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

2. 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

3. 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.”

4. 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

5. What Does Pulmonary Rehabilitation Do???
Helps patients break
out of their
“emotional straightjacket”

6. 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!

7. Why Pulmonary Rehabilitation???
Fear of breathlessness
Reduced exercise
tolerance
Inactivity/Immobility
Muscle weakness
Fatigue, anxiety, isolation

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

9. 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?

10. Pulmonary Rehabilitation
Are you or someone you know missing the benefits of Pulmonary Rehab?

11. “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
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

12. 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

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

14. 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

15. 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.

16. INITIAL ASSESSMENT Interview Medical History Symptom Assessment
Nutritional Assessment
Educational Assessment

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

18. 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

19. What Can You Do For Your LAM????
Healthy Lifestyle
Pulmonary Rehabilitation
Flu Vaccination
Pneumonia Vaccination
NO SMOKING

20. 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

21. Is Exercise Risky For You?

22. ?????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

23. 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.

24. 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

25. 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

26. 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

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

28. 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

29. Lower Extremity Training
MODALITIES
Treadmill
Chair Aerobics
Water Walking/ Aerobics
Walking
Stationary bicycles
NuStep
Elliptical Trainer

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

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

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

33. 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

34. Emotional & Social Well-Being
Breaking the dyspnea cycle
Coping with depression and anxiety
Learn relaxation techniques

35. 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.

36. 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.

37. 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

38. 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”!

39. 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

40. 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

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

43. Questions?????