Pulmonary Rehabilitation – “Inspiration for Life” Saturday, April 13, 2013 Sharon L. Balkenhol, RN, MSN, CNS, APN Manager, Pulmonary Rehabilitation Jewish Hospital, Cincinnati, Ohio

What is Pulmonary Rehabilitation – a 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 Pulmonary Rehabilitation “…a multidisciplinary program 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.”

What is Pulmonary 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 Rehabilitation Do??? Helps patients break out of their “emotional straightjacket”

Why Do I Need 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 Rehabilitation??? Fear of breathlessness Reduced exercise tolerance Inactivity/Immobility Muscle weakness Fatigue, anxiety, isolation

Muscle Reconditioning Pulmonary Rehabilitation CHRONIC LUNG DISEASE Pulmonary Rehabilitation Breathlessness ACTIVITY ↓CO2 ↓Lactate Muscle Reconditioning Decreased Leg Fatigue & Weakness

Do I Need Pulmonary 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 Rehabilitation Are you or someone you know missing the benefits of Pulmonary Rehab?

“COPD” EXTENT OF THE PROBLEM 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. Pulmonary Disease effects every aspect of daily living. Dyspnea – Shortness of Breath (SOB) is the # 1 disability of persons over the age of 60. Reference American Lung Association Lung Disease Data 2003

Significant Statistics 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 Reference American Lung Association Lung Disease Data 2003

How Does LAM Affect Your Lungs?? CYSTS = oxygen uptake Traps air risk of pneumothorax PNEUMOTHORAX Effusions Airway Narrowing

How Will Pulmonary 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 Components of Pulmonary Rehab? Initial Assessment Supervised Progressive Exercise/Activity Functional and ADL Training Energy Conservation Breathing Retraining Stress Management Medication Education Key Points: Emphasize to the audience that living With pulmonary disease means much more than just exercising regularly. Pulmonary Rehab provides the educational information, the support from staff and other patients with similar problems and needs, and serves as the eyes and ears of the MD to assess patient’s adherence to lifestyle changes. PHYSICAL INACTIVITY Physical activity has been shown to have a positive effect on physical decline and improve the feeling of SOB. The intensity/duration does not need to rival that of an athlete in training for the Olympics. The pulmonary rehab staff will develop an individualized exercise/activity program that progresses according to patient stated goals, clinical stability, signs and symptoms, co-morbidities.

INITIAL ASSESSMENT Interview Medical History Symptom Assessment Nutritional Assessment Educational Assessment

INITIAL ASSESSMENT ADL Assessment Psychosocial Assessment Diagnostic Testing Exercise Assessment Physical Assessment

Oxygen & 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 LAM???? Healthy Lifestyle Pulmonary Rehabilitation Flu Vaccination Pneumonia Vaccination NO SMOKING

Physical Activity = “Lifestyle 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????? 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 2.38 Long term cardiac risk is reduced Whang et al JAMA 2006

What About Pneumothorax and 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 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

Stretching & Flexibility 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

Upper Extremity Training? 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 Training MODALITIES Arm Ergometer Rower Dumbells Fitness bands AirDyne Bicycle

Upper Extremity Training 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 Training MODALITIES Treadmill Chair Aerobics Water Walking/ Aerobics Walking Stationary bicycles NuStep Elliptical Trainer

Lower Extremity Training BENEFITS Strengthens Leg Muscles Improves Muscle Tone Increases Flexibility

Patient Education & Training Normal lung A & P Pathophysiology of lung disease Breathing retraining Airway Clearance Preventing infection Medications & oxygen Exercise principles

Patient Education & Training Activities of daily living & energy conservation Smoking cessation Self-assessment & symptom management Emotional and social well- being Travel Nutrition

Control Your Breathing 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 Well-Being Breaking the dyspnea cycle Coping with depression and anxiety Learn relaxation techniques

Who Is Eligible for 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 Key Points: Mention/explain the medical names for each condition Be sure to mention Maintenance (Phase III) programs that your facility hosts. Remember that many older patients are very concerned about out-of-pocket expenses. Emphasize that staff will individually evaluate patient’s insurance coverage (when needed) prior to the patient incurring any expenses.

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. Key Points: Make sure that the presenter understands the concept of APC’s in regards to Medicare coverage and can explain co-pays if the patient has only primary Medicare coverage. Be prepared to “sell” your maintenance programs – compare what you get for the $$ in Maintenance (Phase III) programs vs. what you get for a similar amount of money at a health club or other fitness facility.

The Pulmonary Rehab Team Referring Provider (Physician, Nurse practitioner) Respiratory therapist Registered nurse Physical therapist Occupational therapist Medical Director Exercise physiologist Supporting staff: Dieticians/Nutritionists, Social Workers, Psychologists, Pharmacists All work together as a team with primary physicians to assure the best outcome possible

Again, Why is Pulmonary Rehabilitation Important??? Pulmonary Rehab will give you the tools, knowledge, and motivation you need to fight the progression with your “Daily Breath”! We know that pulmonary disease is a progressive disease…it will worsen over time if aggressive steps aren’t taken to prevent and manage it! Pulmonary Rehab will give you the tools, knowledge, and motivation you need to fight that progression with your “Daily Breath”!

How Do I Find a Quality Pulmonary Rehabilitation Program? American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR)- “Find a Program” American Lung Association Recommendations of physicians, friends

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 Active Do yard work or gardening Walk the dog Clean a closet Go shopping, play miniature golf, dance a little

Questions?????