PR1 Flashcards
Joint statement by the American thoracic society and European respiratory society 2006 – definition of pulmonary rehabilitation
-Evidence based
-Multidisciplinary
-Comprehensive intervention for patients with chronic respiratory disease
-Symptomatic
-Decrease daily life activity
-ID tx of the pt
Pulmonary rehabilitation is designed to
- Reduce symptoms
- Optimize functional status
- Increase participation
- Reduce healthcare cost by stabilizing or reverse and systemic manifestations of the dz
Why do we care about PR?
-ChronicPulmonary disease impact
- 12 million people diagnosed with COPD
- COPD is the third leading cause of death in the US
Third leading cause of death in the US is?
COPD
Demonstrated outcomes
Reduce symptoms, dyspnea, fatigue
- Increase exercise performance
-Increase knowledge of dz and mgmt.
- Increased ability to perform ADLs
- Improve health related quality of life
-Reduce hospitalizations use of medical resources
- Improve psychosocial symptoms, anxiety, depression
-Pt may be able to return to work
Candidates for rehabilitation, PR
Patience with functional limitations affecting quality of life.
COPD
Interstitial disease
Cystic fibrosis
PAH
Bronchiectasis
Asthma
Thoracic cage abnormalities
Each state has his own pulmonary function criteria for reimbursement for admissions to PR program.
Patient selection for PR
Consider for any patient with chronic respiratory disease
Continues to have symptoms
Reduce performance
Decrease health related quality of life despite otherwise optimal medical management
Patient selection, common morbidities which can benefit from PR interventions
Peripheral muscle disease
Cardiac dysfunction
Nutritional abnormalities
Psychosocial maladaption
Patient selection, Benefit
gain regardless of age sex lung function or smoking status
Peripheral muscle weakness is positive predictor of successful outcome
Severe nutrition depletion associated with poor response
Patient selection, selection Criteria
Abnormal pulmonary function test
Symptoms, dyspnea
Reduction in physical activity
Reduction and occupational performance
Reduction in ADLs
Increase in medical resource consumption
Patient selection symptoms and functional limitations become apparent with one or more of the following objective abnormalities
FEV1 < 80% predicted
FEV1% < 70% predicted
DLCO adjusted for Hb <OR = to 65% predicted
Exercise testing demonstrated hypoxemia < OR = 90%, Ventilatory limitation = OR > 0.8, or a raising ratio of dead space to tidal volume.
Conditions appropriate for PR
Obstructive
COPD
persistent asthma
bronchiectasis
cystic fibrosis
bronchiolitis obliterans
Dz appropriate for PR
Restrictive disease
Interstitial disease
chest wall disease
neuromuscular disease
Restrictive diseases appropriate for PR
Interstitial diseases
Interstitial fibrosis
Occupational or environmental lung disease
Sarcoidosis
Restrictive diseases appropriate for PR
Chest wall diseases
Kyphoscoliosis
Ankylosing spondylitis
Restrictive diseases appropriate for PR
Neuromuscular diseases
Parkinsons disease
Post-polio syndrome
Amyotrophic lateral sclerosis, ALS
Diaphragmatic dysfunction
Multiple sclerosis
Post-tuberculosis syndrome
Other conditions are perfect for pulmonary rehab
Lung cancer
primary pulmonary hypertension
before and after Thoracic & ab surgery
Before and after lung transplantation
Before after LVRS
Ventilator dependency
Pediatric pt with respiratory dz
Obesity related respiratory dz
Keys to success: Patient selection, patient motivation
Selection process considerations Patient motivation, hard to assess
Commitment and participation to the program
Patient initially resistant can be “converted”, and show great improvement
Exclusions that may contradict PR
Significant orthopedic, neurologic or Psychiatric problems—> Prohibit ability or cooperation with physical training
Unstable cardiac dz
Severe pulmonary hypertension
Comorbidities Dash medical Director/rehab team looks at during initial
Patient assessment
Initial patient assessment
Initial patient assessment basis
Interview
Medical history and physical exam
Diagnostic test
Symptom assessment
Exercise assessment
Pain assessment
ADLs assessment
Nutritional assessment
Educational assessment
Psychosocial assessment
Patient interview includes
Info from the patient
Describes PR process
Discuss his patients concerns/goals
Goal development
Assessment set foundation for individualized and comprehensive pulmonary rehab program
- Short and long-term goals are formulated and reflected in treatment plan
- Goal surrealistic and compatible with underlying disease
Patient must understand goals and agree to work toward attaining goals
Medical history
Much obtained from patient records, comorbid conditions have direct bearing on health well-being in progress, what are components of medical history?
Physical assessment
Simple, noninvasive evaluation of patient, modern chain and following of patient’s progress, chest exam, measure and evaluate vital signs, use of accessory muscles, clothing, edema, other signs of heart failure, pulse ox at rest and with exercise.
Diagnostic test
ID patience disease,
establish a baseline of current clinical status,
help to evaluate outcomes,
what are essential test?,
What are test to consider for selected patient?
Symptom assessment
Dyspnea and fatigue a primary symptoms
Onset, quality, quantity, frequency and duration
What are irritating factors?
Dyspnea is overriding symptom and usually reduces PR.
Disney is usually rated with 10 point Borg scale of using analog scale.
What are other symptoms?
Muscloskeletal/exercise assessment
Pt exercise tolerance?
Physical limitations?
Supplemental oxygen requirements?
Establish baseline the assessment
Orthopedic limitations
Restrictions requiring modifications
Pain assessment
Assess
Location
duration
intensity
character
What aggravates pain
ADLs Assessment
Dyspnea Dec ADLs
-Functional task performance & work environment demands should be assessed, est. baseline
- Interview others for complementary information
- What info am be obtained in this assessment?
Nutritional Assessment
- Pts Significant alterations in nutritional status and body composition
- Chronic disease caused increased energy expenditure during breathing, increased caloric needs
- 40 to 60% of COPD patience, in adequate nutrition
- Weight gain results of inactivity and medications
- What should be included in assessment?
What is the significant, independent predictor of mortality?
In adequate nutrition in COPD patients, 40 to 60%
Patients that have weight gain from inactivity and medication as well also experience what?
Increase work of breathing and shortness of breath
Educational assessment
Pt know about their disease and how to cope?
What should be included in an education assessment?
-Part of PR, along with log of documentation.
Patience learn about their disease and how to cope in the education plan
Pretest to provide baseline for evaluating change and knowledge and method of documenting outcomes
Psychosocial assessment
- Screening questionnaire is to assess anxiety and depression
- Failure to detect presence of dysfunction may result in poor progress in rehab
- Patients with significant problems can be referred for further eval/treatment
- What items should be included in this assessment?
Goal development
- Shared include short and long-term patient goals
- Formulate goals with patient
- Patient should have a clear understanding of goals and agreed to work toward attaining goals
Example of formulating goals for the patient
Return to work, care for family, walked in mailbox, better understanding of disease
The cornerstone of PR is
Assessment
The best outcome and effectiveness a PR is?
Assessment
Assessment can also prevent?
Potential complications of chronic disease
Potential complications of chronic disease can be prevented by?
Assessment
Assessment is the cornerstone to?
Best outcomes and effectiveness of PR
Assessment can prevent
Potential complications of chronic disease
