Anti-tussivestussives

Transcription

1 PULMONARY REHABILITATION IN COPD WHAT DO WE OFFER ROUTINELY? Treatment of exacerbation Treatment of heart failure Treatment of infection Maintainance pharmacotherapy Domicillary oxygen Help for smoking cessation DO WE NEED TO GO ASTEPAHEAD? AHEAD LESSON LEARNT FROM A QUESTIONNAIRE Can you do following activities? Taking bath changing clothes going for a walk going for shopping/ movie Can you do following? Having sexual intercourse climbing hill playing football LESSON LEARNT FROM A QUESTIONNAIRE Which statement best describes your present status? 1. I can do nothing that I desire 2. I can do few things that I desire 3. I can do most things that I desire 4. I can do everything that I desire PULMONARY REHABILITATION It is an art of medical practice wherein an individually tailored, multidisciplinary program is formulated which through accurate diagnosis, therapy, emotional support and education; stabilizes or reverses both the physio and psychopathology of pulmonary diseases and attempts to return the patient to the highest possible functional capacity allowed by his pulmonary handicap and overall life situation. 1

2 SETTINGS Rehabilitation hospital, comprehensive outpatient rehabilitation facility (CORF) The inpatient setting, including medical center, Hospital or day care center Outpatient hospital based clinic Physician s office Alternate or extended care facility Patient s home TEAM MEMBERS Chest physician * General physician * Psychotherapist * Trained physiotherapist p * Psychiatrist Trained respiratory nurse Social worker Dietician Occupational therapist INFRASTRUCTURE Patient education materials Workbooks and videotapes Lung and skeletal models Anatomical posters Stethoscope Manual sphygmomanometer Stopwatch, peak flow meter, spirometer INFRASTRUCTURE Access to laboratory for arterial blood gas analysis supplemental oxygen source Calibrated cycle ergometer or motorized treadmill (measured walking distance may be used if an ergometer or treadmill is not available.) Free-weights or elastic bands Patient s own equipment, e.g., Metered-dose dose inhaler and spacer, nebulizer Emergency plan and supplies Electrocardiogram (ECG) monitoring during exercise, if indicated, and defibrillation and crash cart WHAT PROBLEMS DO WE NEED Airway collapse and dynamic hyperinflation Respiratory muscle dysfunction Diaphragm fatigue Hypoxia, hypercapnoea Skeletal muscle weakness Severe dyspnoea WHAT PROBLEMS DO WE NEED Skeletal muscle dysfunction limb muscle deconditioning Malnutrition Spill over of cytokines Steroid myopathy Frequent hospitalizations Sleep apnoea 2

3 WHAT PROBLEMS DO WE NEED Cardiac impairment cor pulmonale spill over of cytokines effects of smoking effects of age Osteoporosis Malnutrition & loss of lean body mass WHAT PROBLEMS DO WE NEED Social withdrawal Feeling of helplessness Poor effort tolerance Anxiety Guilt Sleep disturbances Dependency Family & financial issues COMPONENTS 1. Assessment of need for pulmonary rehabilitation 2. Optimization of medical treatment 3. Patient education 4. Exercise training 5. Respiratory muscle training 6. Psychological support 7. Outcome assessment ASSESSMENT OF NEED Exercise tolerance: 6MWT, borg scale, MMRC dyspnoea grade Respiratory structure & function: Spirometry, X-ray chest Quality of life: SGRQ, AQLQ Nutritional assessment: anthropometry, lean body mass, bioelectrical impedence analysis Psychological status: beck depression inventory Assess comorbidities: ECG, echo, dexa scan, polsomnography ASSESSMENT OF NEED RELATIVE CONTRAINDICATIONS Unstable angina Acute exacerbation/ infection Metastatic cancer/ renal failure Severe cognitive defects Uncontrolled psychiatric illness Substance abuse Physical limitations poor eyesite, impaired hearing, orthopaedic impairment These may require modification of the pulmonary rehabilitation setting but should not interfere with participation in a pulmonary rehabilitation program. OPTIMIZATION OF MEDICAL TRETMENT Smoking cessation Bronchodilators & ICS: tiotropium, LABA, SR-theophyllins Treatment of cardiac failure Airway care: mucolytics, steam, chest physiotherapy LTOT (long term oxygen therapy) Vaccinations: influenza and pneumococcal Antioxidants Lung volume reduction surgery? Lung transplant? Alpha 1 antitrypsin replacement therapy Anti-tussivestussives 3

4 PATIENT EDUCATION ON THE DISEASE & THE TREATMENT Pulmonary anatomy and physiology including the pathophysiology of lung disease (mucus secretion, dynamic hyperinflation, diaphragm fatigue) Description and interpretation of medical tests, especially spirometry Indications, actions, and side-effects effects of medications including non-prescription products, such as vitamins, over-the-counter medications, and herbal remedies Indications for oxygen, and methods of delivery PATIENT EDUCATION ON SELF MANAGEMENT Self assessment and symptom management. Early recognition of exacerbation Bronchial hygiene techniques Infection control with emphasis on avoidance, early intervention, and immunization Environment control Available medical resources, community services, patient/family support groups Self-management action plan for emergency PATIENT EDUCATION ON QUALITY OF LIFE Nutrition : high calorie, high protein, low carbohydrate diet (role of anabolic steroids?) Sleep disturbances, e.g., g, Insomnia and sleep apnea as they relate to chronic lung disease Sexuality and intimacy Advanced care planning / end of life issues Travel issues Recreation/ leisure activities Stress management LOWER LIMB Walking, treadmill, stationary bicycle, stair climbing, combination Endurance training Strength training 4

5 BENEFITS UPPER LIMB Reversal of deconditioning, increased aerobic enzymes in muscles, decrease in lactate Psychological benefits: motivation, loss of fear of dyspnoea, antidepressant effect Evidence A Arm ergometer, lifting weights Arm elevation, arm cranking Increase in vital capacity, oxygen uptake, better arm work Evidence B VENTILATORY MUSCLE Inspiratory Resistance training VENTILATORY MUSCLE Abdominal breathing VENTILATORY MUSCLE Pursed lip breathing 5

6 VENTILATORY MUSCLE Abdominal muscle training BENIFITS Delay in fatigue Improvement in exercise tolerance Improvement in lung function Delayed onset of respiratory failure Evidence B PSYCHOLOGICAL SUPPORT Loneliness, reduced social support, negative self image, anxiety, depression, defects in cognitive tasks such as attention, verbal tasks, sexual dysfunction % are depressed! Psychological interventions Health behavior interventions Adherence interventions Evidence A FAMILY SUPPORT Stop criticizing. It is too late! We love you, we need you Help for daily activities Supervise medical treatment Involvement in family and social programmes Give simple duties OUTCOME ASSESSMENT EXPECTED OUTCOME Disability measurement: exercise testing, 6MWT, borg dyspnoea scale, MMRC grade of dyspnoea, respi function questionnaire Measurement of handicap & QOL SGRQ, AQLQ, healthcare resource utilization questionnaires IMPROVEMENT OF DYSPNOEA IMPROVEMENT OF EXERCISE TOLERANCE IMPROVEMENT OF QUALITY OF LIFE REDUCTION IN HEALTHCARE UTILIZATION SURVIVAL BENEFIT A A B B B 6

7 Thank You! I declare that the pictures and cartoons used in this presentation do not belong to me. I have used them as a reference only for the purpose of education 7