COPD Program - Group session 1 Facilitator documents. May 2013

Transcription

1 COPD Program - Group session 1 Facilitator documents May 2013

2 Introduction to the facilitator documents This document supports the facilitator with respect to the contents of the Group Session 1 of the COPD program. When pertinent, a group education is preceded by a slide called «Facilitator notes», that can be identified by a title in yellow fonts. All the supporting documents (identified in red fonts) can be downloaded from the website (password: copd) or from the RQAM website

3 Facilitator notes (Introduction) Presentation of the Facilitator. Presentation of the participants. Introduction to the program «Living Well with COPD». Presentation of the session agenda.

4 The program Living Well with COPD - YOUR EXPECTATIONS - BEING HEALTHY WITH COPD - OBJECTIVES

5 Facilitator notes (Your expectations) Assess participants expectations, goals and objectives with respect to the group education program. Suggested question to start the discussion: What are your expectations as a result of taking part in this group education program? Possible answers from the participants: Remain stable Become more active Continue to be independent Acquire knowledge about my illness Feel in control

6 Your expectations What are your expectations as a result of taking part in this group education program?

7 Facilitator notes (Being healthy with COPD) 1. Explain that disease and health are separate concepts that can coexist and influence each other. 2. Establish clearly that a person with a chronic illness can also be healthy. Suggested questions to start the discussion Do you make time for leisure activities? Why? How can friends and family help you to improve your health? Do you think a healthcare professional can help you improve your health? Notes Participant s answers may vary from one group to another. Bring out the emotions, thoughts, images and associated behaviours. Give personal examples to facilitate and encourage discussion.

8 Being Healthy with COPD Even if you have COPD, a chronic illness, you can still be healthy. Knowing your disease and taking charge of it on a daily basis will help you live better with your COPD.

9 Being Healthy with COPD What does health mean to you? What do you do to stay healthy?

10 Introduction to the program Living Well with COPD Preventing your symptoms and taking your medications. Managing your breathing and saving your energy. Managing your stress and anxiety. Adopting and maintaining a healthy and fulfilling lifestyle. Developing and integrating a Plan of Action into your life.

11 Session Agenda 1. COPD definition 2. Action plan «I feel Well» 3. Medications Their action 4. Inhalation techniques 5. Breathing managing

12 Facilitator notes (Normal lung) Present to the participants an overview of lung anatomy. Use the poster of the Normal Lung to illustrate your explanation. Review with the participants the main elements of lung anatomy. Show on the poster the location of lungs, trachea, bronchi, alveoli and cilia. Suggested script for the facilitator: Every time you breathe, air is drawn into your lungs along with dust and pollutants. Many of these particles are trapped inside your nose and other smaller particles stick on tiny mucous layers in your airways. Mucous secretions move up to your trachea by tiny hairs called cilia and then move further up to your throat. Once in your throat, mucous is then swallowed or removed by coughing. This process prevents particles from reaching the lower airways and doing damage to your bronchi and alveoli.

13 Normal lung

14 Facilitator Notes (COPD - definition) Ask the participants about the meaning of the acronym COPD. Explore within the group the existing knowledge regarding COPD main cause. Suggested question: What does COPD mean? Answer expected from the participants: COPD means chronic obstructive pulmonary disease.

15 COPD - definition What does COPD mean? COPD means chronic obstructive pulmonary disease.

16 Facilitator Notes (What happens when someone has a COPD?) Explain the relationship between COPD, obstructive chronic bronchitis and emphysema. Use the poster COPD Lung to support your teaching. Suggested script for the facilitator: Obstructive chronic bronchitis and emphysema are major breathing diseases that cause airways to become obstructed or blocked. They often occur together but they can also occur separately. They are also known as COPD.

17 What happens when someone has a COPD?

18 Facilitator notes (Obstructive Chronic Bronchitis) Explain the pathophysiological changes caused by obstructive chronic bronchitis. Use the poster COPD Lung to support your teaching. Suggested script for the facilitator : How smoking and other pollutants can alter your airways selfcleaning mechanism. When your airways are constantly attacked by pollutants, such as those found in cigarette smoke, they become inflamed, red and swollen. Your bronchi become filled with thick, sticky mucous. You cough to clear your airways. Later, your bronchi may become obstructed (or there is limited airflow). Because of airway obstruction, your lungs do not fully empty and air is trapped. You have obstructive chronic bronchitis.

19 COPD - Obstructive Chronic Bronchitis

20 Facilitator notes (Emphysema) Explain the pathophysiological changes caused by emphysema. Use the poster COPD Lung to support your teaching. Suggested script for the facilitator : Your bronchial tubes branch into smaller and smaller tubes, which end in millions of tiny air sacs called alveoli. The exchange of oxygen and carbon dioxide takes place in the alveoli. When your alveoli are damaged or destroyed, there is a loss of lung elasticity, it becomes difficult for the lungs to exchange oxygen and carbon dioxide and less oxygen gets into your body. Your lungs do not fully empty and air is trapped. You have emphysema.

21 COPD Emphysema

22 Facilitator notes (Signs and symptoms) 1. Invite the participants to describe their symptoms; complete the explanation of the symptoms related to chronic obstructive pulmonary disease. Suggested question: What are the most common everyday symptoms of COPD? Answers expected from the participants: Shortness of breath Wheezing / bronchospasm Secretion production Anxiety Fatigue

23 Facilitator notes (Signs and symptoms) 2. Guide participants to identify their everyday respiratory symptoms (baseline). Suggested questions: Can you describe me your everyday respiratory symptoms? How short of breath do you feel in a normal day? What type of activities would make you feel short of breath (e.g. walking, climbing stairs, etc.)? The MRC visual dyspnea scale can be used to give an idea of the level of dyspnea in day-to-day life. Do you cough up sputum (phlegm) daily? Could you describe the colour of your sputum? Do you have any idea about the amount (volume) of sputum that you cough every day? Could you describe the consistency of your sputum? Do you cough regularly? What does regularly mean to you?

24 COPD Signs and symptoms What are the signs and symptoms of obstructive chronic bronchitis? Sputum every day Frequent coughing Wheezing Shortness of breath when exercising or during daily activities. What are the signs and symptoms of emphysema? Shortness of breath when exercising or during daily activities.

25 Facilitator notes (COPD cause) Explore within the group the existing knowledge regarding COPD main cause Suggested Question: Can you identify the main cause of COPD? Answers expected from the participants: Cigarette smoke is the leading cause of COPD. Suggested script for the facilitator: Many people who suffer from COPD are current or former smokers.

26 COPD Main cause Can you name the primary pollutant that can damage your lungs? Cigarette smoke is the primary pollutant and the leading cause of COPD. Many people who suffer from COPD are current or former smokers.

27 Action plan - INTRODUCTION TO THE ACTION PLAN - ACTION PLAN SECTIONS - «I FEEL WELL»

28 Facilitator notes (Action plan) Present this section in an interactive way. Provide a copy of the Written Plan of Action to the participants or ask them to use their own plan of action. 1. Describe the objectives of the action plan of Living Well with COPD. 2. Briefly describe the content of the different sections of an action plan. Suggested script for the facilitator: Your Plan of Action plays an important part in your life, as it will help you make key decisions in treating COPD when your symptoms get worse. If you use your Plan of Action properly, you will become more independent and feel more in control when your symptoms get worse. Your Plan of Action may make the difference between a trip to the hospital and treatment at home!

29 Action plan Your Plan of Action will help you to: Better recognize your everyday respiratory symptoms. List what you are doing every day to remain well, including taking your medication as prescribed. Recognize a worsening of your respiratory symptoms and the situations that can trigger it. Know what to do to prevent a worsening of your respiratory symptoms and start treatment as soon as possible if that happens. Know when and whom to call if your symptoms get worse and/or do not improve.

30 A Plan of Action includes the following sections Contact list «I feel well» «I feel worse» (additional treatment if needed) «I feel much worse» «I feel I am in danger»

31 Facilitator Notes (Contact list) Review the section Contact List of the written action plan to guide the participants to identify their key resources. Suggested script for the facilitator : An essential part of your Plan of Action is to have the phone numbers of your contacts close at hand. These are the key people you can call when you have a problem with your respiratory symptoms or treatment. Write their names and numbers in the spaces below.

32 Contact list

33 Facilitator notes («I feel well») Present the sub-section My usual symptoms to the participants Review with the participants the elements that should be covered in this section and that will help them to identify their everyday respiratory symptoms (baseline). Guide participants to identify the following symptoms: Shortness of breath : Their normal level of shortness of breath and the type of activities that make them feel short of breath (e.g. walking, climbing stairs, etc.). Sputum: Whether they cough up sputum (phlegm) daily and the characteristics of their sputum: colour, amount (volume), consistency. Cough: Whether cough is present as part of their regular symptoms.

34 Let us look at your Plan of Action when you FEEL WELL What are your usual respiratory symptoms?

35 Facilitator notes («I feel well») Present the sub-section My actions to the participants 1. Review with the participants the elements that should be covered in this section and that will help them to identify: The healthy behaviours they should maintain in the long term. The activities they are able to perform when they feel well. Present the sub-section My regular treatment to the participants 2. Review with the participants the elements that should be covered in this section and that will help them to identify the medications included as part of the everyday treatment for COPD.

36 Let us look at your Plan of Action when you FEEL WELL What are the healthy behaviours to develop? What is my regular treatment?

37 COPD medications - THEIR ACTION

38 Facilitator notes (Taking your medication) 1. Evaluate participants knowledge about COPD medication. 2. Assess participants concerns that may affect compliance. 3. Ask each of the participants and write the answers on the board.

39 Taking your medication Which medications are used for the treatment of COPD (inhalers and pills)? Which COPD medication must be used in case of emergency? Do you know how COPD medications act inside the lungs? Do you believe that the medication you take for COPD is effective? Do you believe that it is necessary to take your COPD medication regularly? What are the concerns you have in regards to the medications you take for your COPD?

40 Facilitator notes (Medications used to treat COPD) Use the posters of the Normal Lung and the COPD Lung to support your teaching. You can also use the Educational Flipchart (section medication, see facilitator notes) and COPD medication posters available in your region. Present the role of each of the 3 groups of medication used in COPD treatment: Bronchodilators Anti-inflammatories Antibiotics

41 Medications used to treat COPD Bronchodilators the most important medications in COPD - They open up the airways, prevent and relieve shortness of breath on exertion.

42 Medications used to treat COPD Anti-inflammatories - Reduce inflammation and swelling in your airways and can be helpful to prevent exacerbations (worsening of respiratory symptoms); in COPD, inhaled anti-inflammatories need to be prescribed in combination with a bronchodilator. It is important to rinse your mouth after taking this medication to avoid thrush (yeast infections).

43 Medication used to treat COPD during an exacerbation Oral Anti-Inflammatory (Prednisone) - Usually prescribed for short periods (1-2 weeks) when your respiratory symptoms get worse (exacerbations). Antibiotics - Are useful in treating respiratory infections and can be used with COPD medications during an exacerbation.

44 Facilitator notes (Summary) 1. Evaluate and reinforce participants understanding and compliance with respect to COPD medication. 2. Invite patients to ask questions. 3. Have each patient respond at least one of the questions. Write the answers on the board.

45 Summary What is the use of a bronchodilator? What is the use of an anti-inflammatory? Which medication should you use in case of emergency? Antibiotics and Prednisone are helpful to treat? Why is it important to take your COPD medication regularly and as prescribed? What could help you to take your medication regularly?

46 COPD medications - INHALATION TECHNIQUES

47 Facilitator notes (Inhalation devices) Evaluate participants knowledge about inhalation devices. Assess participants concerns that may affect the use of inhalation devices. Ask each of the participants and write the answers on the board.

48 Inhalation devices Which inhalation devices are you using? Can you please show them to me? Do you find it difficult to use inhalation devices? Which one and why? Do you feel uncomfortable in taking your inhaled medication in public?

49 Facilitator notes (all devices) Present each inhalation device individually, in the following order: Describe its advantages and disadvantages. Demonstrate the inhalation technique and have participants practice in front of you. Correct and reinforce. Describe the maintenance technique required.

50 Facilitator notes (Metered-dose inhaler - MDI) Important points 9 out of 10 patients do not use their MDI properly Most common errors are: inhaling too fast and insufficient breathing retention after activation. Technique Shake the device 3-4 times from top-down. Body straight, exhale normally away from the device. Place carefully the mouthpiece within your teeth and seal your lips around it. Begin to breathe in slowly through your mouth. Press down once on the canister and continue breathing in slowly for 3-5 seconds. Breathing must be deep and slow. Hold your breath for 5 to 10 seconds, before breathing out normally.

51 Metered-Dose Inhaler 1. Remove the cap 2. Shake the device 3. Exhale normally 4. Seal your lips around the mouthpiece 5. Inhaling slowly through your mouth 6. Press down once on the canister

52 Metered-Dose Inhaler 7. Continue to breathe in slowly and deeply until your lungs are full 8. Hold your breath for 5-10 seconds and breathe out. 9. Rinse your mouth

53 MDI (Metered-dose inhaler) Maintenance and Cleaning 1. Once a week, clean the cap and plastic container, without the canister, by soaking them in warm, soapy water. 2. Rinse and allow to air-dry. 3. The canister should be kept away from heat sources and cold. Roll the canister between the palms of your hands to warm it up. Estimate quantity left in the device 1. Shake the inhaler and listen for movement sounds. 2. Some MDI have a dose-counter.

54 Facilitator notes (Spacing device) Important points Compared to the MDI alone: medication deposition in the airways by 50%. 4 times less medication deposition in the throat, hence less secondary effects by corticosteroids. The spacing device has a whistle which indicates if inhalation is too fast (faster than 45 L/min). The medication remains suspended in the device for up to 10 seconds. The MDI should only be activated once. No coordination is needed between the MDI activation and the inhalation.

55 Facilitator notes (Spacing device) Technique Shake the inhaler 3-4 times and connect it to the spacing device, keeping the inhaler upright. Body straight, exhale normally. Place the spacing device mouthpiece carefully between your teeth and seal your lips around it and press down canister once. Single breath technique: Inhale for 3-5 seconds. Hold your breath for 5 to 10 seconds, then exhale normally. Tidal volume technique: breathe slowly in and out of the spacing device, 3-4 times in a row. Inspiration must be slow and deep you should not hear the whistle

56 Metered-Dose Inhaler with a Spacing Device 1. Remove the caps 2. Shake inhaler 3. Connect it to the spacing device 4. Exhale normally 5. Place the spacing device in your mouth and press down on the canister once 6. Breathe slowly in and out 4-5 times in a row and breathe out. 7. Rinse your mouth

57 Facilitator notes (Spacing device) Maintenance and Cleaning Separate all the parts. Method # 1: soap and water 1. Mix warm water with a few drops of mild detergent. Let the spacing device soak in this mix for around15 min and carefully shake. 2. If needed clean with a soft cloth (if there were still some residues) 3. For the model «Aerochamber Plus Flow-Vu»: Rinse with clean water. 4. Let the spacing device air dry in a vertical position for a few hours (do not use a cloth). Method # 2: dishwasher Only for the model «Aerochamber Plus Flow-Vu»: place the parts in a vertical position on the upper level of the dishwasher (make sure that parts will not fall). Frequency: 1/week or more often if the patient has an upper airway infection.

58 Spacing device Maintenance and Cleaning 1. Clean the spacing device prior to the first use and once a week after as per the manufacturer instructions. If you have an infection, clean it more often. 2. If your spacing device has a good maintenance, it can last for one or two years depending on the type. 3. Keep the spacing device in a safe place to assure that no strange object will fall inside the chamber.

59 Facilitator notes (Dry powder inhalers) Common techniques for the Turbuhaler and the Diskus Body straight. Hold the inhaler away from your mouth and exhale normally. Place the mouthpiece carefully between your teeth and seal your lips around it. Breathe in deeply and forcefully through your mouth. Hold your breath for 5 to 10 seconds, then breathe out normally away from the inhaler. Reminders Do not shake the inhaler after having loaded it. It is very important to not breathe out on the device. If the device falls after having been loaded, consider that the dose is lost and repeat the steps.

60 Facilitator notes (Dry powder inhalers) Important points pour le Turbuhaler Hold the Turbuhaler upright when loading it to get the exact dose. Turn the coloured grip as far as it will go in one direction, and then turn it back again as far as it will go in the opposite direction. You will hear a click sometime during these steps. Repeat this step for a new device. The medication powder has lactose and is contraindicated for patients allergic to milk protein (Oxeze et Symbicort ).

61 Facilitator notes (Dry powder inhalers) Important points for the Turbuhaler Always keep the device closed, to protect it against humidity and dirt. Turbuhaler contains a desiccant agent (dehydrating agent to remove humidity); there is a rattle sound when shaking the device (not to confound with remaining amount of medication).

62 Facilitator notes (Dry powder inhalers) When is the Turbuhaler (not applicable to Symbicort ) finished? There is a window on the side of Turbuhaler that indicates the following : White = multiple doses remaining. Red mark that starts to show = around 20 doses left. Red mark on ¾ of the window = empty.

63 Facilitator notes (Dry powder inhalers) Important points for the Diskus Hold the Diskus horizontally. Hold the outer case in one hand and put the thumb of the other hand on the thumb grip. Push the thumb away as far as it will go until a click is heard. Slide the lever away as far as it will go until a click is heard; release. The medication powder has lactose and is contraindicated for patients allergic to milk protein. When is the Diskus finished? The device has a dose counter. The last 5 doses are marked in red.

64 Dry powder inhalers 1. Open the device 2. Load the device 3. Exhale normally 4. Place the inhaler in your mouth, inhale quickly and deeply 5. Hold your breath for 5-10 seconds 6. Breathe out and rinse your mouth

65 Dry powder inhalers Maintenance and Cleaning Wipe the mouthpiece with a clean dry cloth. Always keep the device closed, at room temperature in a dry place, to protect it against humidity. Never immerse the inhaler in water or exhale within the inhaler to avoid humidity entering the device and preventing from proper functioning.

66 Facilitator notes (Dry powder inhalers with capsules) Common techniques for Handihaler & Breezhaler Body straight. Hold the inhaler away from your mouth and exhale normally. Place the mouthpiece carefully between your teeth and seal your lips around it. Breathe in slowly and deeply to hear the capsule vibrate. Hold your breath for 5 to 10 seconds, then breathe out normally away from the inhaler. Reminders Do not store capsules inside the inhaler. The medication powder has lactose and is contraindicated for patients allergic to milk protein.

67 Facilitator notes (Dry powder inhalers with capsules) Important Points on Spiriva (Diskus) Risk of eye irritation (if touching eyes after touching the used capsule). Technique (Diskus) Body straight, press the green button after inserting the capsule. Release the green button. Technique (Breezhaler) Body straight, press the buttons after inserting the capsule. Release the buttons.

68 Inhalation Technique for dry powder inhalers with capsules 1. Open the device 2. Open the mouthpiece 3. Place a capsule in the centre chamber 4. Close the mouthpiece 5. Press the button and release 6. Exhale normally away from the device

69 Inhalation Technique for dry powder inhalers with capsules 7. Breathe in slowly and deeply 8. Hold your breath for 5-10 seconds 9. Breathe out and rinse your mouth

70 Dry powder inhalers with capsules Cleaning (Diskus) Clean once a month or as needed. Open the dust cap and the mouthpiece in order to open the base. Rinse the inhaler with warm water in order to eliminate powder residues (do not use soap). Allow the device to air dry thoroughly. Cleaning (Breezhaler) A new device is provided at each medication renewal.

71 Facilitator notes (Inspiratory flow) Inhalation device MDI MDI + Spacing device Diskus Turbuhaler Handihaler Breezhaler Nebulizer Inspiratory flow 30 L/min L/min or Normal breathing L/min L/min 20 L/min 30 L/min Normal breathing

72 Facilitator notes (Advantages of a proper use of inhalation devices) 1. Evaluate participants understanding with respect to inhalation devices. 2. Reinforce the importance of taking medication as prescribed and using the proper technique. 3. Invite patients to ask questions. Write the answers on the board.

73 Advantages of a proper use of inhalation devices What are the benefits of using your inhalation devices correctly? What are the advantages of using a spacing device with your inhalation aerosol? What can you do to use properly your inhalation devices? Reminder : Ask your resource person, or your pharmacist, to verify your inhalation technique at each visit.

74 Facilitator notes (Conclusion) Answer the questions of the participants. Summarize the points to remember by type of medication/inhalation device. Underline the importance of taking the medication as directed by their physician and using the appropriate inhalation technique. Learning Contract: Encourage the participants to ask their resource person, at each visit, to verify their inhalation technique.

75 Questions?

76 Breathing management - BREATHING TECHNIQUES - BODY POSITIONS

77 Facilitator notes (Shortness of breath in COPD) Explain to participants how breathing works and the impact of air trapping on the lungs. Suggested script for the Facilitator: When you have COPD, air remains trapped inside your lungs. Air trapped in the lungs : Due to an obstruction in the air passage and a loss of elasticity of the lungs, your lungs do not completely empty and the air remains trapped. Breathing becomes more difficult : Due to the fact that air remains trapped in your lungs, your diaphragm must work harder and its movement is less efficient. Furthermore, you must use your accessory muscles in the neck, sides and chest to breathe. You feel short of breath : Since you have air trapped in your lungs, you have difficulty bringing in fresh air and you feel short of breath. If you reduce the air trapped in your lungs, you will allow fresh air to enter more easily, consequently you will be less short of breath.

78 Shortness of breath in COPD Why do you feel short of breath when you have COPD? When you have COPD, air remains trapped inside your lungs.

79 Facilitator notes (Pursed-lip breathing technique) Use the poster of the Pursed-lip breathing technique Evaluate the existing knowledge of participants with respect to pursed-lip breathing. Present the goal, benefits and points to remember of the pursed-lip breathing technique. Demonstrate the steps of the technique. Ask the participants to demonstrate the technique. Provide them constructive feedback and reinforcement on the performance of the technique.

80 Pursed-lip breathing technique With this technique, you breathe out slowly, which allows you to exhale more air, thus leaving less air trapped inside your lungs. If you reduce the air trapped in your lungs, you will allow fresh air to enter more easily, consequently you will be less short of breath.

81 Pursed-lip breathing technique

82 Facilitator notes (Walking, climbing stairs, carrying parcels) 1. Demonstrate the use of pursed-lip breathing technique with activities requiring effort : 1. Walking 2. Climbing stairs 3. Carrying parcels 2. Have participants practice in front of you (walking, climbing stairs) according to the steps, while integrating the pursed-lip breathing technique. Provide them constructive feedback and reinforcement on the performance of the techniques learned. 3. Focus on taking longer time to exhale than to inhale but without forcing the exhalation.

83 Walking Inhale 1 2 Exhale

84 Climbing stairs If you suffer from severe shortness of breath: Inhale at rest. Climb one step while exhaling, and stop for inhaling. Repeat for each step. If you are able to climb some steps: Inhale at rest. Climb 3-4 steps while exhaling, stop for inhaling. If you are able to climb at least a flight of stairs: Inhale at rest. Climb 3-4 steps while exhaling. Climb 2 steps while inhaling. Climb 3-4 steps while exhaling, etc.

85 Carrying parcels Before lifting a heavy object, inhale through the nose. Bend down and pick up the object while exhaling through pursed lips. Use pursed-lip breathing while carrying the object. Repeat the process when putting the object down. Always bend at the knees, keeping your back straight.

86 Facilitator notes (BODY POSITIONS) Use the poster Body Positions to reduce Shortness of breath. 1. Evaluate the existing knowledge of participants with respect to body positions. 2. Present the goal, benefits and points to remember of the body positions to reduce shortness of breath. Demonstrate the five body positions. 3. Have participants practice the different body positions in front of you according to the steps, while integrating the pursed-lip breathing technique. Provide them constructive feedback and reinforcement. Suggested questions at the end of the practice session: Did your breathing change when you used one of the body positions previously described? How did it feel different?

87 Body positions Goal: To offer relief to accessory muscles and improve diaphragm function. Benefits: 1. Help the diaphragm to move easier. 2. Help reduce shortness of breath.

88 Sitting

89 Standing

90 Facilitator notes (S.O.S. in an attack of shortness of breath) 1. Explore participants experience in managing an attack of shortness of breath. 2. Present the goal, benefits, and points to remember of the S.O.S. technique. Demonstrate the steps of the technique. 3. Have participants name the order of the steps. Provide them constructive feedback and reinforcement.

91 S.O.S. in an attack of shortness of breath Goal: To bring your breathing back to normal during an acute attack of shortness of breath. Benefits: 1. Learn how to control shortness of breath. 2. Help reduce the panic associated with an attack. Point to remember: Give yourself the space and time to get your breathing back to normal.

92 S.O.S. in an attack of shortness of breath Steps: 1. Stop and find a comfortable position. 2. Stay as calm as possible; relax your shoulders. 3. Introduce the pursed-lip breathing technique: inhale through your mouth if you cannot through your nose; purse your lips to exhale. 4. Slow down your breathing by taking more time to breathe out than you would to breathe in. Do not force your lungs to empty. 5. Continue to exhale slowly while keeping your lips pursed; start to inhale through your nose if you have not been able to do it so far. 6. Continue to pursed-lip breathe for at least 5 minutes.

93 Questions?

94 Facilitator notes (Conclusion) 1. Answer the questions of the participants. 2. Summarize the points to remember and ask the participants to repeat them. 3. Learning Contract : Ask the participants to review and practice at home each one of the different techniques taught in the present session (at least one technique each day). 4. Evaluate the satisfaction of the participants with regards to the present session.

95 Acknowledgements Mrs. Maria Sedeno, Living Well with COPD Mr. Michel Lebel, Living Well with COPD and Network Case Manager, Centre-West region Mrs. Esther César, Network Case Manager, North region Mrs. Kathy Noël, Network Case Manager, East region Mrs. Lorraine Isabelle, Network Case Manager, West region Mrs. Nathalie Poupart, Network Case Manager, South-East region Mrs. Lyse Millette, Network Case Manager, Centre-East region Mrs. Cathy Dresdell, planning, programmation and research agent, Agence de la santé et des services sociaux de Montréal Mrs. Édith Lemay, planning, programmation and research agent, Agence de la santé et des services sociaux de Montréal Mrs. Lucie Des Groseillers, administrative technician, Agence de la santé et des services sociaux de Montréal Mrs. Élodie Cornier, administrative agent, Agence de la santé et des services sociaux de Montréal