidities The BODE index, a simple multidimensional grading system, is better than theFEV1 at predicting the risk of death from any cause and from respiratory causesamong patients with COPD( a good prognostic indicator ). Scoring: Add each of 4 criteria scores for total from 0-10 points 1. FEV1 1. Points 0: FEV1 >64% 2. Points 1: FEV1 50-64% 3. Points 2: FEV1 36-49% 4. Points 3: FEV1 <36% 2.Six-Minute Walk Test 5. Points 0: Walks >349 meters 6. Points 1: Walks 250-349 meters 7. Points 2: Walks 150-249 meters 8. Points 3: Walks <150 meters 3.MRC Dyspnea Index 9. Points 0: Dyspnea Index 0-1 10. Points 1: Dyspnea Index 2 11. Points 2: Dyspnea Index 3 12. Points 3: Dyspnea Index 4-5
4.Body Mass Index (BMI) 13.Points 0: BMI >21 14.Points 1: BMI 21 or less Interpretation Higher BODE scores correlate with an increasing risk of deathInterpretation of BMI :BMI Classification Results<16 Severe16-17 Moderate17-18.5 Mild18.5-20 Marginal20-25 Normal25-29.9 Grade 1 obesity30-40 Grade 2 obesity>40 Grade 3 obesityInterpretation of Waist-Hip ratio :Normal Male 1 Female 0.85Interpretation of Triceps skin-fold thickness14. Psychiatric guidance for Smoking CessationFagerstrom’s Test for Nicotine DependenceInterpretation of the scores0.2 very low dependence
3.4 low dependence5 medium dependence6-7 high dependence8-10 very high dependence