Saturday, April 13, 2013

Sharon L. Balkenhol, RN, MSN, CNS, APN

Manager, Pulmonary Rehabilitation

Jewish Hospital, Cincinnati, Ohio

What is Pulmonary What is Pulmonary

Rehabilitation – a Rehabilitation – a Patient’s Perspective?Patient’s Perspective? “Pulmonary rehabilitation has been a life-saving pathway between inactivity and activity, isolation and socialization, depression and hope, and from being an observer of life to an active participant.”

1994 Graduation class of The Pulmonary Rehabilitation

Program at Mt. Diablo Medical Center, Concord, CA

ATS Definition of ATS Definition of Pulmonary RehabilitationPulmonary Rehabilitation

“…“…a multidisciplinary program of care a multidisciplinary program of care for patients with chronic respiratory for patients with chronic respiratory

impairment that is individually impairment that is individually tailored and designed to optimise tailored and designed to optimise each patient’s physical and social each patient’s physical and social

performance and autonomy.”performance and autonomy.”

What is Pulmonary What is Pulmonary Rehabilitation?Rehabilitation?

A comprehensive service designed for those who experience lung problems

Monitored, supervised exercise

Education about your lung disease/condition

Psychosocial support, stress management, and coping strategies

What Does Pulmonary What Does Pulmonary Rehabilitation Do??? Rehabilitation Do???

Helps patients break Helps patients break

out of theirout of their

““emotional emotional straightjacketstraightjacket””

Why Do I NeedWhy Do I Need Pulmonary Rehabilitation?? Pulmonary Rehabilitation??

For many people, shortness of breath affects every aspect of daily living.

As a result, you may become fearful of physical activity and become less active with increased shortness of breath!

Why Pulmonary Why Pulmonary Rehabilitation???Rehabilitation???

Fear of breathlessness

Reduced exercise tolerance

Inactivity/Immobility

Muscle weaknessFatigue, anxiety, isolation

CHRONIC LUNG DISEASE

↓CO2

↓Lactate

Pulmonary Pulmonary RehabilitationRehabilitation

ACTIVIT

Y

Breathlessness

PulmonaryRehabilitatio

n

Muscle Reconditionin

g

Decreased Leg

Fatigue&

Weakness

Do Do II Need Need Pulmonary Pulmonary

Rehabilitation?Rehabilitation?Do you have a chronic lung disease such as

asthma, emphysema, chronic bronchitis (COPD), LAM?

Because of shortness of breath, is it hard for you to do the things you used to do easily, such as showering, climbing stairs, walking?

Because of your condition, do you find yourself avoiding people and activities you used to enjoy?

Do you have questions or concerns about your symptoms, medications, oxygen, or exercise?

Pulmonary Pulmonary RehabilitationRehabilitation

Are you or someone you know missing the benefits of Pulmonary Rehab?

EXTENT OF THE EXTENT OF THE PROBLEM PROBLEM “ “COPD”COPD”COPD is the 4th leading cause of

death worldwide, yet 75% of those affected remain untreated.

World Health Organization estimates 600 million worldwide have COPD.

Third leading cause of death by 2020 -

2007 there were 124,477 deaths in U.S.

Significant Significant StatisticsStatistics

COPD ranks second as a cause of disability

COPD cost US TOTAL$49.9 billion $29.5 B indirect cost $ 8.0 B indirect morbidity cost $12.4 B indirect mortality cost

How Does LAM Affect Your How Does LAM Affect Your Lungs??Lungs??

CYSTS = oxygen uptake

Traps air

risk of pneumothorax

PNEUMOTHORAX

Effusions

Airway Narrowing

How Will Pulmonary How Will Pulmonary Rehabilitation Help You?Rehabilitation Help You?

Lessen your shortness of breath

Increase your awareness of your capabilities

Improve your strength and endurance

Manage your stress, anxiety and depression

Encourage your sense of well-being and improve your self-confidence

Teach you how to use your medications and oxygen appropriately

Reduce hospitalizations

What are the ComponentsWhat are the Componentsof Pulmonary Rehab?of Pulmonary Rehab?

Initial Assessment

Supervised Progressive Exercise/Activity

Functional and ADL Training

Energy Conservation

Breathing Retraining

Stress Management

Medication Education

INITIAL ASSESSMENTINITIAL ASSESSMENTInterview

Medical History

Symptom Assessment

Nutritional Assessment

Educational Assessment

INITIAL ASSESSMENTINITIAL ASSESSMENT

ADL Assessment

Psychosocial Assessment

Diagnostic Testing

Exercise Assessment

Physical Assessment

Oxygen & ExerciseOxygen & Exercise

Some patients may need oxygen with exercise, even though they do not need it at rest

Patients already on oxygen may need increased flow rates with exercise

Ideally, oxygen saturation (SpO2) should be

= or > 88-90%

Oxygen needs may vary day to day

What Can You Do For Your What Can You Do For Your LAM????LAM????

Healthy Lifestyle

Pulmonary Rehabilitation

Flu Vaccination

Pneumonia Vaccination

NO SMOKING

Physical Activity = “Lifestyle Physical Activity = “Lifestyle Exercise”Exercise”

Any activity that requires bodily movement

Some activity is better than none, more is better than some

The surgeon general’s report recommends that we accumulate a minimum of 30 minutes of moderate intensity activity on most days if not all days of the week

Is Exercise Risky For You?

?????Risk??????????Risk?????Maximal symptom-limited exercise testing is

relatively safe.

Death rate between 2-5/100,000 (1 in 20-50,000) ATS/ACCP Statement on CPET Am J Resp Crit Care Med 2003

Safer than base jumping or pregnancy

Risk of sudden cardiac death during moderate to vigorous exercise in women is 1:35,000,000 hours (4000 yrs)Relative risk vs no exercise is 2.38Long term cardiac risk is reducedWhang et al JAMA 2006

What About What About Pneumothorax and Pneumothorax and

Exercise?Exercise?In CF population

Pneumothorax 0.15% per 1000 patient years.

Injury 0.39% per 1000 patient years

Asthma attack 0.84% per 1000 patient years

Hemoptysis 0.12% per 1000 patient years

Pneumothorax seemed to be associated with coughing.

So What Exercise Should So What Exercise Should You Do???You Do???

Warm–up: HR, lubricates joints,

warms muscles

Cool-down: Prevents muscle soreness & stiffness, lessens chance of lightheadedness & irregular heart rate and reduces risk of bronchospasm

Should be part of warm-up and cool-down

May be done sitting or standing

Helps prevent muscle soreness, joint stiffness, improves balance and posture

Stretching & Stretching & FlexibilityFlexibility

Strength and endurance training improves work capacity (O2 consumption) and reduces metabolic (CO2 production) ventilatory requirements.

Inspiratory Muscle Training -

NO - unlikely to be safe in LAM

Upper Extremity Upper Extremity Training?Training?

Upper Extremity Upper Extremity TrainingTraining

MODALITIES

Arm Ergometer

Rower

Dumbells

Fitness bands

AirDyne Bicycle

Upper Extremity Upper Extremity TrainingTraining

Benefits

Increased strength of arm & shoulder muscles

Increased exercise tolerance

Decreased shortness of breath during ADLs

These muscles provide support to the ribcage - strengthening them can make breathing easier

Lower Extremity Lower Extremity TrainingTraining

MODALITIES

Treadmill

Chair Aerobics

Water Walking/ Aerobics

Walking

Stationary bicycles

NuStep

Elliptical Trainer

Lower Extremity Lower Extremity TrainingTraining

BENEFITS

Strengthens Leg Muscles

Improves Muscle Tone

Increases Flexibility

Patient Education & Training

Patient Education & Training

Normal lung A & P

Pathophysiology of lung disease

Breathing retraining

Airway Clearance

Preventing infection

Medications & oxygen

Exercise principles

Patient Education & Patient Education & TrainingTraining

Activities of daily living & energy conservation

Smoking cessation

Self-assessment & symptom management

Emotional and social well-being

Travel

Nutrition

Control Your Control Your BreathingBreathing

Stop or slow down!

Assume rescue breathing position –sitting –propping your arms on pillows, or leaning against a wall

Use pursed-lip breathing

Relax your shoulders

Use your rescue inhaler

Emotional & Social Emotional & Social Well-BeingWell-Being

Breaking the dyspnea cycle

Coping with depression and anxiety

Learn relaxation techniques

Who Is Eligible for Who Is Eligible for Pulmonary Rehab?Pulmonary Rehab?

Medicare covers pulmonary rehab for those who have had any of the following: COPD Asthma Restrictive pulmonary disease Other chronic lung conditions

Private insurances vary and reviewed and cleared by staff prior to starting a program

What is the cost of pulmonary

rehab?

What is the cost of pulmonary

rehab?

Most charges for outpatient pulmonary rehab are covered by insurance

Staff assist in evaluating coverage and calculating out of pocket costs (if any) prior to starting

“Maintenance” programs are designed to help patients continue their commitment to exercise. These programs are not covered by insurance.

The Pulmonary Rehab The Pulmonary Rehab TeamTeam

Referring Provider (Physician,

Nurse practitioner)Respiratory therapist Registered nurse Physical therapistOccupational therapist Medical DirectorExercise physiologist Supporting staff:

Dieticians/Nutritionists, Social Workers, Psychologists, Pharmacists

Again, Why is Pulmonary Again, Why is Pulmonary Rehabilitation Rehabilitation Important???Important???

Pulmonary Rehab will give you the tools, knowledge, and motivation you need to fight the progression with your “Daily Breath”!

How Do I Find a Quality How Do I Find a Quality Pulmonary Rehabilitation Pulmonary Rehabilitation

Program?Program?

American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR)- “Find a Program”

American Lung Association

Recommendations of physicians, friends

Be Active and Stay Active

Be Active and Stay Active

Go for a walk

Take stairs instead of an elevator

Follow a small child or toddler

Park the car further from the door

Be Active and Stay Be Active and Stay ActiveActive

Do yard work or gardening

Walk the dog

Clean a closet

Go shopping, play miniature golf, dance a little

Questions?????