“ The Downward Spiral ”AirflowlimitationInactivityIsolationDyspneaMuscleImpairmentHyper InflationSevereDyspneaDeconditioningWeight LossDepressionPoor Qualityof LifeMortalityHypoxia
(C)Less symptoms,high risk(D)Moresymptoms,high risk(A)Less symptoms,low risk(B)More symptoms,low riskGOLD 2013Combined assessment of COPDRisk≥201ExacerbationhistorymMRC ≥2CAT ≥10mMRC 01CAT <10RiskGOLDclassificationofairflowlimitation1234 Assess symptoms first Assess risk of exacerbations next Patient is now in one of four categories:Adapted from GOLD 2013
Patient Characteristic SpirometricClassifficationExacerbationsper yearmMRC CATALow RiskLess SymptomsGOLD 1-2 ≤ 1 0-1 < 10BLow RiskMore SymptomsGOLD 1-2 ≤ 1 > 2 ≥ 10CHigh RiskLess SymptomsGOLD 3-4 > 2 0-1 < 10DHigh RiskMore SymptomsGOLD 3-4 > 2 > 2≥ 10Combined COPDassessmentWhen assessing risk, choose the highest risk accordingto GOLD grade or exacerbation historyAdapted from GOLD 2013(one or more hospitalizations for COPD exacerbationsshould be considered high risk )
GOLD 2013(C)(B)(A)(D)124310Ormore2mMRC 0-1CAT<10mMRC 2+CAT10+Risk(GOLDclassificationofAirflowLimitation)Risk(ExacerbationHistory)SymptomsThe treatment recommendations are linked to the 4 new categories A, B, Cand D:COPD Treatment:FIRST CHOICE of Therapy:SABA or SAMAAlternatives: SABA and SAMA, LABAor LAMA(previously mild-moderate)FIRST CHOICE of Therapy:• LABA or LAMA• Alternatives: LABA and LAMA(previously mild-moderate)FIRST CHOICE of Therapy:• LABA/ICS and LAMAAlternatives: LABA and LAMA,ICS/LABA and PDE4 inhibitor,LAMA and PDE4 inhibitor.(previously severe-very severe)FIRST CHOICE of Therapy:•LABA/ICS or LAMAAlternatives:•LABA and LAMA(previously severe-very severe)MRC: Medical Research Council questionnaireCAT: COPD assessment test
Pulmonary Rehabilitation PositionStatement- ATS 2006PR is an evidence-based multidisciplinary, andcomprehensive intervention for patients with chronicrespiratory diseases who are symptomatic and oftenhave decreased daily life activities. Integrated intoindividualized treatment of the patient, PR Is designedto reduce symptoms, optimize functional status,Increase participation, and reduce health care coststhrough stabilizing or reversing systemicmanifestations of the disease.
Pulmonary Rehabilitation Team:• RT - Medication, supplementaloxygen, infection control,airway clearance, diagnostictesting• PT - Strength and Endurance-6 rep max, ROM, exerciseprescription, body mechanics• OT-Activities of Daily Living,relaxation• SIN - Depression, sexualdysfunction, family/socialissues /support• Chaplain - End of Life, family,coping• Dietician - Nutrition• RN - Medication, PhysicalAssessment• MD - H & P, review all testing,plan of care
Basic PR Equipment: Pulse oximeter BP cuff/monitor Stethoscope Treadmill Stationary Bike NuStep Weights Upper body ergometer Theraband Oxygen Emergency
Educational Material / Devices Patient literature / books Lung model Medication devices Oxygen delivery devices Airway clearance devices BORG scale QOL measurement tool Depression scale Intimacy Handout Relaxation Exercises
PR Patient Goals: Breathe easier Be more active Have a better quality of life Take a shower, clean house cook Travel with greater ease Experience fewer hospitalizations Go to a movie Play Golf again!
Patient Selection Criteria for PR: COPD, IFP, Lung Transplant, LVRS, etc. Dyspnea/fatigue with chronic respiratorysymptoms Impaired health related QOL Decreased functional status Difficulty performing ADLs Difficulty with medication regimen
Patient Initial Assessment-Medical History- Respiratory history Active medical problems Surgical/other medical history Family history of respiratory disease Use of Medical Resources Current medications Allergies /drug intolerance Smoking history Occupational, environmental exposures Alcohol / other substance abuse history
Six Minute Walk Test:Determines how far a patient walks in sixminutesPremeasured - hallway or trackRecord: distance walked, number of rest stops,can monitor HR and 02 satClinical practice guidelines- ATSIs useful in determining exercise prescription /supplemental oxygen
Functional Status Assessment:Physical limitationsMuscle strength and enduranceJoint pain, limited ROMOxygen needsDyspneaLack of understanding ofFitness and exerciseFear of exertionInability to pace activitiesBalance abnormalitiesGait instabilityPain levels and locations
Pain Assessment:Assessment should be made during initialevaluation and with daily sessions:▫ Location▫ Duration▫ Intensity - 1-10 or facial descriptor seale▫ Character
Activities of Daily Living (ADL)Assessment: Functional task performance Breathing techniques with ADLs Extremity function Energy Conservation Need for adaptive equipment Food preparation leisure impairment Sexual function Vocational evaluation
Minimal Level of Tolerance: Eating, table top activities, paperwork Grooming (shaving, make-up, brushing teeth,washing dishes, etc.) Simple cooking preparations ( microwave,washing produce, cutting vegetables, etc.) Socializing, talking, laughterActivities performed In a sitting or standing position withoccasional reaching
Moderate Level of Tolerance: Dressing, showering, bathing Light housework, putting away laundry Standing up, sitting down Putting items in cabinets/closetsActivities involving transfers, changing from one positionto another or repeated reaching
Maximum Level of Tolerance: Climbing stairs, bleachers Heavy gardening Car maintenance Heavy household chores Walking distances, mall shopping, out for social..activities Carrying heavy objectsActivities requiring endurance, frequent changes in bodypositions and strength.
Nutritional Assessment: Height and weight Body mass index (BMI) Weight changes Dietary/eating patterns Shop/ food preparation Fluid Intake Alcohol consumption Need for nutritional supplements
Educational Assessment: Knowledge of disease and treatment Hearing Vision Cognitive ability Language Literacy Cultural diversity
Psychological Assessment: Perception of QL and ability to adjust Interpersonal conflict Anxiety and depression Substance abuse Addictive disorders Neuropsychological impairment Sexual dysfunction Motivation for PR
PR Orientation: Introductions - Patients, Team Why am I here? What to expect What is COPD? Communicating with Health Care Providers Can I really Exercise? What, Me Stressed? PR agreement/schedule
Breathing Retraining:Diaphragmatic breathing:1. Sit comfortably and relax your shoulders.2. Put one hand on your abdomen, now inhale slowlythrough your nose, Push your abdomen out whileyou breath in)3. Then push in your abdominal mussels and breathout using your pursed-lip technique, (you shouldfeel your abdomen go down)Note :-Repeat the above maneuver three times and then take a little rest.-This exercise can be many times a day-By doing diaphragmatic breathing you help your lung expand and take in more air.
Supplemental Oxygen / Devices Assessment Access Choosing the right device Lifestyle Compliance
Intimacy / Sexuality: More than 67% COPD have problems Frequent problems with relationship, degree ofaffection, communication, level of satisfactionwith partner Sensitive topic - keep it factual
Pulmonary Rehab – ExerciseTraining: Individualized Plan Patient Safety - use of equipment Exercise Prescription Stretch/Flex Neck, upper body and lower body Upper body strength training wts, resistancebands, UBErgometerLower body strength training wts, treadmill,bike, NuStep, stairs
Exercise Program-Stretching:Flexibility exercise refers to stretching, range ofmotion, and movement exercises.Flexibility reduces soreness and risk of muscleinjury.
Exercise Program-ResistanceTraining:Resistance training includes:▫ hand and leg weight exercises▫ wall pulleys, elastic bands, or working againstbody welghr or gravityResistance training improves:▫ Endurance▫ Muscle tone▫ Joint stability and injury prevention▫ Posture▫ Bone density and strength▫ Activity tolerance
Pulmonary Rehab-Water BasedExercise:Evidence-based:▫ Improvement to land basedLane walkingResistance:▫ Kick board▫ Hand paddles▫ Noodles▫ Floatation devices
Patient Discharge from PR:• Patient and Program Goalsmet?• Medication Profile• Supplemental Oxygen• Six minute walk• Nutritional• Inspiratory muscle training• Six Rep Max• Exercise Stress Test• Post QOL (St. George, SF-36)• Home Exercise Program• Effective use ofcoping/relaxation techniques• Demonstration ofEC/WS/Body techniquesduring activity performancewith breathing techniques• Return toleisure/community/socialactivities and life roles• Re-evaluation of ADL• Family Community Support• Physician ReportAll testing performed during the assessment prior toentering PR is reassessed with patient discharge.
Pulmonary Rehab – MeasuringOutcomes:Quality of Life –▫ St. George QOL Questionnaire, SF-36Exercice and Endurance- 6MW, Exercise StressTestStrength- Six Rep MaxActivities of Daily Living functionSmoking CessationNutritionSymptoms - Shortness of Breath
Benefits of PulmonaryRehabilitation: Reduced respiratory symptoms Increased exercise performance Increased knowledge -disease/management Enhanced ability to perform ADLs Improved health-related QOL Improved psychosocial symptoms Reduced hospitalizations and use of medical..resources Return to work for some patients