COPD Educator Course.www.copdegypt.org

1. Pulmonary Rehabilitation
Living With COPD

3. “ The Downward Spiral ”
Airflow
limitation
Inactivity
Isolation
Dyspnea
Muscle
Impairment
Hyper Inflation
Severe
Dyspnea
Deconditioning
Weight Loss
Depression
Poor Quality
of Life
Mortality
Hypoxia

4. (C)
Less symptoms,
high risk
(D)
More
symptoms,
high risk
(A)
Less symptoms,
low risk
(B)
More symptoms,
low risk
GOLD 2013
Combined assessment of COPD
Risk
≥2
0
1
Exacerbationhistory
mMRC ≥2
CAT ≥10
mMRC 01
CAT <10
Risk
GOLDclassificationofairflow
limitation
1
2
3
4
 Assess symptoms first
 Assess risk of exacerbations next
 Patient is now in one of four categories:
Adapted from GOLD 2013

5. Patient Characteristic Spirometric
Classiffication
Exacerbations
per year
mMRC CAT
A
Low Risk
Less Symptoms
GOLD 1-2 ≤ 1 0-1 < 10
B
Low Risk
More Symptoms
GOLD 1-2 ≤ 1 > 2 ≥ 10
C
High Risk
Less Symptoms
GOLD 3-4 > 2 0-1 < 10
D
High Risk
More Symptoms
GOLD 3-4 > 2 > 2
≥ 10
Combined COPD
assessment
When assessing risk, choose the highest risk according
to GOLD grade or exacerbation history
Adapted from GOLD 2013
(one or more hospitalizations for COPD exacerbations
should be considered high risk )

6. GOLD 2013
(C)
(B)(A)
(D)
1
2
4
3
1
0
Or
more
2
mMRC 0-1
CAT<10
mMRC 2+
CAT10+
Risk
(GOLDclassificationofAirflowLimitation)
Risk
(ExacerbationHistory)
Symptoms
The treatment recommendations are linked to the 4 new categories A, B, C
and D:
COPD Treatment:
FIRST CHOICE of Therapy:
SABA or SAMA
Alternatives: SABA and SAMA, LABA
or LAMA
(previously mild-moderate)
FIRST CHOICE of Therapy:
• LABA or LAMA
• Alternatives: LABA and LAMA
(previously mild-moderate)
FIRST CHOICE of Therapy:
• LABA/ICS and LAMA
Alternatives: LABA and LAMA,
ICS/LABA and PDE4 inhibitor,
LAMA and PDE4 inhibitor.
(previously severe-very severe)
FIRST CHOICE of Therapy:
•LABA/ICS or LAMA
Alternatives:
•LABA and LAMA
(previously severe-very severe)
MRC: Medical Research Council questionnaire
CAT: COPD assessment test

7. Pulmonary Rehabilitation Position
Statement- ATS 2006
PR is an evidence-based multidisciplinary, and
comprehensive intervention for patients with chronic
respiratory diseases who are symptomatic and often
have decreased daily life activities. Integrated into
individualized treatment of the patient, PR Is designed
to reduce symptoms, optimize functional status,
Increase participation, and reduce health care costs
through stabilizing or reversing systemic
manifestations of the disease.

8. Pulmonary Rehabilitation Team:
• RT - Medication, supplemental
oxygen, infection control,
airway clearance, diagnostic
testing
• PT - Strength and Endurance-
6 rep max, ROM, exercise
prescription, body mechanics
• OT-Activities of Daily Living,
relaxation
• SIN - Depression, sexual
dysfunction, family/social
issues /support
• Chaplain - End of Life, family,
coping
• Dietician - Nutrition
• RN - Medication, Physical
Assessment
• MD - H & P, review all testing,
plan of care

9. Basic PR Equipment:
 Pulse oximeter
 BP cuff/monitor
 Stethoscope
 Treadmill
 Stationary Bike
 NuStep
 Weights
 Upper body ergometer
 Theraband
 Oxygen
 Emergency

10. Educational Material / Devices
 Patient literature / books
 Lung model
 Medication devices
 Oxygen delivery devices
 Airway clearance devices
 BORG scale
 QOL measurement tool
 Depression scale
 Intimacy Handout
 Relaxation
 Exercises

11. Lung Volume Reduction Surgery:

12. PR Patient Goals:
 Breathe easier
 Be more active
 Have a better quality of life
 Take a shower, clean house cook
 Travel with greater ease
 Experience fewer hospitalizations
 Go to a movie
 Play Golf again!

13. PR Patient Goals:
 Individual treatment plan
 Integrate prevention and long-term adherence
 Increase strength, endurance, exercise
 Control/alleviate symptoms
 Decrease anxiety/depression
 Train-Motivate-Educate
 Improve QOL
 Reduce economic burden

14. Patient Selection Criteria for PR:
 COPD, IFP, Lung Transplant, LVRS, etc.
 Dyspnea/fatigue with chronic respiratory
symptoms
 Impaired health related QOL
 Decreased functional status
 Difficulty performing ADLs
 Difficulty with medication regimen

15. Patient Initial Assessment
-Medical History-
 Respiratory history
 Active medical problems
 Surgical/other medical history
 Family history of respiratory disease
 Use of Medical Resources
 Current medications
 Allergies /drug intolerance
 Smoking history
 Occupational, environmental exposures
 Alcohol / other substance abuse history

16. Physical Assessment:
 Vital signs
 Breathing pattern
 Accessory muscle use
 Chest exam
 Signs of heart disease
 Finger clubbing
 02 saturation
 Upper and lower extremity evaluation

17. Diagnostic Tests - Essential
 Spirometry
 02 saturation at rest/exercise
 CXR
 EKG
 Six Minute Walk
 Screening for anxiety and depression

18. Diagnostic Tests:
 Complete PFT
 CPET
 Sleep study
 Alpha-1 antitrypsin
 CV testing
 Bone density
 Skin tests
 Sinus x-rays
 NPO

19. Six Minute Walk Test:
Determines how far a patient walks in six
minutes
Premeasured - hallway or track
Record: distance walked, number of rest stops,
can monitor HR and 02 sat
Clinical practice guidelines- ATS
Is useful in determining exercise prescription /
supplemental oxygen

20. Symptom Assessment:
Dyspnea – BROG
Fatigue
Cough
Sputum Production
Wheeze
Hemoptysis
Chest Pain
Post nasal drainage
Reflux, heartburn
Edema: pedal,
pretibial
Dysphagia,
swallowing problems
Extremity pain or
weakness

21. Functional Status Assessment:
Physical limitations
Muscle strength and endurance
Joint pain, limited ROM
Oxygen needs
Dyspnea
Lack of understanding of
Fitness and exercise
Fear of exertion
Inability to pace activities
Balance abnormalities
Gait instability
Pain levels and locations

22. Pain Assessment:
Assessment should be made during initial
evaluation and with daily sessions:
▫ Location
▫ Duration
▫ Intensity - 1-10 or facial descriptor seale
▫ Character

23. Activities of Daily Living (ADL)
Assessment:
 Functional task performance
 Breathing techniques with ADLs
 Extremity function
 Energy Conservation
 Need for adaptive equipment
 Food preparation
 leisure impairment
 Sexual function
 Vocational evaluation

24. ADL Assessment Tool
Patient performs 3 minimum, 3 moderate, 3
maximum tasks
 BORG Scale
 Functional measure of breathing
 Dyspnea scale
 Pain
 Oxygen saturation
 Heart rate

25. Minimal Level of Tolerance:
 Eating, table top activities, paperwork
 Grooming (shaving, make-up, brushing teeth,
washing dishes, etc.)
 Simple cooking preparations ( microwave,
washing produce, cutting vegetables, etc.)
 Socializing, talking, laughter
Activities performed In a sitting or standing position with
occasional reaching

26. Moderate Level of Tolerance:
 Dressing, showering, bathing
 Light housework, putting away laundry
 Standing up, sitting down
 Putting items in cabinets/closets
Activities involving transfers, changing from one position
to another or repeated reaching

27. Maximum Level of Tolerance:
 Climbing stairs, bleachers
 Heavy gardening
 Car maintenance
 Heavy household chores
 Walking distances, mall shopping, out for social
..activities
 Carrying heavy objects
Activities requiring endurance, frequent changes in body
positions and strength.

28. RTs and ADL Assessment

29. Nutritional Assessment:
 Height and weight
 Body mass index (BMI)
 Weight changes
 Dietary/eating patterns
 Shop/ food preparation
 Fluid Intake
 Alcohol consumption
 Need for nutritional supplements

30. Educational Assessment:
 Knowledge of disease and treatment
 Hearing
 Vision
 Cognitive ability
 Language
 Literacy
 Cultural diversity

31. Psychological Assessment:
 Perception of QL and ability to adjust
 Interpersonal conflict
 Anxiety and depression
 Substance abuse
 Addictive disorders
 Neuropsychological impairment
 Sexual dysfunction
 Motivation for PR

32. PR Orientation:
 Introductions - Patients, Team
 Why am I here? What to expect
 What is COPD?
 Communicating with Health Care Providers
 Can I really Exercise?
 What, Me Stressed?
 PR agreement/schedule

33. Breathing Retraining:
Diaphragmatic breathing:
1. Sit comfortably and relax your shoulders.
2. Put one hand on your abdomen, now inhale slowly
through your nose, Push your abdomen out while
you breath in)
3. Then push in your abdominal mussels and breath
out using your pursed-lip technique, (you should
feel your abdomen go down)
Note :
-Repeat the above maneuver three times and then take a little rest.
-This exercise can be many times a day
-By doing diaphragmatic breathing you help your lung expand and take in more air.

34. Supplemental Oxygen / Devices
 Assessment
 Access
 Choosing the right device
 Lifestyle
 Compliance

35. Intimacy / Sexuality:
 More than 67% COPD have problems
 Frequent problems with relationship, degree of
affection, communication, level of satisfaction
with partner
 Sensitive topic - keep it factual

36. Pulmonary Rehab – Exercise
Training:
 Individualized Plan
 Patient Safety - use of equipment
 Exercise Prescription
 Stretch/Flex Neck, upper body and lower body
 Upper body strength training wts, resistance
bands, UBErgometer
Lower body strength training wts, treadmill,
bike, NuStep, stairs

37. Pulmonary Rehab – Exercise
Training Prescription:

38. Exercise Program-Stretching:
Flexibility exercise refers to stretching, range of
motion, and movement exercises.
Flexibility reduces soreness and risk of muscle
injury.

39. Exercise Program-Resistance
Training:
Resistance training includes:
▫ hand and leg weight exercises
▫ wall pulleys, elastic bands, or working against
body welghr or gravity
Resistance training improves:
▫ Endurance
▫ Muscle tone
▫ Joint stability and injury prevention
▫ Posture
▫ Bone density and strength
▫ Activity tolerance

40. Pulmonary Rehab-Water Based
Exercise:
Evidence-based:
▫ Improvement to land based
Lane walking
Resistance:
▫ Kick board
▫ Hand paddles
▫ Noodles
▫ Floatation devices

41. Patient Discharge from PR:
• Patient and Program Goals
met?
• Medication Profile
• Supplemental Oxygen
• Six minute walk
• Nutritional
• Inspiratory muscle training
• Six Rep Max
• Exercise Stress Test
• Post QOL (St. George, SF-36)
• Home Exercise Program
• Effective use of
coping/relaxation techniques
• Demonstration of
EC/WS/Body techniques
during activity performance
with breathing techniques
• Return to
leisure/community/social
activities and life roles
• Re-evaluation of ADL
• Family Community Support
• Physician Report
All testing performed during the assessment prior to
entering PR is reassessed with patient discharge.

42. Pulmonary Rehab – Measuring
Outcomes:
Quality of Life –
▫ St. George QOL Questionnaire, SF-36
Exercice and Endurance- 6MW, Exercise Stress
Test
Strength- Six Rep Max
Activities of Daily Living function
Smoking Cessation
Nutrition
Symptoms - Shortness of Breath

43. Benefits of Pulmonary
Rehabilitation:
 Reduced respiratory symptoms
 Increased exercise performance
 Increased knowledge -disease/management
 Enhanced ability to perform ADLs
 Improved health-related QOL
 Improved psychosocial symptoms
 Reduced hospitalizations and use of medical
..resources
 Return to work for some patients