Systolic Heart Failure • Systolic heart failure is also known as HF with reduced left ventricular ejection fraction (LVEF) as well as HF with left ventricular systolic dysfunction • Systolic heart failure occurs when the heart muscle can’t contract hard enough to squeeze out a sufficient amount of blood, resulting in a reduced ejection fraction. Think of the analogy of trying to squeeze water out of a water bottle and only using 2 fingers to do so. • Systolic dysfunction usually begins in the left ventricle and is usually due to MI, cardiomyopathy, myocarditis, or valvular heart disease 8 20
Diastolic Heart Failure • Also known as HF with preserved LVEF • Diastolic heart failure occurs when the heart is unable to adequately fill with enough blood. This occurs due to the ability of the heart muscle to relax is decreased or slowed, making it difficult for the ventricle to fill with enough blood. Think of the water bottle analogy again, but this time you are unable to fill the water bottle with enough water to squeeze out an adequate amount. • Patients with diastolic heart failure will have a preserved ejection fraction, but will have a reduced stroke volume. 21
Left/Right Sided heart failure • Heart failure typically begins in the left ventricle, but may affect either the left side, the right side or both sides of the heart. 8 • With left sided heart failure, fluid is backed up into the patient’s lungs leading to shortness of breath • With right sided heart failure, fluid is backed up into the periphery with patient exhibiting edema in the abdomen, legs and the feet 22
Causes 5 Most common cause of HF is Coronary Artery Disease, leading to Myocardial Infarction and ischemic cardiomyopathy 23
Causes • Other causes include: • systemic hypertension • valvular heart disease • severe renal failure • constrictive pericarditis • dilated cardiomyopathy • Hypertrophic cardiomyopathy • Infiltrative disorders • Peripartum cardiomyopathy • Myocarditis • Infectious endocarditis • arrhythmia 24
Diagnostic Criteria • Cardinal symptoms include • Weight gain of greater than 3 pounds in one day • Dyspnea • Fatigue • Exercise intolerance • Fluid retention 25
Symptoms • Classic symptom is dyspnea. Initially, dyspnea occurs with activity and as HF worsens, dyspnea will occur at rest • Fatigue • Resting heart rate > 100 bpm • Orthopnea • Third heart sound • Nocturia • Cold extremities 26
Symptoms • Pulmonary edema • Peripheral edema • Diaphoresis • Global muscle atrophy • Organ system dysfunction. Heart failure begins as a single organ system problem, but progresses to a multiple organ system problem as blood flow is decreased 27
ACC/AHA Stage A and B “at risk” stages 6 Stage A Patients at risk of These are patients with a developing heart history of conditions that failure can put them at increased risk of developing heart failure such as CAD, hypertension, or DM Stage B Patients who have This group includes those developed structural individuals who have had a heart disease but have previous cardiac incident not shown such as an MI or LVH (left signs/symptoms of ventricular hypertrophy) heart failure 28
Stage C and D Stage C These are patients that These individuals are have current or prior currently undergoing symptoms of heart heart failure failure with underlying treatment structural disease of the heart Stage D These are individuals These are individuals with advanced structural with frequent heart disease of the heart, failure marked symptoms of hospitalizations, heart failure at rest. End ‐ possible referral to stage heart failure hospice services 29
NYHA Classification of Heart Failure 9 • Class I (mild) puts no limits on physical activity. Everyday activity does not cause fatigue, shortness of breath, or palpitation. BNP 100 ‐ 300 pg/ml • Class II (mild) shows slight limitation with physical activity. Patient is comfortable at rest but may experience fatigue, shortness of breath, or palpitation with everyday activity. BNP 300 ‐ 599 pg/ml • Class III (moderate) shows obvious limitation with physical activity. Patient shows no symptoms at rest but displays fatigue, palpitations, and shortness of breath with less than ordinary activity. BNP 600 ‐ 899 pg/ml • Class IV (severe) patient in discomfort with any physical activity. At rest, there are signs of cardiac insufficiency. 30 BNP >900 pg/ml
Precautions/Relative contraindication to exercise 9 • Monitor vital signs and general symptoms at all times • Therapist should note if there are any specific precautions or contraindications from the physician • Heart rate > 100 bpm in supine at rest • Ventricular arrhythmia *Keep risk versus benefit ratio in mind 31
Precautions/Relative Contraindications to exercise • Class IV HF (patient has discomfort with any physical activity and at rest; there are signs of cardiac insufficiency) • Use of dobutamine (acute care) • Body mass increase > 3 to 5 lbs over course of 1 to 3 days • Systolic blood pressure decreases with exercise • Systolic blood pressure > 180 mm hg or diastolic blood pressure > 110 mm hg 81 32
Absolute Contraindications to Exercise 10 • New onset of atrial fibrillation • Uncontrolled Diabetes * • Acute illness or fever • Thrombophlebitis or embolism • Pericarditis or myocarditis • Moderate to severe aortic stenosis • Further reduction in exercise tolerance, or dyspnea at rest, or upon exertion over the last few days • Exercise ‐ training induced hypotension 33
Patient Evaluation—Invest time in patient history • History should include cardiac history. Document date of diagnosis and classification (I ‐ IV) if available and any cardiac events, cardiac surgeries • Diagnostic tests performed ‐ blood tests, EKG, echocardiogram, peak VO2 to determine peak exercise intensity • Symptoms • Sleep disturbance/quality of sleep, nocturia, sleep apnea, how many wakings/night, number of pillows used, is patient able to sleep in bed? • Respiratory status, use of oxygen, cpap • Medical management including dietary restrictions, alcohol consumption • Medication Review 34
Medications used to treat heart failure Diuretics • Thiazide diuretics 11 Examples include chlorothiazide, chlorthalidone, hydrochlorothiazide, indapamide, metolazone. Possible side effects include hyponatremia, hypokalemia, decline in renal function, gout, or hyperglycemia • Loop diuretics. Examples include bumetanide, furosemide, torsemide. Possible side effects include hypokalemia, hyponatremia, low magnesium levels, and high levels of calcium. These can lead to weakness and possible abnormal heart rhythms • Potassium sparing diuretics. Examples include amiloride, triamterene, spironolactone. Side effects can include feeling faint, dizzy, confused, sleepy, and hyperkalemia. 35
Medications used in HF treatment ACE inhibitors ACE inhibitors are used in the treatment of heart failure as a vasodilator, helping to improve blood flow and decrease the work load on the heart. Examples include enalapril, lisinopril, and captopril Side effects of ACE inhibitors can include low blood pressure, low white blood cell count, and kidney or liver problems 36
Medications used in HF treatment Angiotensin II Receptor Blockers (ARBS ) ARBS have many of the same effects as ACE inhibitors, but may work well for patients that have difficulty tolerating ACE inhibitors. Examples include losartan, irbesartan, and valsartan May work well with patients with chronic kidney disease Side effects can include low blood pressure, elevated potassium levels, muscle or joint pain, dizziness, drowsiness, headache, and nausea/vomiting 37
Beta Blockers • Examples include propranolol, metoprolol, acebutolol, atenolol • Side effects can include fatigue, cold hands and feet, weight gain. Less common side effects can include shortness of breath, trouble sleeping, and depression • Beta blockers are good for the management of diastolic heart failure by decreasing the heart rate and allowing the ventricles to fill with more blood between contractions • Should be avoided in patients with asthma secondary to medication may trigger asthma attacks • May block signs of low blood sugar in patients with diabetes, including increased heart rate. Diabetic patients should monitor blood sugar 38
Calcium Channel Blockers • Examples include amlodipine, diltiazem, verapamil, felodipine • Calcium channel blockers work by relaxing blood vessels, increasing blood supply, and decreasing work load on the heart • Side effects can include constipation, headaches, palpitations, dizziness, rash, drowsiness, flushing, swelling in lower extremities, nausea 39
Beers Criteria 4 • Medication included in the Beers Criteria as PIM in older adults include disopyramide, as it may induce heart failure in older adults. • Dronedarone should be avoided in patients with recently decompensated heart failure • Digoxin listed as having questionable effects on patients with heart failure, may be associated with increased mortality in older adults with heart failure. Most recent update to AGS Beers Criteria recommends digoxin not be used as a first line medication, and when it is used, dosages should be below .125 mg. • Amiodarone is a medication used to maintain normal heart rhythm, but has greater toxicities than other medications like it. However, it may a reasonable first ‐ line medication in patients who also have heart failure or left ventricular hypertrophy 40
Patient Evaluation • Past medical history • Depression is common with this population affecting up to 40% of patients with chronic HF with clinical depression and up to 75% of patients with chronic HF reporting elevated depressive symptoms 12 . Be sure to screen for depression (PHQ 2 or PHQ 9) • Additionally, approximately 20 to 30% of patients with chronic HF also have COPD 13 • Patient centered goals • Functional limitations, ADL assistance required • Living environment, number of stairs to enter home as well as within home, handrails, grab bars in bathroom, caregivers 41
Lab Values in Heart Failure 13,14 • Elevated BUN levels > 45 mg/dl at discharge from hospitalization related to increased readmission rate. Elevated levels indicate decreased renal blood flow • Increased Creatinine levels also indicate decreased renal blood flow • Hyponatremia defined as serum sodium levels concentration less than 130 mmol, one study demonstrated 33.7% of patients with heart failure had hyponatremia. • Hyponatremia has been shown by numerous studies to be indicative of increased mortality risk. • Patients with hyponatremia also have been shown to have longer hospital stays 42
Lab Values • BNP 15 • BNP is B ‐ type natriuretic peptide • The strongest independent predictor of heart failure. • Substances that are released into the blood stream when the heart is stretched and is working hard • Used to detect, diagnose, and evaluate the severity of heart failure • Levels are increased in heart failure, correlate to NYHA classification 43
Pro BNP • NT ‐ Pro BNP 76 • Similar to BNP, as it is a substance present in the blood stream produced when the heart is stretched or strained. • NT ‐ Pro BNP is a precursor to BNP, and has a longer half life. • Median values, NT ‐ Pro BNP loosely correlated with NYHA heart failure classes: • Class I: 377 • Class II: 1223 • Class III: 3130 • Class IV: not provided 44
Evaluation • BMI, body weight measurements needed daily (assess patient’s ability to step on and balance on the scale) • Arousal and attention • Assistive and adaptive devices • Balance in sitting and standing. Retrospective study determined 94.7% of patients with HF in a home health setting were at risk for falls (16) • Cardiorespiratory function and endurance. Monitor the following at rest, in sitting and standing, with ADLs, during and after gait, and after a rest period • Blood pressure, heart sounds, heart rate, borg rating of perceived exertion, O2 saturation levels • Assess inspiratory muscle strength as indicated using an 45 inspirometer
Evaluation • Circulation, assess dorsalis pedis/radial pulses • Strength • Range of motion • Gait • Functional mobility • Posture • Self care/ ADLs 46
Outcome Measures • Assess patient health literacy regarding heart failure • Dutch Heart Failure Knowledge scale or the Atlanta Heart Failure Knowledge Scale • Assess cardiopulmonary endurance and function: • 6 MWT, Borg RPE scale , 10 meter incremental shuttle ‐ walk test, 2 MWT, 2 minute step test, stair climbing ability • Assess balance: • Berg Balance Scale, Dynamic Gait Index • Quality of Life: • Disease specific questionnaire include Kansas City Cardiomyopathy Questionnaire, Minnesota Living with Heart Failure Questionnaire (need permission from McMasters University), Chronic Heart Failure Questionnaire 47
Exercise Guidelines • Review relative and absolute contraindications to exercise. • Supervised exercise programs have been shown to reduce mortality in patients with heart failure. • Current clinical standard for exercise programs for patients with heart failure is moderate ‐ intensity aerobic exercise. 48
Monitoring response to exercise, use of heart rate max • Unless your patient has participated in exercise testing and metabolic gas analysis, you cannot rely on heart rate as a reliable tool to monitor exercise response. This is due to many cardiac medications blunting a heart rate response to exercise. • Utilizing Borg’s Rate of Perceived Exertion (RPE) or Rate of Dyspnea to monitor patient’s response to exercise. 49
Exercise Guidelines • All exercises should be tailored to the patients individual level of tolerance with maintenance of appropriate vital signs. • Compromised patients can begin with intervals of 5 to 10 minutes of exercise, 2 ‐ 3 times per week. Progress minutes of exercise gradually, as tolerated, to 20 to 30 minutes, 3 or more times per week. Educate patient on self monitoring of blood pressure, heart rate, oxygen saturation, and Borg RPE. 9 50
Exercise Guidelines • A combination of strength training along with interval training has been reported to be beneficial 17 • Strength training for upper and lower extremities and trunk using light weights, resistance band, weight machines or body resistance begin with low resistance and high repetitions, avoiding the Valsalva maneuver • May begin strength training with 1 set and progress to 3 sets of each exercise, performing 10 to 15 repetitions 2 to 3 days per week • Once patient able to lift a weight 10 to 15 repetitions without muscular fatigue, increase amount of weight lifted to an amount the patient can lift only 8 to 10 reps without having to stop due to muscular fatigue • Older persons with heart failure have an increased risk of skeletal fracture (e.g. hip fracture) and require supervision or restrictions for exercise modalities that can cause increased risk for falls 18 51
Monitoring for worsening of Symptoms during therapeutic interventions • The goal is to identify worsening of symptoms as early as possible, refer back to physician with worsening of symptoms . • Vital signs must be monitored before, during, and after therapy treatments and progression of treatments. If patient doesn’t have the expected vital sign reaction to exercise, this information needs to be reported to the patient’s physician • Monitoring body weight with each therapy session. You should know your patient’s daily “dry weight” with each therapy session • Lung auscultation is also helpful. Listen for the development or worsening of crackles. • Assessing heart sounds is also helpful. Listening for the 52 development or worsening of S3 heart sound.
Aerobic training • Patients can initially work at 40 to 50 % of VO2 max, progressing to working at 60 to 80% of VO2 max. Utilizing Borg’s RPE exertion, initially patients should work at around 10 ‐ 14/20, progressing to working at 15 ‐ 16/20 • Moderate intensity aerobic training has strong evidence to support use in therapy programs to decrease mortality in patients with heart failure. • Protocols include a frequency of 3 to 5 times per week, with a duration of 20 to 45 minutes of continuous exercise or interval training 53
Interval Training • Many patients with heart failure are unable to tolerate continuous exercise. These patients may benefit from interval training in one session, or even possible multiple sessions over the course of a day if your setting allows (Long term care) • Optimal protocol appears to consist of short intervals with passive recovery. • A randomized study conducted in France used a protocol with short intervals (30 seconds) interspersed with passive recovery time. Patients were better able to tolerate exercise, increase their total exercise time without compromising training time spent at >85% VO2 max 19 54
Is High Intensity Exercise safe/more effective than moderate intensity exercise? • A systematic review was conducted in 2013 that looked at high intensity interval training and found there was insufficient evidence to support high intensity interval training 20 . • In another study conducted in Norway, group ‐ based high intensity aerobic interval training demonstrated improvement in functional capacity and quality of life. The study included 80 patients with stable chronic heart failure who performed high intensity interval training twice a week for 65 to 80 minutes for 16 weeks. At 4 months, the exercise group showed an improvement in the 6 minute walk test by 58 meters versus the control group showed a decline of 15 meters. At 12 months, the exercise group showed an improvement of 41 meters versus the control group showed a decline of 20 meters 22 . 55
Inspiratory Muscle Training • Patients with heart failure can experience weakness of respiratory muscles, as well as increased airway resistance. Signs can include dyspnea, especially with exertion. Patients may experience early onset of fatigue with exercise training, and patients may benefit from inspiratory muscle training. 24 • Due to changes in ventricular function, reduced lung compliance, increased airway resistance, patients with HF have an altered breathing pattern. This could lead to patient’s experiencing increased respiratory muscle fatigue, leading to decreased activity and exercise tolerance 56
Inspiratory Muscle training • Protocols include performing inspiration at 30% max inspiratory pressure (Pimax) initially, progressing gradually to 60% Pimax for two 15 minute sessions daily, or 30 minutes once daily • Gradually increase reps, taking rest breaks as needed, with multiple studies having subjects performing 30 minutes daily. Instructions are to take rest breaks as needed, but perform as many reps as possible during time frame • Devices such as the respiratory muscle trainer (Respironics Health) can be used. Various small diameter orifices are used to provide resistance during inhalation • If your patient also has a history of COPD, be sure to include expiratory muscle training in your therapy program to avoid trapping of air. 57
Aquatic Therapy 25 • During swimming, the hydrostatic pressure compresses superficial veins, particularly in the lower extremities and the abdomen, causing a blood volume shift to the chest and heart • Decompensated heart failure is an absolute contraindication to aquatic therapy • Patient with severe HF should remain in upright position, and submerge body in water no deeper than the xiphoid process. • Obtain physician’s clearance, as well as recommendations for water temperature and time spent in pool. • Patient should be closely monitored for cardiac symptoms and changes in vital signs. 58
Referrals to other disciplines • Social services for any equipment needs, community resources • Back to physician if patient has an abnormal response to exercise • Smoking cessation program if necessary • Nutritionist/Dietician for fluid, calorie, fat and sodium reduced diet • Mental health professional if there are psychological issues (depression) • Sleep specialist if sleep apnea is present • Cardiac Rehab program 59
Patient Education in Heart Failure • The HF Society of American Guidelines recommends ongoing education due to the lack of efficacy of a single session • Education must be a routine part of all therapy visits, targeted to health literacy level of the patient, and post ‐ teaching patient understanding should be assessed 26 • Additional Patient Education includes edema management via lower extremity elevation, sleeping position to alleviate/decrease orthopnea, educate on dietary changes such as sodium restrictions/fluid restrictions, fall prevention 60
Chronic Obstructive Pulmonary Disorder 61
Copd COPD is a collective term for any disease process that blocks or disrupts the passage of air through the lungs over time. Three diseases are recognized to be included within the term: asthma, emphysema and chronic bronchitis 62
We will discuss two main types of COPD • Emphysema decreases airflow through the actual destruction of lung tissue. Over time, the elastic tissues of the alveolar membranes become damaged and permanent distention of air spaces occurs. • Chronic bronchitis decreases airflow due to inflammation in the bronchial tubes with increased mucus production. This inflammation and mucus gland hyperplasia are due to chronic irritation • Most patients with COPD present with a combination of emphysema and chronic bronchitis 63
COPD video 64
COPD X ‐ ray imaging of the lungs of a patient with COPD often show hyperinflated lungs and a flattened diaphragm Patient with COPD often present with a barrel chest. In addition to the flattening of the diaphragm, the diaphragm also weakens, losing it’s ability to contract 65
Functional Consequences • Functional consequences of both types of COPD include: • Expiratory airflow is limited • Patients experience dynamic hyperinflation. Due to the difficulty with expiration, patients with COPD begin to inhale before they have fully exhaled. • Elastic load of the respiratory system is increased and reduces the performance of the respiratory muscles. 66
Signs and Symptoms • Main signs and symptoms are SOB and decreased capacity for physical activity. Other signs and symptoms include productive coughing, non productive coughing, loss of appetite, weight loss, skeletal muscle atrophy, respiratory muscle weakness, and increased fatigue 67
Global Initiative for Obstructive Lung Disease (GOLD) classifies COPD into 4 stages 27 • Mild COPD: mild limitation to airflow. Patients may or may not be aware of abnormal lung function at this time. FEV 1 > 80% predicted • Moderately severe COPD: patients may start feeling symptoms of shortness of breath (SOB), coughing, and coughing phlegm during exertion. FEV 1 > 50% to < 80% • Severe COPD: patients continue to complain of SOB and are more limited in activities of daily living (ADLs). May present with increased fatigue and feelings of tiredness FEV 1 > 30% to <50% • Very severe COPD: severe reduction in air flow, which can affect the cardiovascular system. May require supplemental oxygen. FEV 1 < 30% 68
Causes The most common causes are years of smoking, exposure to second hand smoke or chemical irritants. Can also be caused by irreversible airway inflammation. 28 95% of cases are due to years of cigarette smoking. 69
Risk Factors • cigarette smoking • breathing chemical fumes • dust or air pollution over a long period of time • secondhand smoke exposure • history of several severe lung infections • severe viral pneumonia early in life • allergies • genetics (i.e. antiprotease deficiency) 70
Precautions • Frequent pulse oximetry should be used to monitor for adequate oxygen levels, especially if patient is using supplemental oxygen • Patients hospitalized for exacerbations of COPD are at increased risk for deep vein thrombosis (DVT) and pulmonary embolism • Adverse effects of medications used to treat COPD include tachycardia and cardiac rhythm disturbances in susceptible patients (with beta 2 agonists), atrial and ventricular arrhythmias (with methylxanthines), and myopathy and decreased bone density ( with long term corticosteroids) 28 • Follow vital sign parameters established by patient’s physician or your organization 71
Precautions • Whole ‐ body exercise often causes patients with COPD to become dyspneic and stop exercise before the exercising muscles and circulatory system reach their critical limits • Avoid isometric resistance exercise • Avoid outdoor exercise when weather is very hot, humid, or cold 72
Patient Evaluation • History of present illness/injury, reason for referral. Is patient having an exacerbation, or is COPD stable? • Smoking history? Is the patient currently smoking? • Is there a productive cough present? How long has the cough been present? How often does the patient become short of breath? • Medical treatment. Use of oxygen therapy, inhalers/bronchodilators, smoking cessation programs, history of pulmonary rehab program participation 73
Patient Evaluation • Sleep disturbance: wakings per night due to dyspnea, number of pillows patient needs to sleep due to orthopnea, CPAP use, has patient undergone a sleep study? Symptoms of COPD can be accentuated during sleep, and risk of nocturnal death is a possibility • Respiratory status, document use of oxygen • Past medical history, comorbid diagnoses. Cardiovascular disease is the most frequent disease coexisting with COPD. Anxiety and depression are also highly prevalent co ‐ occurring in patients with COPD. Lung cancer is also frequently seen with COPD and is the most common cause of death in patients with COPD. Pneumonia occurs frequently with COPD • A good set of vital signs needs to be taken with every therapy visit including BP, O2 sats, Temperature, RR, HR, Borg RPE, lung sounds, and heart sounds 74
Patient Evaluation • Manometer can be used to determine maximal inspiratory pressure and maximal expiratory pressure • Note breathing pattern, diaphragmatic breathing, use of accessory muscles. Also, note if patient has a preferred “breathlessness” position • Assess cough, four stages of cough, productive cough, color, consistency, and amount of sputum • Observe for edema in extremities, clubbing of fingers • Social/occupational history. What are the patient’s goals? Functional limitations, ADL status, living environment including number of stairs, floors, with whom does the patient live, caregivers, etc. 75
Patient Evaluation • Diagnostic tests completed may include • Arterial blood gases (ABG) • Complete blood count (CBC) • Chest x ‐ ray, Chest CT • Ventilation perfusion scan • EKG • Pulmonary functions tests will include the following along with additional tests: forced expiratory volume in 1 second (FEV 1 ) and forced vital capacity (FVC), tidal volume, vital capacity, peak expiratory air flow • Nocturnal oximetry 76
Lab Values 29 • Commonly referred to as ABG, arterial blood gases is a blood test which can be used to see how well your lungs are functioning. This test measures the amount of oxygen, carbon dioxide, bicarbonate, and ph of the blood. • Low blood levels of oxygen is referred to as hypoxia. Mild hypoxia is paO2 60 to 80 mm, moderate is paO2 is 40 to 60 mm, and severe is < 40 mm. • Normal blood ph is 7.35 to 7.45, normal partial pressure of oxygen is 80 to 100 mm hg, normal partial pressure of carbon dioxide is 38 to 42 mm hg, and normal bicarbonate is 22 ‐ 26 mEq/l. • Lower blood ph may be indicative of higher carbon dioxide levels (hypercapnia). 77
Relevant Tests and Measures • Height, weight, BMI • Measurement of chest girth • Arousal, attention, and cognition • Balance assessment • Cardiorespiratory function and endurance • 6 MWT • 2 MWT • 2 Minute Step Test • stair climbing ability • Borg Rating of Perceived Exertion • Borg Rating of Dyspnea 78
Relevant Tests and Measures • Functional mobility. • Gait • Assess for need for assistive device. Rollator walker has been shown to show clinically relevant improvements with sedentary patients with the 6 MWT as compared to use of unaided 6 MWT 30 • Muscle strength • Range of motion • Self Care/ADLs • What happens to patient’s breathing when performing ADL requiring use of upper extremities? How does this affect patient’s ability to use accessory muscles to assist with breathing? 79
Relevant Tests and Measures • Assess viability of diaphragm • Place your finger tips just below the patient’s xyphoid process. Ask them to sniff 3 times. You should be able to feel the diaphragm contract underneath your fingertips if the diaphragm is viable. • Also, observe patient’s breathing pattern. Note if the abdomen is rising and falling with each breath, or if they are using accessory muscles for breathing • Note lowest point of patient’s breathing pattern, diaphragmatic, middle chest, upper chest 80
Ventilatory Response Index (VRI) • Great objective tool that can be used to quantify breathlessness • Have patient count from 1 to 15 in 8 seconds. You can tap or snap to keep time • Count the number of breaths the patient has to take. • 0 to 4 scale depending upon the number of breaths the patient has to take 81
Ventilatory Response Index 0 Able to count to 15 in a single breath, no additional breaths taken 1 Able to count to 15 with one additional breath 2 Able to count to 15 with two additional breaths 3 Able to count to 15 with three additional breaths 4 Able to count to 15 with four additional breaths 82
Prognosis • COPD is one of the leading causes of morbidity and mortality in the United States. • The BODE (Body mass index, degree of airflow Obstruction, Dyspnea, Exercise capacity) index can be used to assess risk of mortality in patients with COPD. 31 • Smoking cessation is important for improved prognosis. • There is a concern that supplemental oxygen may cause patients with COPD to develop what is known as oxygen ‐ induced hypercapnia. However, supplemental oxygen, when indicated, has been shown to improve survival. Recommend O2 sats be maintained at 88 to 92% 79 83
Prognosis • Malnutrition, cor pulmonale, hypercapnia, and resting pulse > 100 are indicators of a poor prognosis. • Weight loss of >10% in past 6 months also poor prognostic indicator • O2 Sats < 88% on oxygen • Factors that have been found to be predictive of hospital readmission: • Prior hospitalization • use of oral corticosteroids • use of long ‐ term oxygen therapy • poor health ‐ related quality of life • lack of routine of physical activity 84
Common medications used to treat COPD 32 • Bronchodilators. The purpose of bronchodilators is to relax the smooth muscles of the lungs so that more air can move in and out. • 3 types • Beta2 ‐ agonists: increase airway patency through smooth muscle relaxation. There are two types, rescue and long acting. Rescue inhalers include albuterol and albuterol sulfate (Proventil, Ventolin, ProAir) and long acting include Serevent, Brovana, and Perforomist • Anticholinergic Agents: increase airway patency by preventing bronchoconstriction. Examples include Atrovent (short acting) and Spiriva (long acting). • Combination beta2 ‐ agonists and anticholinergic agents. 85
Bronchodilators • Patients will be prescribed a rescue inhaler first, but if they are needing their rescue inhaler more than two times per week, they will be prescribed a long acting bronchodilator. • Rescue inhalers are also known as short acting inhalers • The purpose of long acting bronchodilator is to control symptoms, not for quick relief of symptoms • Side effects of bronchodilators can include tachycardia and other arrhythmias, trembling/shakiness, nervousness, and headaches 86
Glucocorticosteroids/Corticosteroids • Anti ‐ inflammatory agents. Act by preventing inflammatory ‐ induced bronchoconstriction by inhibiting inflammatory cells. • Examples include Aerobid, Budesonide (Pulmicort), fluticasone (Flovent), ciclesonide (Alvesco), beclomethasone (Qvar), and mometasone (Asmanex) • Not used to control acute inflammation, used for long term symptom control • Side effects are few, and may include development of thrush. Rinsing the mouth after use of these medications can help decrease the risk of thrush 32. 87
Other Combination Drugs • Advair: combination between fluticasone, a corticosteroid and salmeterol, a long acting, beta agonist bronchodilator. • Symbicort: contains formortor, a long acting, beta ‐ agonist bronchodilator and budesonide, a corticosteroid • Combivent (inhaler) or DuoNeb (nebulizer). Contains two bronchodilators, albuterol and ipratropium (Atrovent). • Trelegy has 3 medications included: long acting beta 2 agonist, corticosteroid, and a long acting anticholinergic agent. 88
Medications used to promote mucus clearing • Mucolytics: reduce the viscosity of the mucus, an example includes acetylcysteine. Side effects are rare, but can include gi bleeding. They should not be used in patients with history of stomach ulcers • Expectorants: Increase the volume and hydration of secretions. Examples include guaifenesin. Side effects include can possibly induce coughing, N/V, or diarrhea 89
Therapy medication related goals: • If patient experiences dyspnea with activity or therapy treatment, patient should be educated to time performance of therapeutic activities after use of rescue inhaler (as prescribed) • Medication goals can be incorporated into therapy treatments. Examples include: • PT: patient to be independent with use of rescue inhaler in order to control dyspnea with ambulation to increase ambulation endurance and return to community ambulation distances. • OT: patient to improve fine motor skills in order to allow independent use of rescue inhalers, nebulizer including medication vial 90
Referrals to other disciplines • Respiratory therapist for airway management • Smoking cessation counselor • Back to physician if oxygen saturation levels are not maintained and supplemental oxygen or other medical management is warranted. Notify physician if vital sign response to activity is not as expected • Support groups for psychological and emotional support • Social work for availability of community resources • Mental health professional if depression is present • Pulmonary rehab ***Effective COPD management depends upon multidisciplinary communication and collaboration 91
Effective Therapeutic Interventions 92
General Guidelines • There is a high level of evidence that therapy programs with patients with COPD aid recovery from exacerbations of COPD and prevent reoccurrence • Treatment interventions are based on minimizing additional damage to remaining lung tissue, increasing the amount of gas exchange during respiration, and improving quality of life and physical activity. 93
Aerobic Exercise Training • As with heart failure, patients can initially work at an intensity of 40 to 50 % of VO2 max, progressing to working at 60 to 80% of VO2 max. Utilizing Borg’s RPE exertion, initially patients should work at around 10 ‐ 14/20, progressing to working at 15 ‐ 16/20 • As with heart failure, compromised patients can benefit from interval training. Begin with 5 to 10 minutes of interval or continuous exercise, and progress to 20 to 30 minutes of exercise 3 to 5 times per week 94
Programs to increase Physical Activity • Patients with COPD will need to be educated on programs to increase physical activity. These programs may help to decrease incidence of hospital admissions as well as improve mortality • Study conducted in which patients who were hospitalized for exacerbation of COPD wore an accelerometer (measures movement by measuring acceleration forces) for the first 30 days after hospitalization • Patients with increased minutes of physical activity (average 114 minutes)had a lower rate of hospital readmission than those with lower minutes of physical activity (average 42 minutes) • Patient who were eventually rehospitalized had a gradual decline in physical activity, whereas those who were not readmitted had a gradual increase in physical activity 38 95
Strength and Resistance training programs • Patients with COPD are going to experience muscle wasting and benefit from strength and resistance training programs • RT programs in addition to an ET program can lead to better results than an endurance based program alone in regards to improvements in strength and overall function • As with heart failure, initiate RT programs with higher reps and lower resistance. • Start with one set of 10 to 15 reps, can progress to 3 sets performing 5 to 10 exercises utilizing major muscle groups. • As patient acclimates to strength training, increase resistance to a level that a patient can perform only 8 to 10 repetitions due to muscular fatigue • Educate patient to perform 2, preferably 3 times per week. 96
Strength and Resistance Training Programs 39,40 • Strength and resistance training programs may be a good alternative for patients that are experiencing severe dyspnea, as it can result in decreased dyspnea when compared to endurance training • A systematic review conducted in 2015 looked at the effects of RT versus ET in patients with COPD. Outcome measures that were studied included quality of life, ADLs, dyspnea, possible harm, and mortality. The result of their study showed no clinically significant difference between RT and ET in patients with COPD in regards to the outcomes listed. Therefore, RT may be a good alternative for patients with COPD and should be considered when developing exercise programs 97
Breathing Exercises • Incorporate breathing exercises into your therapy plan of care. Utilize breathing exercise devices as applicable • Breathing exercises can include pursed lip breathing, diaphragmatic breathing if viable, paced breathing. Pursed lip breathing has the strongest level of evidence to support its use. • Position your patient in a position to help them succeed, depending upon the viability of their diaphragm 35 • Posterior pelvic tilt, arms at side, and forward head posture helps to facilitate the muscle fibers of the diaphragm • Anterior pelvic tilt, arms up in a “hold em up” position, and head neutral/extended helps to facilitate the upper and middle chest fibers 98
Pursed Lip Breathing • Cue patient to breathe in through the nose and out through pursed lips. • Educate patient on exhale to inhale ratio of 2:1. Count out loud with patient inhale 1…2… exhale 1…2…3…4… • Can incorporate diaphragm if it is viable!! • The purpose of pursed lip breathing is it provides positive pressure to pop open any closed alveoli. • Pursed lip breathing has been shown to reduce HR, BP, and RR and promote relaxation if done progressively slower 99
Inhale 1..2… Exhale 1..2..3..4 100
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