Lecture 6 , COPD Course Pulmonary Rehabilitation


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Lecture 6 , COPD Course Pulmonary Rehabilitation

  1. 1. Pulmonary RehabilitationLiving With COPD
  2. 2. “ The Downward Spiral ”AirflowlimitationInactivityIsolationDyspneaMuscleImpairmentHyper InflationSevereDyspneaDeconditioningWeight LossDepressionPoor Qualityof LifeMortalityHypoxia
  3. 3. (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 01CAT <10RiskGOLDclassificationofairflowlimitation1234 Assess symptoms first Assess risk of exacerbations next Patient is now in one of four categories:Adapted from GOLD 2013
  4. 4. 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 )
  5. 5. 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
  6. 6. 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.
  7. 7. 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
  8. 8. Basic PR Equipment: Pulse oximeter BP cuff/monitor Stethoscope Treadmill Stationary Bike NuStep Weights Upper body ergometer Theraband Oxygen Emergency
  9. 9. 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
  10. 10. Lung Volume Reduction Surgery:
  11. 11. 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!
  12. 12. PR Patient Goals: Individual treatment plan Integrate prevention and long-term adherence Increase strength, endurance, exercise Control/alleviate symptoms Decrease anxiety/depression Train-Motivate-Educate Improve QOL Reduce economic burden
  13. 13. 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
  14. 14. 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
  15. 15. Physical Assessment: Vital signs Breathing pattern Accessory muscle use Chest exam Signs of heart disease Finger clubbing 02 saturation Upper and lower extremity evaluation
  16. 16. Diagnostic Tests - Essential Spirometry 02 saturation at rest/exercise CXR EKG Six Minute Walk Screening for anxiety and depression
  17. 17. Diagnostic Tests: Complete PFT CPET Sleep study Alpha-1 antitrypsin CV testing Bone density Skin tests Sinus x-rays NPO
  18. 18. Six Minute Walk Test:Determines how far a patient walks in sixminutesPremeasured - hallway or trackRecord: distance walked, number of rest stops,can monitor HR and 02 satClinical practice guidelines- ATSIs useful in determining exercise prescription /supplemental oxygen
  19. 19. Symptom Assessment:Dyspnea – BROGFatigueCoughSputum ProductionWheezeHemoptysisChest PainPost nasal drainageReflux, heartburnEdema: pedal,pretibialDysphagia,swallowing problemsExtremity pain orweakness
  20. 20. Functional Status Assessment:Physical limitationsMuscle strength and enduranceJoint pain, limited ROMOxygen needsDyspneaLack of understanding ofFitness and exerciseFear of exertionInability to pace activitiesBalance abnormalitiesGait instabilityPain levels and locations
  21. 21. Pain Assessment:Assessment should be made during initialevaluation and with daily sessions:▫ Location▫ Duration▫ Intensity - 1-10 or facial descriptor seale▫ Character
  22. 22. 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
  23. 23. ADL Assessment ToolPatient performs 3 minimum, 3 moderate, 3maximum tasks BORG Scale Functional measure of breathing Dyspnea scale Pain Oxygen saturation Heart rate
  24. 24. 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
  25. 25. 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
  26. 26. 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.
  27. 27. RTs and ADL Assessment
  28. 28. 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
  29. 29. Educational Assessment: Knowledge of disease and treatment Hearing Vision Cognitive ability Language Literacy Cultural diversity
  30. 30. 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
  31. 31. 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
  32. 32. 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.
  33. 33. Supplemental Oxygen / Devices Assessment Access Choosing the right device Lifestyle Compliance
  34. 34. Intimacy / Sexuality: More than 67% COPD have problems Frequent problems with relationship, degree ofaffection, communication, level of satisfactionwith partner Sensitive topic - keep it factual
  35. 35. 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, UBErgometerLower body strength training wts, treadmill,bike, NuStep, stairs
  36. 36. Pulmonary Rehab – ExerciseTraining Prescription:
  37. 37. Exercise Program-Stretching:Flexibility exercise refers to stretching, range ofmotion, and movement exercises.Flexibility reduces soreness and risk of muscleinjury.
  38. 38. Exercise Program-ResistanceTraining:Resistance training includes:▫ hand and leg weight exercises▫ wall pulleys, elastic bands, or working againstbody welghr or gravityResistance training improves:▫ Endurance▫ Muscle tone▫ Joint stability and injury prevention▫ Posture▫ Bone density and strength▫ Activity tolerance
  39. 39. Pulmonary Rehab-Water BasedExercise:Evidence-based:▫ Improvement to land basedLane walkingResistance:▫ Kick board▫ Hand paddles▫ Noodles▫ Floatation devices
  40. 40. 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.
  41. 41. Pulmonary Rehab – MeasuringOutcomes:Quality of Life –▫ St. George QOL Questionnaire, SF-36Exercice and Endurance- 6MW, Exercise StressTestStrength- Six Rep MaxActivities of Daily Living functionSmoking CessationNutritionSymptoms - Shortness of Breath
  42. 42. 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