Pulmonary Rehabilitation

Chapter 27


Pulmonary Rehabilitation


Kathryn Patterson



Objectives


Upon the completion of the chapter activities and content review topics, the student should be able to:


1. Identify pertinent interview information that would guide the initial exercise program and the progression of exercise.


2. Perform a 6-minute-walk test (6MWT).


3. Calculate a patient’s target heart rate (THR).


4. Explain and use the dyspnea scale.


5. Explain and use the Borg scale.


6. Instruct a patient on the proper method for pursed-lip breathing (PLB).


7. Instruct a patient on the proper method for diaphragmatic breathing (DB).


8. Instruct a patient on the proper method for active cycle of breathing technique (ACBT).


9. Instruct a patient on the proper method for autogenic drainage (AD).


10. Instruct a patient with a weak diaphragm on the proper method for the use of an inspiratory muscle trainer (IMT).


11. Identify appropriate topics for education.



Key Terms
















Equipment




Pulmonary rehabilitation is an integral part of keeping a patient healthy at his or her home. The respiratory therapist (RT), who strives to keep a discharged patient strong and focuses on helping him or her function at home, must understand the importance of patient education regarding pulmonary rehabilitation. When patients understand the importance of the techniques and activities that will help them get and stay fit, they will successfully return to a functional strength and to a status where activities of daily living (ADLs) are attainable.


Patient goals are developed with the help of the RT. They must be realistic and agreeable to the patient. Some common educational topics discussed in pulmonary rehabilitation are listed in Box 27-1. A clear understanding of these goals and a discussion of progress toward them should involve the patient’s family as well. Examples of goals may be resuming a leisure activity that the patient once enjoyed, returning to work, or participating more in family responsibilities. Teaching patients to recognize how they feel, preparing them to use the tools that help cope with shortness of breath (SOB), and facilitating in rebuilding their strength and endurance are ways that pulmonary rehabilitation can decrease hospitalizations and prevent readmissions. The most common cause of intensive care unit (ICU) readmission is a pulmonary problem. Boxes 27-2 and 27-3 list patient characteristics and risk factors associated with ICU readmissions.



Box 27-1


Common Educational Topics in Pulmonary Rehabilitation




From Hodgkin JE, Celli BR, Connors GL: Pulmonary rehabilitation: guidelines for success, ed 4, St. Louis, 2009, Mosby.



Box 27-2   Patient Characteristics that Can Increase ICU Readmissions


Patient characteristics include:




Box 27-3   Risk Factors Associated with Higher ICU Readmission Rates





image Reality Check Many pulmonary rehabilitation facilities have licensed counselors to help patients cope with social adjustment disorders, depression, or both.


This is important not only for the individual but also for the hospital financially, since Medicare now has a 30-day readmission criterion for reimbursement. Common goals for a pulmonary rehabilitation program are listed in Box 27-4.



Box 27-4


Common Goals for Pulmonary Rehabilitation Programs




From Kacmarek RM, Stoller JK, Heuer AJ: Egan’s fundamentals of respiratory care, ed 10, St. Louis, MO, 2013, Mosby.



image Reality Check Reimbursement issues are a hot topic in pulmonary rehabilitation. It is a service covered by Centers for Medicare and Medicaid Services, but conditions and outcomes must be met. The 30-day readmission criterion may cause refusal of payment on a readmission within 30 days of discharge if the admission diagnosis is related to the previous admission.


In the case of chronic obstructive pulmonary disease (COPD) as well as other obstructive disorders, pulmonary rehabilitation is an integral part of efforts to decrease repeated admissions and save both patient health and medical costs.


This chapter will cover educational topics such as evaluation tools, breathing techniques, and the use of equipment aids in pulmonary rehabilitation.



Patient Interviewing: Review


When beginning to structure a pulmonary rehabilitation program, you should first determine the patient’s chief complaint related to his or her diagnosis and the duration of this symptom. Even though the patient’s medical history may be provided by the referring physician’s office, interviewing the patient and his or her significant other may enhance your evaluation. Symptoms such as dyspnea, fatigue, cough, sputum production, sleep disturbance, pain, and swelling contribute to the overall picture. Orthopedic concerns, comorbidities, hospitalizations, smoking history, exposure to second-hand smoke, and occupational exposure to noxious substances need to be explored. Outcomes, from the start of the program to the finish, can be measured by providing surveys at the beginning and again at the end of the program. These may include a depression questionnaire and an SOB questionnaire. Outcome may also be estimated “before and after” the 6-minute-walk test (6MWT). These beginning parameters are obtained as part of the intake or interview session.



image Reality Check Immobility during recent hospitalization may lead to decreased muscle mass caused by decreased protein synthesis and muscle catabolism. This may result in lower extremity weakness.


Diagnostic and laboratory tests such as pulmonary function test, electrocardiography (ECG), and arterial blood gas (ABG) analysis are helpful in establishing a patient’s baseline status and ruling out any contraindications. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines for assessing stages of COPD are available on the Internet. They have been updated and published in the Annals of Internal Medicine (see 155:179-191, 2011).



image Reality Check Stage III is commonly associated with referral into Pulmonary Rehabilitation; however, this guideline suggests more study of referral during stage II to improve quality of life and decrease readmissions.


The patient’s medication regimen, oxygen saturation at rest, nutrition, and fluid status must also be evaluated before starting any exercise. Functional status is often assessed using activities of daily living (ADLs). See Tables 27-1 and 27-2 for examples of this assessment. Vaccines are important to protect patients from common infections. If patients are vaccinated, they are less likely to be readmitted with an exacerbation of their underlying pulmonary condition. If their vaccination status is not up to date, provide instructions on how and where to get vaccinated.



TABLE 27-1


Occupational Therapy Multidimensional Functional Assessment*









































































Dimensions of Function Measurement of Dimension and Assessment Goals Evaluation Methods and Tools
Participation Determine impact of health conditions and of social and physical environment on everyday lifestyle, particularly social and productive activities Interview
  Canadian Occupational Performance Measure
  School Function Assessment
  Functional Status Questionnaire
  Identify important activities for performance-based assessment Activity configuration
  Activity checklist
  Environmental assessment
Activity Determine ability to perform specific activities relative to difficulty, assistance needed, duration limits, and outlook on activity Activity analysis
  Metabolic equivalent table
  Rate of perceived dyspnea
  Rate of perceived exertion
  Determine areas of strength that enable performance Functional Independence Measure (FIM)
  Determine which impairments should be evaluated in depth Wee-FIM
  Assessment of Motor and Process Skills
Body functions and structure Determine degree of severity, location, or duration of impairments that impede activities and social participation Endurance: 6- or 12-minute-walk test
Strength: manual muscle test, grip strength
  Determine whether the impairment can be remediated or whether it should be compensated for Range of motion: goniometry
  Oxygen saturation: pulse oximetry
  Determine areas of strength Visual perception, cognitive performance, and motor control tools


image


*Organized according to International Classification of Functioning and Disability (ICF) Dimensions of Function: Participation, Activity, and Body Functions and Structure


Data from International Classification of Functioning, Disability and Health (ICF): http://www.who.int/classifications/icf/en/. Accessed January 2008. (In Hodgkin JE, Celli BR, Connors GL, editors: Pulmonary rehabilitation: guidelines for success, ed 4, St. Louis, MO, 2009, Mosby.)



TABLE 27-2


Metabolic Equivalent Values for Some Occupational Performance Areas
















































































































MET Levels (Oxygen Consumed) [Level of Activity] Self-Care Activities Work and Productive Activities Play and Leisure Activities
1.5–2.0 METS (4–7 mL/kg/min) [Very light/minimal] Eating Desk work Playing cards
Shaving, grooming Typing Sewing
Getting in and out of bed Writing Knitting
Standing    
2–3 METS (7–11 mL/kg/min) [Light] Showering in warm water Ironing Level bicycling (8 km or 5 mph)
Level walking (3.25 km or 2 mph) Light woodworking Billiards
  Riding lawn mower Bowling
    Golfing with power cart
3–4 METS (11–14 mL/kg/min) [Moderate] Dressing, undressing Cleaning windows Bicycling (10 km or 6 mph)
Walking (5 km or 3 mph) Making beds Fly-fishing (standing in waders)
  Mopping floors Horseshoe pitching
  Vacuuming  
  Bricklaying  
  Machine assembly  
4–5 METS (14–18 mL/kg/min) [Heavy] Showering in hot water Scrubbing floors Bicycling (13 km or 8 mph)
Walking (5.5 km or 3.5 mph) Hoeing Table tennis
  Raking leaves Tennis (doubles)
  Light carpentry  
5–6 METS (18–21 mL/kg/min) [Heavy] Walking (6.5 km or 4 mph) Digging in garden Bicycling (16 km or 10 mph)
  Shoveling light earth Canoeing (6.5 km or 4 mph)
    Ice-skating or roller-skating (15 km or 9 mph)
6–7 METS (21–25 mL/kg/min) [Very heavy] Walking (8 km or 5 mph) Snow shoveling Bicycling (17.5 km or 11 mph)
  Splitting wood Light downhill skiing
    Ski touring (4 km or 2.5 mph)


image


MEQ, Metabolic equivalents; mL/kg/min, milliliters of oxygen consumed per kilogram body weight per minute; km, kilometer; mph, miles per hour.


Schell BA, Scaffa M, Gillen G and Cohn ES: Willard & Spackman’s Occupational therapy, ed 12, Philadelphia, 2013, Lippincott, Williams and Wilkins, Inc.


Information regarding respiratory support groups should be offered to your patients. These groups allow patients to share their feelings about their pulmonary problems and their concerns with others and gather useful information that will help them cope with their situation. The Lung Association is a useful resource for finding these groups in the patient’s area. The respiratory support group may provide the patient with long-term support. Better Breathers Clubs (BBCs) are affiliated with the Lung Association, but stand-alone support groups exist as well.



image Reality check Adult education is a complex issue. Most adults are self-directed, rely on past experiences, and learn what they need to know only for real life situations that they can apply immediately. Patient backgrounds are diverse, and the educator needs to be aware of this to provide successful patient and family education.



» Skills Check List


27-1 Performing the 6-Minute-Walk Test


As an RT, you will interview patients entering pulmonary rehabilitation. Information you gather will allow you to structure a program to meet your patient’s specific needs. Performance of the 6MWT may provide a baseline for exercise prescription. Initially, pulmonary rehabilitation may be done in the hospital setting. However, it is typically done on an out-patient basis. Indications and contraindications for the 6MWT are given in Table 27-3. The Borg scale is commonly used to assess dyspnea, perceived level of exertion, and pain. An adaptation of this scale is given in Table 27-4.


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Jun 12, 2016 | Posted by in RESPIRATORY | Comments Off on Pulmonary Rehabilitation

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