Pulmonary Rehabilitation 肺康复 许灵玲

Transcription

1 Pulmonary Rehabilitation 肺康复 许灵玲

2 Contents 目录 What s pulmonary rehabilitation? Who are the members of the Interdisciplinary Team? Who benefits from pulmonary rehabilitation? What s the goals of pulmonary rehabilitation? What s the programme of pulmonary rehabilitation?

3 Definitions 定义 Pulmonary rehabilitation, also known as respiratory rehabilitation, is an important part of the management and health maintenance of people with chronic respiratory disease who remain symptomatic or continue to have decreased function despite standard medical treatment. It is a broad therapeutic concept. 肺康复, 又称呼吸康复, 是经过传统的医学治疗后仍然存在主要症状或功能障碍的慢性呼吸道疾病患者健康管理与维持的一个重要组成部分 这是一个广泛的治疗概念

4 Definitions 定义 Pulmonary rehabilitation can be defined as an interdisciplinary programme of care for patients with chronic respiratory impairment that is individually tailored and designed to optimise each patient s physical and social performance and autonomy. Programmes comprise individualised exercise programmes and education 肺康复可以被定义为 : 是一种针对具有慢性呼吸功能障碍患者的量身定制的, 旨在优化患者的身体素质, 社会表现及自主性的多学科的干预方案, 该方案包括个性化的锻炼方案和教育 英国国家卫生与临床优化研究所 National Institute for Health and Clinical Excellence. Chronic obstructive pulmonary disease. Management of chronic obstructive pulmonary disease in adults in primary and secondary care ( partial update) nicemedia/live/13029/49397/49397.pdf (accessed May 2013).

5 Definitions 定义 Pulmonary rehabilitation is a comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies, which include, but are not limited to, exercise training, education, and behavior change, designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence of health-enhancing behaviors. 肺康复是一种在对患者全面评估的基础上为患者量身定做的一种综合多方面干预治疗方案, 包括但不限于运动训练, 教育和行为改变, 旨在改善慢性呼吸道疾病患者的身体和心理状况, 且促进患者长期坚持改善健康行为 - 美国胸科学会和欧洲呼吸学会共识 : 肺康复要点与进展 Spruit MA, Singh SJ, Garvey C, ZuWallack R, Nici L, Rochester C, Hill K, Holland AE, Lareau SC, Man WD, et al.; ATS/ERS Task Force on Pulmonary Rehabilitation. An official American Thoracic Society/ European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med 2013;188:e13 e64

6 Definitions 定义 In general, pulmonary rehabilitation refers to a series of services that are administered to patients of respiratory disease and their families, typically to attempt to improve the quality of life for the patient. 一般而言, 肺康复是指对呼吸道疾病患者及其家属实施的一系列服务, 通常是为了改善患者的生活质量

7 Interdisciplinary Team Pulmonary rehabilitation is implemented by a dedicated, interdisciplinary team, including physicians and other health care professionals; the latter may include physiotherapists, respiratory therapists, nurses, psychologists, behavioral specialist, exercise physiologists, nutritionists, occupational therapists, and social workers. 肺康复是由一个专门的 跨学科的团队实施的, 包括医生和其他医护专业人员 ; 后者可以包括理疗师 呼吸治疗师 护士 心理学家 行为专家 运动生理学家 营养师 作业治疗师和社会工作者

8 Who benefits from pulmonary rehabilitation? 谁能从肺康复计划中获益? 阻塞性疾病 : COPD; 哮喘 ; 支气管扩张 ; 囊性纤维化 ; 支气管炎 限制性疾病 : 间质性肺疾病 ; 间质性纤维化 ; 职业性或环境性肺疾病 ; 高敏性肺炎 ; 急性呼吸窘迫综合征幸存者 ; 胸壁性疾病等 其他肺动脉高压 ; 胸腹部手术前后 ; 肺移植前后 ; 肥胖相关呼吸疾病等 Spruit MA, Singh SJ, Garvey C, ZuWallack R, Nici L, Rochester C, Hill K, Holland AE, Lareau SC, Man WD, et al.; ATS/ERS Task Force on Pulmonary Rehabilitation. An official American Thoracic Society/ European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med 2013;188:e13 e64

9 The goals of pulmonary rehabilitation minimizing symptom burden maximizing exercise performance promoting autonomy increasing participation in everyday activities enhancing (health-related) quality of life effecting long-term health-enhancing behavior change.

10 What s the programme of PR? 患者评估 运动训练 Patient Assessment Exercise Training Program evaluation Patient Education 疗效评估 患者教育

11 Patient Assessment 患者评估 Medical History 病史 Assessing Exercise Capacity 运动能力 Assessing Quality of Life 生活质量 Assessing Shortness of Breath 呼吸急促

12 Assessing Exercise Capacity 运动能力的评估 Reasons for Assessing Exercise Capacity Determine the level of functional impairment and activity limitation. Determine the factors that limit exercise capacity. Provide information that will guide exercise prescription( 运动处方 ). Identify oxygen desaturation ( 氧饱和度 )during exercise and aid prescription of supplemental oxygen( 补充氧 ) during training. Evaluate the effectiveness of rehabilitation in altering exercise capacity and exertional dyspnoea( 运动性呼吸困难 ).

13 Assessing Exercise Capacity The Six-Minute Walk Test (6MWT) 6min 步行测试 The Incremental Shuttle Walk Test (ISWT) 递增穿梭步行试验 The Endurance Shuttle Walk Test (ESWT) 耐力穿梭步行试验

14 6MWT Equipment The equipment needed to conduct the 6MWT is outlined below: At least one chair, positioned at one end of the walking course A validated scale to measure dyspnoea (Modified breathlessness scale) and subjective fatigue Sphygmomanometer for blood pressure measurement 血压计 Pulse oximeter 脉搏血氧计 Stopwatch 秒表 Pre-measured marks along the track/corridor 沿轨道 / 走廊预先测量好的标记 Access to oxygen and telephone in case of an emergency An emergency plan 应急预案 Portable supplemental oxygen if required by patient to perform exercise test Clipboard with reporting sheet and pen 评定表 \6MWT 所需设备清单中文版.pdf

15 Before the 6MWT Ensure that you have already obtained a medical history( 病史 ) for the patient and have taken into account any precautions or contraindications( 禁忌症或注意事项 ) to exercise testing. Instruct the patient to dress comfortably, wear appropriate footwear and to avoid eating for at least one hour before the test (where possible or appropriate). Any prescribed inhaled bronchodilator medication ( 气管扩张药物 )should be taken within one hour of testing or when the patient arrives for testing. The patient should rest for at least 15 minutes before beginning the 6MWT. Record: Blood pressure. Heart rate. Oxygen saturation. Dyspnoea score.* * Note: Show the patient the dyspnoea scale (i.e. Borg scale) and give standardised instructions on how to obtain a score.

16 Instructions for the 6MWT 测试指引 Before the Test Describe the walking track to the patient and then give the patient the following instructions: The aim of this test is to walk as far as possible for 6 minutes. You will walk along this hallway between the markers, as many times as you can in 6 minutes. I will let you know as each minute goes past, and then at 6 minutes I will ask you to stop where you are. 6 minutes is a long time to walk, so you will be exerting yourself. You are permitted to slow down, to stop, and to rest as necessary, but please resume walking as soon as you are able. Remember that the objective is to walk AS FAR AS POSSIBLE for 6 minutes, but don t run or jog. Do you have any questions? 6MWT 测试指引.pdf

17 During the Test Monitor the patient for untoward signs and symptoms. Use the following standard encouragements during the test: 1 min You are doing well. You have 5 minutes to go. 2 min Keep up the good work. You have 4 minutes to go. 3 min You are doing well. You are halfway. 4 min Keep up the good work. You have only 2 minutes left. 5 min You are doing well. You have only 1 minute to go. 6 min Please stop where you are. 评定表 \6MWT 测试指引.pdf

18 At the End of the 6MWT Put a marker on the distance walked. Seat the patient or, if the patient prefers, allow to the patient to stand. Immediately record oxygen saturation (SpO 2 )%, heart rate and dyspnoea rating on the 6MWT recording sheet. Measure the excess distance with a tape measure and tally up the total distance. The patient should remain in a clinical area( 测试地点 ) for at least 15 minutes following an uncomplicated test.

19 Clinical Note Normally the clinician does not walk with the patient during the test to avoid the problem of setting the walking pace. The pulse oximeter should be worn continuously and levels to be recorded at every minute. In some instances, the clinician may choose to walk with the patient for the entire test. If this is the case the clinician should try to walk slightly behind the patient to avoid setting the walking pace. Six-Minute_Walk_Test_Recording_Sheet.pdf

20 If the Patient Stops During the Six Minutes Allow the patient to sit in a chair if they wish. Measure the SpO 2 % and heart rate. Ask patient why they stopped. Record the time the patient stopped (but keep the stop watch running). Once SpO2%>/= 85% give the following encouragement (repeat this encouragement every 15 seconds if necessary). Begin walking as soon as you feel able. 当你觉得可以的话就尽快开始继续步行 Monitor the patient for untoward signs and symptoms. 监测病人的不良症状和体征

21 Stop the Test in the Event of Any of the Following Chest pain suspicious for angina. 胸口痛并怀疑是心绞痛 Evolving mental confusion 精神紊乱 or lack of coordination 协调能力. Evolving light-headedness. 头晕 Intolerable dyspnoea. 无法忍受的气短 Leg cramps 痉挛 or extreme leg muscle fatigue. Persistent SpO 2 < 80%. (In a community setting the test may be stopped if SpO2 < 85%) Any other clinically warranted reason.

22 6MWT as an Outcome Measure The change in the distance walked in the 6MWT: 1) after completion of a pulmonary rehabilitation program can be used to evaluate the effectiveness of the exercise training program; 2)may be used to trace the natural history of change in exercise capacity over time.

23 Incremental Shuttle Walking Test 递增穿梭步行试验 The equipment is very simple, all you need is a CD or MP3 player and two markers placed 9 metres apart.

24 Endurance Shuttle Walk Test 耐力穿梭步行试验 This is a standardised field test for the assessment of endurance capacity 耐力 in patients with chronic lung disease. The test was developed as an adjunct to the ISWT 这项试验是作为 ISWT 的附属品开发的 so that together they form a practical method of assessing both functional and endurance exercise capacity using the same 10 metre shuttle course.

25 Assessing Quality of Life 生活质量的评估 Enhancing quality of life is a central aim of PR programs and is highly valued by patients. Chronic Respiratory Disease Questionnaire 慢性呼吸疾病调查问卷 (CRDQ or CRQ) St George s Respiratory Questionnaire 圣乔治医院呼吸调查问卷 (SGRQ) Medical Outcomes Study Short Form 36 简明健康调查问卷 36 (MOS SF 36) According to Lung Foundation Australia s 2015 national survey of PR programs- the SGRQ and CAT are the most commonly used QoL questionnaires used.

26 Assessing Shortness of Breath 呼吸短促的评估 There are a number of measurement tools available for assessing dyspnoea, including: Modified Medical Research Council (MMRC) Dyspnoea Scale. 医学研究委员会气短测量表 Modified Borg Dyspnoea Scale (0-10). 改良伯格评分量表 MMRCDyspnoeaScale.doc modified_borg_dyspnoea_scale.pdf

27 Exercise 运动训练 Exercise training is an essential component of a pulmonary rehabilitation program. 运动训练是肺康复计划的重要组成部分

28 Exercise Prescription 运动处方 An exercise training program requires an individual prescription in terms of: Intensity 强度 Duration 持续时间 Frequency 频率 Type (interval or continuous) 类型 ( 间隔或连续 ) Mode (e.g. walking, cycling, arm exercise) 模式 ( 例如步行 骑车 手臂锻炼 ) Progression 调整 The prescription for each patient should be based on his / her results from tests of exercise capacity and strength.

29 Endurance Training Lower Limb Lower limb aerobic exercises 下肢有氧训练 (uses large muscle mass): Walking training for all patients (over-ground or treadmill). Stationary cycling training if possible. 固定自行车训练

30 Endurance Training Lower Limb (intensity) Lower intensity continuous exercise training is as beneficial as high intensity continuous exercise training. Both high and low intensity interval training are also equally effective Walking training intensity: It is recommended that for walking training a starting intensity should be 80% of the average six-minute walk test (6MWT) speed or 70% of the peak speed achieved on the incremental shuttle walk test (ISWT)

31 Endurance Training Lower Limb (duration) The recommended duration for a lower limb endurance exercise session is 30 minutes (e.g. 30 minutes of walking and/or cycling). 下肢耐力运动的推荐持续时间为 30 分钟 If a patient is very debilitated, the duration of the initial exercise sessions can be shortened (e.g. to 10 minutes with short rests if required). The duration should be built up towards 30 minutes in duration during the first two weeks of the program. If a stationary cycle is available, the program can be split into 15 minutes of cycling and 15 minutes of walking.

32 Endurance Training Lower Limb( frequency) The frequency of lower limb endurance exercise training should be: Supervised exercise training: Three times per week.3 次 / 周 Home exercise training: A further one or two times per week so that exercise is integrated into home life.1-2 次 / 周 However, many centres cannot provide supervised sessions three times per week If this is the case, the frequency of training should be: Supervised exercise training: Two times per week.2 次 / 周 Home exercise training: Two or three times per week.2-3 次 / 周

33 Endurance Training Upper Limb Although most research studies have concentrated on lower limb exercise training, the upper limbs should not be neglected as the arms are important for everyday tasks.

34 Endurance Training Upper Limb(mode) The following points should be taken into account when prescribing unsupported arm exercises with the aim of increasing endurance exercise capacity: A weight should be chosen that the patient can only lift 15 times. Each exercise should be repeated up to 15 times (or a smaller number of reps if required) followed by rest. Try to limit the rest period between each set of repetitions to one minute. It may help to instruct the patient to move their arms up as they breathe in and down as they breathe out. However, if they find this difficult then just emphasise that the most important point is not to hold their breath. 不要屏气 It is generally recommended to perform the exercises in the in the sitting position with back supported. However, in everyday life upper limb activities are often carried out in standing. Some of the exercises can be performed in standing providing the patient can perform a correct technique.

35 Endurance Training Upper Limb(mode)

36 Endurance Training Upper Limb(mode)

37 Endurance Training Upper Limb (intensity) Prescribing intensity based on weights and repetitions To elicit an endurance training effect, use the upper limb endurance exercises, and prescribe low weights with high repetition. Start with a weight that the patient can use to perform at least 15 repetitions of the chosen arm exercise (for some patients, the weight of their arms is sufficient as a starting weight ). After the patient can perform 15 repetitions of each exercise (one set) then increase to three sets of each exercise. After the patient can perform three sets of each exercise, the weight held can be increased by 0.5 kg.

38 Endurance Training Upper Limb (duration) The duration of each upper limb endurance exercise session will depend on the number of sets the patient is able to achieve (15 repetitions of each exercise is one set). 每组重复 15 次 If the patient is able to perform three sets of each exercise, then the duration will be approximately ten minutes.

39 Endurance Training Upper Limb (frequency) Supervised exercise training: Three times per week recommended.3 次 / 周 Home exercise training: A further one or two times per week so that exercise is integrated into home life.1-2 次 / 周

40 Strength Training 肌力训练 Strengthening the muscles in the lower limbs is important as these muscles are used everyday. A relationship has been shown between lower limb strength and lower limb work capacity. Having stronger lower limb muscles may help patients to perform short bursts of activity (such as getting on a bus), and may also reduce falls. The studies that have examined strength training for the upper limbs have focused on the accessory muscles of inspiration and muscle groups used in everyday functional tasks. These muscles include: Pectoral muscles 胸肌 Latissimus dorsi 背阔肌 Trapezius 斜方肌 Biceps 肱二头肌 Triceps 肱三头肌

41 Strength Training Lower Limb Strength Exercises (high weight and low repetition)

42 Strength Training Upper Limb Strength Exercises (high weight and low repetition)

43 Flexibility exercises 柔韧性训练 Flexibility of the joints in the spine (particularly the thoracic spine 胸椎 ) is important for people with respiratory disorders to enable thoracic mobility when breathing. When prescribing, the following points should be considered: Patients should perform two or three repetitions of each exercise using slow, smooth movements. Patients should only perform each exercise as far as they can without causing pain/discomfort.

44 Stretching exercises 牵伸训练 When prescribing stretching exercises, the following points should be considered: Ask the patient to hold each stretch for five to ten seconds Ask the patient to perform two or three repetitions of each stretch. Patients should gradually lengthen the muscle to the point that feels as if they are stretching the muscle, but no pain is experienced. After this point is reached, the patient should be asked to hold it there. Encourage the patient to gradually stretch a little further if they feel able to do so. Encourage patients to breathe while stretching, some patients hold their breath and others are unable to hold stretches for as long as 5 seconds due to breathlessness.

45 Stretching Exercises Pectoralis stretch Hamstring stretch Triceps stretch

46 Balance 平衡 The following exercises can help improve balance: Static and dynamic stance exercises (such as stand with eyes closed, tandem stance, one-legged stance and throw and catch ball), lower limb muscle strength training (such as sit to stand exercises and stepping up and down on a block 上下台阶 ) and gait exercises (tandem, sideway 横向行走 and backward walk)

47 Home Training 家庭训练 The home training program should consist of: Walking for 30 minutes at the same pace as in the supervised program. An exercise circuit that includes, where possible, identical exercises to the exercises that are completed during the supervised sessions. Progression of the exercises in the home program should occur at the same time that exercises are progressed during the supervised sessions. The home training program should include the following advice to patients: Instructions not to exercise if unwell (eg. flu, chest infection) or within 1-2 hours of a meal Instructions to stop and rest in the event of the following symptoms: excessive shortness of breath (much more than usual); chest, neck or arm pain of unknown origin in which case the patient should stop exercising immediately; excessive fatigue (much more than usual); dizziness, nausea, light-headedness; irregular heart beat or palpitations that are not usually experienced by the patient.

48 Length of Training Program 训练计划的持续时间 Programs should last for a minimum of 8 weeks. 至少 8 周 Most of the studies that have shown an improvement in exercise capacity have used programs of 8 to 12 weeks in duration. These programs have included at least 2 supervised sessions each week Lung Foundation Australia & The Thoracic Society of Australia and New Zealand, Australia and New Zealand Pulmonary Rehabilitation Clinical Practice Guidelines, l.: Wiley.

49 Location of Training Program 实施计划的地点 Hospital-based programs 以医院为基础的训练计划 Community-based programs 以社区为基础的训练计划 Home-based programs 以家庭为基础的训练计划

50 Maintaining the Gains 维持在康复计划中所得的益处 Options for maintenance exercise programs: Continue to exercise 3 to 5 days per week by either:3-5 天 / 周 once a week, supervised exercise program in a health facility, community or hospital outpatient setting plus unsupervised exercise on 2 to 4 other days per week. or unsupervised home exercise program with regular review 定期审查 (e.g. every 3 to 6 months) at the pulmonary rehabilitation program

51 Use of Supplemental Oxygen during Exercise Training

52 Use of Bronchodilators 支气管扩张剂的使用 Long-acting bronchodilators 长效支气管扩张剂 should be taken as prescribed. Short-acting bronchodilators may be indicated in those patients who experience significant chest tightness and/or wheeze 严重胸闷和 / 或喘息 during exercise. In such patients, taking short-acting bronchodilators before exercise may enable exercise training: At a greater intensity. For a longer duration. With less symptoms.

53 Other possible program inclusions Inspiratory Muscle Training in COPD 吸气肌训练 Single leg cycling 单腿自行车 Water-based exercise training Non-invasion ventilation (NIV) (severe disease) 非侵入性通气 Helium-hyperoxia 氦气 - 高氧气体混合物

54 Patient Education 患者教育 The education of patients and their families should be a component of a pulmonary rehabilitation program There are numerous benefits associated with education, including: Helping patients become active participants 积极参与者 in their health care. Helping patients and their families gain a better understanding of the physical and psychological changes that occur with chronic illness. Helping patients and their families to explore ways to cope with those changes. Through the educational process, patients can become more skilled at collaborative self-management 更有能力协作自我管理 and more adherent to their treatment plan 训练计划的依从性 which in turn may result in a reduction in hospital admissions. 减低住院率

55 Aims 目的 The aims of the education component of a pulmonary rehabilitation program are to: Promote behaviour change 行为模式 Provide information to help enhance physical fitness 体适能 and increase physical activity Improve the patient s quality of life. Increase the patient s ability to cope with the acute and chronic phases of chronic obstructive pulmonary disease. 应对能力 Reduce the length of stay in hospital. 减少住院时间 Reduce hospital admissions. 减低住院率 Optimise nutritional status. 改善营养状况 Improve mental health status 改善精神健康状态

56 Aims In terms of learning objectives, the education component of a pulmonary rehabilitation program should assist participants to acquire: Self-management skills. Knowledge of respiratory illnesses, risk factors, symptom recognition and management. An understanding of the role of exercise and physical activity and knowledge of appropriate modes of exercise. Knowledge regarding the correct and appropriate use of medications including oxygen therapy. Emotional management skills. Breathing control skills. A means of improving quality of life. The ability to develop action plans in consultation with a health professional. Knowledge of primary, secondary and tertiary care options, including community support services. Understanding of importance of nutrition and maintaining good nutritional status.

57 Education Topics 教育主体 the most important educational topics (in order) were: 1. The role and correct use of medications. 药物的作用和正确的使用方法 2. Breathing techniques / managing breathlessness. 呼吸技巧 / 呼吸困难的管理 3. Physical exercise. 运动训练 4. Nutrition / healthy eating. 营养 / 健康饮食 5. Information on diseases (e.g. what the lungs do). 关于疾病的信息 6. Coping with chronic lung disease and management of depression, anxiety and panic attacks. 应对慢性肺疾病和管理抑郁 焦虑和惊恐的发作

58 Education Topics Other education topics may include: Sputum clearance. 痰液清除 Energy conservation techniques. 节能技术 Continence. 失禁 Sexuality issues. 性问题 Swallowing. 吞咽 Community resources, legal issues and palliative care. 社会资源 / 法律问题 / 姑息治疗 Home Oxygen 家庭氧疗

59 Education Topics the format of the content and the level of detail in the education sessions should be determined based on the: 教育课程中的内容与详细程度基于 : Needs of the participants. 参与者的需求 Availability of resources. 可利用的资源 Level of staff expertise. 工作人员的专业知识水平

60 Self-Management 自我管理 At the end of the session, the participant will have: An understanding of self-management. 理解自我管理 Knowledge of the benefits of self-management. 自我管理的好处 Identified one area for improvement in self-management. 在自我管理中确定一个需要改进的领域 Developed a plan to improve self-management of chronic obstructive pulmonary disease. 制定一项改善慢性阻塞性肺病的自我管理计划

61 Lungs, Lung Disease and Management of Chronic Obstructive Pulmonary Disease Objectives: Increased knowledge of the lungs and the disease process. 增加肺和病程的认识 An understanding of the management of chronic obstructive pulmonary disease (COPD). 了解 COPD 的管理策略 Eg. Risk factors for respiratory disease. 呼吸系统疾病的危险因素 Diagnosis and monitoring of COPD.COPD 的诊断和监测

62 Medications 药物 Objectives: Identify the use, effects and side effects 副作用 of common medications. Demonstrate the most efficacious use of respiratory medication devices 演示呼吸系统药物设备最有效地使用方法. Understand the use of medications in the management and treatment of chronic obstructive pulmonary disease.

63 Managing Breathlessness Objectives: Increased understanding of the causes of breathlessness. Increased ability to evaluate their own level of breathlessness. Increased skills in managing breathlessness. Reduced sense of anxiety or fear when experiencing breathlessness. Increased ability to safely exercise when breathless. Eg. Inspiration and expiration 正常呼吸介绍 Methods to control dyspnoea. 呼吸困难的控制方法

64 Exercise and Physical Activity Objectives: Increased knowledge of physical fitness. Awareness of the need to increase their level of physical activity and exercise to optimise lung health. Knowledge of how to safely achieve an increased level of physical activity and exercise. EG. Precautions for exercise. Where to exercise. When to exercise. 锻炼的注意事项 在哪里锻炼 什么时候锻炼 Monitoring dyspnoea during exercise 在运动过程中监测呼吸困难

65 Nutrition and Health Eating Objectives: Define a healthy diet. 认识健康饮食的定义 Identify why healthy eating is important for people who have lung conditions. State how to improve their own nutritional intake. 懂得描述如何提高自身的营养摄取量 Identify energy boosting foods. 识别提升能量的食品 Identify potential nutritional issues common in lung disease and how to manage these. Identify associated link to quantity and quality of foods that increase breathlessness. 识别与增加呼吸困难相关的食物数量和质量

66 Stress, Anxiety and Depression 紧张, 焦虑, 抑郁 Objectives: An understanding of the psychological factors of chronic obstructive pulmonary disease (COPD). 了解 COPD 患者的心理状况 ( 因素 ) Recognition of what stress is and how it affects the body, particularly in the context of breathlessness. 识别压力是什么以及它如何影响身体, 特别是在呼吸困难的情况下 Increased skills in managing stress, anxiety and depression. 提高管理紧张, 焦虑和抑郁的技巧 Increased understanding of, and ability to use cognitive techniques to manage stress and physical symptoms (other than chest pain). 增加理解和运用认知能力去管理紧张和身体症状 ( 除胸痛 )

67 Airway Clearance 气道清洁 Objectives: Increased knowledge of the role and function of sputum 痰液 and the mucociliary pathway 纤毛系统 in chronic obstructive pulmonary disease (COPD). Increased ability to recognise the signs and symptoms of a chest infection. Increased understanding of airway clearance techniques with an emphasis on independent techniques. 加强对气道清除技术的了解, 强调独立运用

68 Energy Conservation 节能技术 Objectives: Have a better understanding of the physiological response 生理反应 to daily activities. Be able to set realistic goals 切实可行的目标 while undertaking self care activities. Be able to adopt and utilise energy conservation techniques. 能够使用和利用节能技术 E.g. Optimising body mechanics. 改善身体力学 Lightweight equipment. 使用轻便的设备

69 Others Contience Sexuality Swallowing Home oxygen

70 Program Education Evaluation of the effectiveness of pulmonary rehabilitation programs can be based on: Patient outcomes (i.e. what were the effects on the patient s exercise capacity and quality of life?). Patient feedback (i.e. what did the patient think of the program?). Evaluating the effectiveness of a pulmonary rehabilitation program depends on the assessment of patients before and after the program.

71 What Effects Did the Program Have on Key Outcomes? As a minimum, the assessments made at the completion of a pulmonary rehabilitation program should be repeated at the completion of the program. These include: Measurement of exercise capacity: Repeat the same exercise test used to assess the patient s exercise capacity before the program Dyspnoea scores 气短指数 and oxygen saturation (SpO 2 )% 血氧饱和度 should be recorded before and at the end of the 6MWT or ISWT. Measurement of health-related quality of life Repeat the same quality of life questionnaire used to assess the patient s quality of life before the program (e.g. the St George s Respiratory Questionnaire or the Chronic Respiratory Disease Questionnaire).

72 What Did My Patient Think of the Program? The following points should be considered when asking patients for feedback: Patients should not feel pressured into providing positive feedback( 正面反馈 ). To help alleviate potential concerns by patients, coordinators should consider de-identification of patient responses to satisfaction questionnaires( 满意度问卷 ). The questions presented in the satisfaction questionnaire should be reflecting the content of the centre s program. 所使用的问卷要能反映训练计划的中心内容 The questionnaire should also provide patients with a variety of answering options Patient Satisfaction Survey.doc

73 How to Provide Feedback to the Referring Doctor? When patients are assessed after completing a pulmonary rehabilitation program, the results should be sent to the referring doctor. Feedback to the referring doctor should include comments about the patient s progress in the supervised and home exercise programs. A sample final assessment letter is available. Ongoing communication with the referring doctor promotes continued reinforcement of the patient s program and can help to maintain a good working relationship with medical staff.

74 THANKS