PULMONARY REHAB FINAL

Definition of pulmonary rehabilitation

A comprehensive intervention based on a
thorough patient assessment followed by patient-
tailored therapies that 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 to health enhancing behaviors

COPD Facts

• COPD is 3rd leading cause of death in U.S

• COPD costs U.S economy 32.1 billion/ year- 18 direct and 14.1 indirect

• In 2000, the number of women dying of COPD was greater than men

• In 2001, 12.1 million adults diagnosed with COPD

• About 24 million have impaired lung function and are undiagnosed

• 85% caused by cigarette smoking

• The other 15% is due to factors such as occupational and environmental exposures previous serious lung infections or genetic abnormalities such as Alpha-1 Antitrypsin Deficiency

What % of smokers develop COPD

15-20%

• can lay dormant for 20 years before the patient becomes symptomatic 

• 50% of patients die within 10 years of a diagnosis of COPD

in 1965 smoking statistics revealed that for individuals aged 18 years and older 

52% of men were smokers 

34% of women were smokers

in 2006 smoking statistics revealed that for individuals aged 18 years and older

23% of men were smokers 

18% of women were smokers 

Essential components of pulmonary rehab

• promotion of long term adherence 

• education and training

• assessment

• exercise

• psychosocial intervention

• prevention and outcomes ( In middle)

Patient goals and program goals

• Staff should be consistent in their understanding of the goals 

• patient goals need to be established and reviewed with the patient significant other at the beginning of the program 

• goals should be realistic and readily achievable 

• goals may be altered as program progresses 

Patient goals

• Breath better 

• more active- return to work and participate in hobbies 

• improve quality of life 

• improve activities of daily living 

• be able to travel with greater ease 

Program goals

• increase exercise tolerance

• increase patient compliance

• decrease psychological symptoms 

• education 

• infection control 

• treatment plan ( smoking cessation, weight loss or gain) 

• return the pt to gainful employment or active retirement if applicable 

Demonstrated outcomes of pulmonary rehab

• Reduced resp symptoms ( dyspnea and fatigue ) 

• increased exercise tolerance and endurance 

• increased knowledge of pulmonary disease 

• enhanced ability to perform activities of daily living 

• improved health related quality of life 

• improved psychosocial symptoms ( anxiety and depression) 

• reduced hospitalizations 

• return to work for some patients 

Physiologic impairment

Abnormal PFT’s

• FEV1/FVC < 70% of predicted 

• FEV1 < 80% of predicted 

• DLco < 65% of predicted 

Resting hypoxemia SpO2< 90% 

Oxygen desaturation with exercise: SpO2< 90%

Functional impairment

• Dyspnea 

• Occupational performance 

• increased use of medical resources 

• reduction in activities of daily living 

• reduction in physical activity 

Chronic lung conditions appropriate for pulmonary rehab

Obstructive diseases 

• Emphysema 

• persistent asthma 

• bronchiectasis

• chronic bronchitis 

• cystic fibrosis 

Chronic lung conditions appropriate for pulmonary rehab

Restrictive diseases 

• interstitial fibrosis 

• sarcoidosis 

• occupational lung disease: asbestosis and silicosis

Chronic lung conditions appropriate for pulmonary rehab

Neuromuscular diseases 

• myasthenia gravis 

• diaphragmatic dysfunction 

• postpolio syndrome 

Chronic lung conditions appropriate for pulmonary rehab

Chest Wall Diseases

• kyphoscoliosis 

• ankylosing spondylitis 

Chronic lung conditions appropriate for pulmonary rehab

Other lung conditions

• lung cancer 

• pre / post lung transplantation 

• pre / post lung volume reduction surgery 

• pulmonary hypertension 

• post COVID-19 infection 

Conditions that exclude a patient from pulmonary rehab

• unstable cardiac disease 

• severe pulmonary hypertension 

• metastatic cancer 

• severe cognitive defect 

• severe psychiatric disease 

• significant orthopedic impairment 

• tobacco abuse

• pt motivation

• financial situation

• transportation

The Gold spirometric criteria ( post- bronchodilator FEV1) for COPD severity

• MILD

• MODERATE

• SEVERE 

• VERY SEVERE

The Gold spirometric criteria ( post- bronchodilator FEV1) for COPD severity for Mild COPD

• FEV1/ FVC < .70

• FEV1> 80% predicted 

The Gold spirometric criteria ( post- bronchodilator FEV1) for COPD severity of Moderate COPD

• FEV1/FVC < .70 

• 50% < FEV1 < 80% of predicted

The Gold spirometric criteria ( post- bronchodilator FEV1) for COPD severity of Severe COPD

FEV1/FVC < .70

30% < FEV1 < 50% of predicted

The Gold spirometric criteria ( post- bronchodilator FEV1) for COPD severity of Very Severe COPD

• FEVI/FVC < .70 

• FEV1< 30% predicted or FEV1 < 50% predicted plus chronic resp failure 

Medicare Law HR 6331 requieres

Stage 2, 3 and 4 COPD to be approved for pulmonary rehab

Components of initial patient interview

1. Observation skills 

2. Listening skills 

3. Ability to ask the right questions 

Characteristics of the patient in pulmonary rehab

Developmental Stage 

• Includes the physical cognitive and psychosocial elements 

• some patients experienced successful learning in the past ( formal education or a non traditional setting ) 

• other patients experienced frustrations and conflict in dealing with school settings 

• physical changes may have a negative influence, such as a decreased hearing or vision 

• life changing events such as “ empty- nest syndrome” may serve as a stressor in learning 

• shortness of breath, denial and depression all act to decrease the effectiveness of the learning environment 

Characteristics of the patient in pulmonary rehab

Motivation Stage 

• The capacity to learn 

• the readiness to learn 

• the presence of moderate anxiety 

• previous successful experiences 

• a positive teacher learner relationship 

• a social support system 

Characteristics of the patient in pulmonary rehab

Compliance

Elements consistent with patients adherence to behaviors requested of them include: 

• the pt must value the healthy state that pulmonary rehab promotes 

• the pt believes that the actions occurring in rehabilitation will help them attain a healthy state

• the pt sees how others cope with chronic lung disease and better understand and accept the rehab process 

Characteristics of the patient in pulmonary rehab

Health Literacy 

The degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions 

• Research show the strongest predictor of an individuals health status is health literacy 

other factors that may predict an individuals health status are: 

• age

• income 

• employment status 

• education level

• racial or ethnic group

Health literacy

• adults with no insurance are more likely to have basic or below basic health literacy

• a higher percentage of adults with low literacy receive their info about health issues from radio and TV than through written sources, the internet or social contacts 

• avg handout of health information is written at the 10th grade level and the avg american reads at only a 5th grade level 

• low health literacy exacerbates further the negative health impact of the social determinants of health

Characteristics of the patient in pulmonary rehab

Deficits and Disabilities 

• Hearing problems- pts may not use their hearing aids or they may use them improperly 

• vision difficulties- may be overcome with corrective lenses or contacts 

• learning disabilities- usually plague individuals from childhood 

Education sessions taught in pulmonary rehab

• normal pulmonary anatomy and physiology 

• pathophysiology of lung disease 

• description and interpretation of medical tests 

• breathing training 

• bronchial hygiene 

• medication delivery devices 

• medications, including oxygen

Educational materials

Education materials utilized in pulmonary rehab classes should

• be printed in large font 

• be written at a low education level ( 5th grade level) 

• utilize terms and expressions that patients can understand ( do not use medical jargon ) 

Medical Director qualifications

Must be under the direction of a licensed physician ( M.D or Doctor if Osteopathy 

Medical Director responsibilities

• training or experience in the care of patients with chronic resp disease

• ultimate responsibility for the safety and quality of care provided 

• provides supervision of the rahab process 

• responsible for determining the appropriateness of the pulmonary rehab plan of care for the pt 

• Administrative- review policies, protocols and procedures 

• Education- training of healthcare professionals ( RT’s, residents, pulmonary fellows) 

• Clinical- patient evaluations, exercise prescription and treatment plans 

• responsible and accountable for the PR program including overshight of the PR staff

• must re-avulaute each pt and revise the plan of care for each pt at least every 30 days 

• is involved substantially in consultation with staff, in directing the progress of the individuals in the PR program.

Program director qualifications

• the american association of cardiovascular and pulmonary rehab- recommends the programs coordinator have graduated from an accredited program such as RT, PT, RN, OT or exercise physiologist and hold a national certification or licensure 

• AACVPR recommends that the coordinator has a minimum of 3 years of clinical pulmonary rehab experience after a BS degree or 

• five years of pulmonary rehab experience after an associates degree 

Program director is responsible for

• coordinator needs to be competent in reimbursement, documentation and marketing strategies 

• duties include clinical, administrative, educational and advocacy

• serves as the liaison among the pt, medical director , referring physicians and rehab staff

   

Physician oversight of pulmonary rehab exercise sessions

• Physician must be in close proximity to the rehab area

• supervising physician does not have to be the medical director

• direct supervision of pulmonary rehab must be established by each program and documented in the protocol manuals

Common symptoms observed of patients in pulmonary rehabilitation

Psychological

• Depressed mood- up to 59% have depression

• Anxiety- among COPD patients ranges from 30% to 40%

• Anger

• Guilt

• Embarrassment

Common symptoms observed of patients in pulmonary rehabilitation

Cognitive

• mild deficits

• impaired psychomotor speed

• impaired problem solving

• impaired attention

Common symptoms observed of patients in pulmonary rehabilitation

Social

• reduced social activity

• change in family roles

• reduced independence

Common symptoms observed of patients in pulmonary rehabilitation

Behavioral

• impaired ADL’s

• smoking

• malnourishment

• decreased exercise capacity

• medication noncompliance

Psychological functioning

evaluation of psychological functioning includes tools to assess symptom specific indicators such as

• brief symptoms inventory

• beck depression inventory

• the COPD coping questionnaire

• the COPD self efficacy scale

Beck Depression Scale

The BDI is a self report rating inventory introduced in 1961 that measures characteristics attitudes and symptoms of depression

• BDI uses 21 items to measure the severity and depth of depression symptoms as listed in the american psychiatric association diagnostic and statistical manual of mental disorders

Scoring of the beck depression inventory

Patients rate 21 symptoms and attitudes of
depression on a scale of zero to three to best
reflect their level of intensity.

• Each of the symptoms in the Beck Depression
  Inventory fit the diagnostic criteria of the DSM-V.
  - An example of a question and rating scale:
  0. I do not feel sad
  1. I feel sad
  2. I am sad all the time, and I can’t snap out of it
  3. I am so sad and unhappy that I can’t stand it

Beck scoring

Score of 1-10: These ups and downs are considered
normal
 Score of 11-16: Mild mood disturbance
 Score of 17-20: Borderline clinical depression
 Score of 21-30: Moderate depression
 Score of 31-40: Severe depression
 Score of 40+ Extreme depression

The COPD self efficacy scale

Used to measure the degree of
confidence patients with COPD have
regarding their ability to avoid breathing
difficulty while participating in specific
activities.

• This scale rates the strength of
  expectations of managing or avoiding
  breathing difficulties in 34 situations such
  as . . . .
  o physical exertion
  o weather/environmental
  o behavioral factors
  o intense emotional situations

Treatment if psychological distress

• counseling

• psychotherapy

• exercise, rehab

• support groups

The three commonly used QOL measures:

• SF 36

• St Georges Respiratory Questionnaire

• CAT assessment

Gold definition of COPD

COPD is a heterogeneous lung condition
characterized by chronic respiratory symptoms
(dyspnea, cough, sputum production and/or
exacerbations) due to abnormalities of the
airways (bronchitis, bronchiolitis) and/or alveoli
(emphysema) that cause persistent, often
progressive, airflow obstruction.

Arterial hypoxemia ranges

35 to 45 mmHg

Airflow limitations in COPD ( FEV1 post bronchodilator )

• If airflow obstruction is minimally improved, then
  chronic airflow obstruction is considered.
  

• If airflow obstruction has a high improvement, then
  Asthma is considered.
  

• ATS states that improvement of airflow is considered
  significant for increases > 10% for either FEV1 or FVC
  (use of GLI 2012 reference equation is required for this
  calculation)

Static Hyperinflation

is a permanent elevation of the
Functional Residual Capacity (FRC) at rest due to the
loss of elastic recoil

Dynamic Hyperinflation

occurs with exercise and is due
to expiratory airflow limitation when ventilatory demands
are increased and expiratory times are reduced.

Hyperinflation

An increased RV/TLC ratio in the presence of
increased TLC equals hyperinflation

Air Trapping

An increased RV/TLC ratio with a normal TLC equals

Purpose of the MRC dyspnea scale

to measure the severity of breathlessness (dyspnea) and its impact on a patient's daily activities and mobility

How is CAT score range

5-40

CAT score impact level

> 30 Very High
• > 20 High
• 10-20 Medium
• < 10 Low
• 5 (Upper limit of normal
in healthy non-smokers)

CAT is a tool used to

measure health status

Involuntary weight loss criteria:

Weight loss > 10% of usual body weight in the past 6 months

or

Weight loss > 5% in the past month

BMI calculation

Weight in kilograms divided by height in meters x height in meters= kg/m2

Carbohydrate oxidation produces an RQ near

1.0

Fat oxidation produces an RQ near

0.71

Protein oxidation produces an RQ of

.82

Depletion of fat free mass in males

FFM < 16 kg/m2

Depletion of fat frass mass in females

FFM < 15 kg/m2

cachexia

underweight and low FFM

Semistarvation

underweight and relative preservation of FFM

Sarcopenia

normal weight and depletion of FFM

Modified Borg Scale is considered

subjective

10 point category ratio scale with descriptive terms

Unidimensional instruments

• visual analog scale

• modified borg scale for breathlessness

• medical research council breathlessness scale

Multidimensional instruments

• Chronic resp disease questionnaire

• san diego shortness of breath questionnaire

Critical strategy for decreasing dyspnea

exercise

BODE index

B- body mass index

O- degree of obstruction

D- dyspnea

E- exercise endurance ( 6 min walk test )

• A higher BODE score correlates with an increased
  risk of death.
  • Improvement in the BODE score is associated with
  better survival over time

The primary outcome is 6 minute walk distance is

feet or meters

A 6 minute walk test with a value of less than 350 meters is considered

abnormal

Minimum clinical important distance is

30 meters for adults with chronic resp disease

Calculate predicted max HR

220- age in years = max HR

the target HR range for exercise

60%- 85% of max HR

Average 6 MWT walking speed

speed= total distance / time x 0.01136

Premature Ventricular Contractions

V-tach

V-Fib

STEMI

Determining Limitations During Graded Exercise testing

• dynamic hyperinflation

• excerise-induced bronchospasm

• rising VD/VT

• rising PaCO2

• failling SpO2

• falling blood pressure

• chest pain

• arrhythmias

• musculoskeletal

• deconditioning

Purpose of the tinetti gait and balance instrument

used to predict the risk of a fall of an elderly patient

Who is a candidate for home care

patients that

• are newly diagnosed with a disease that requires education and training

• have a terminal disease and desire to be treated at home

• require medical devices that necessitate monitoring and maintenance

• have repeated hospitalizations

Candidates for home care part 2

• patients with functional limitations- cognitive disabilities, inability to perform ADL’s and inability to monitor and administer medications

• patients with physical limitations- dyspnea that limits ADL’s, ambulatory limitations and difficulties with speech, vision or hearing

Benefits of home care

• improves quality of life

• is cost effective

• encourages self- management and independence

• allows for ongoing monitoring of patient response to treatment

• reduces the need for clinic visits, ER visits, and hospital admissions

• reduces risk of nosocomial infections

Role of the home care RT

• teach patients how to correctly and safely use resp care equipment

• pt evaluation and assessment

• train the caregivers to perform reps care procedures

• provides education and training to other member of the home care team

Part A

covers inpatient care in hospitals , skilled nursing
facilities, hospice care, and some home health care

Part B

is an optional coverage of doctor’s services,
outpatient care, services of PT, OT, and some home health
care.
◦ Patients pay a monthly premium to cover the cost of Part B.
 2024 Medicare premium is $185 per month;
 Increases every year; 2026 premium is estimated to be
$206.50
 Medicare provides reimbursement for Nursing, Physical
Therapy, Occupational Therapy, Speech Therapy, Social
Workers, and Home Health Aides.
 Current Medicare law does not provide direct
reimbursement for Respiratory Therapy services in the

H.R 941 Medicare Resp Therapy initiative act of 2011

• To amend title XVIII of the Social Security Act to provide for
  Medicare coverage of services of qualified respiratory
  therapists performed under the general supervision of a
  physician.
  

• Representatives of the AARC proposed to revise the Medicare
  statute to add recognition of respiratory therapy services as a
  separate Medicare Part B benefit and to permit qualified
  respiratory therapists to provide respiratory therapy services
  under the general supervision of a physician.

Reimbursement for DME equipment and supplies

DMEPOS

Reimbursement for most Durable Medical Equipment
Prosthetic/Orthotics and Supplies (DMEPOS) is
established by fee schedules.

Reimbursement for DME equipment and supplies

DMEPOS competitive bidding program

Mandated by Congress through the Medicare
Prescription Drug, Improvement, and Modernization Act
of 2003 (MMA).

• There is no active competitive-contract round right
  now for respiratory DME - CMS has a temporary gap
  period while it finishes rulemaking

FDA definition of a tobacco product

A “tobacco product” is defined by the FDA as a
product made or derived from tobacco and intended
for human consumption, including any component,
part or accessory of a tobacco product

How an individual becomes tobacco dependent

For a patient to be tobacco dependent, two
independent processes must occur:

• Nicotine in cigarette smoke must activate the
  CNS genetic systems, creating the cellular
  substrate for nicotine dependence.
  

• The development of classic conditioned
  responses to cigarettes.

Nicotine in a cigarette

11.9 mg to 14.5 mg

Smokers nicotine yield is up to

2mg per cig