WMMC Pulmonary Rehab Rick Kenney, MSM, RRT, RCP Director Respiratory Care Services WMMC Pulmonary Rehabilitation Program (PR) Making Friends in PR WMMC GYM Strength training is an essential part of PR Definition of PR • According to the 2006 American Thoracic Society/European Respiratory Society statement on PR, “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 the 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” AACVPR Statement • Pulmonary rehabilitation is an integral component of comprehensive medical therapy for patients with chronic respiratory disease. • In Genreal, PR provides the greatest improvements in symptoms, exercise capacity, and health-related quality of life of any therapy available for patients with COPD. • In light of this PR is now prominently placed in virtually all major guidelines for treatment of COPD Condition’s Appropriate for PR Obstructive Diseases • COPD (including alpha-1 antitrypsin deficiency) • Persistent asthma • Bronchiectasis • Cystic Fibrosis • Bronchiolitis obliterans Restrictive Diseases Interstitial diseases – Interstital fibrosis – Occupational or environmental lung disease – Sarcoidosis Chest wall diseases  Kyphoscoliosis  Ankylosing Spondylitis Neuromuscular diseases • Parkinson’s disease • Postpolio syndrome • Amyotropic lateral sclerosis • Diaphragmatic dysfunction • Multiple sclerosis • Posttuberculosis syndrome Other Conditions • • • • • • Lung cancer Primary pulmonary hypertension Before and after thoracic and abdominal surgery Before and after lung tranplantation Before and after lung volume reduction surgery Ventilator dependence • Pediatric patients with respiratory disease • Obesity-related respiratory disease Patient Assessment • • • • • • Patient interview Medical Hx Physical exam Diagnostic tests Symptom assessment Musculoskeletal and exercise assesment Patient Assessment (cont.) • • • • • • Activities of daily living Nutrition assessment Education assessment (understanding disease) Psychosocial assessment Goal achievement Pain assessment Pulmonary Rehab Consent White Memorial Medical Center PULMONARY REHABILITATION PROGRAM AGREEMENT TO PARTICIPATE AND GUIDELINES 1. DEFINITION This program has been recommended to me by: Dr._________________ Pulmonary rehabilitation is an outpatient program provided for patients with chronic lung Disease. It is designed to enhance the health status and quality of life of participants through increase knowledge, better exercise tolerance, reduced respiratory symptoms, and enhanced self-care and coping skills. 2. COMPONENTS . PATIENT RESPONSIBILITIES ________ If you take nitroglycerin, I will bring and administer my nitroglycerin for chest pain. I will also bring my glucometer to all sessions to check my blood sugar if needed.  The program consists of up to 36 – 1 hour sessions. The best outcome is achieved by regular attendance and participation in all activities. Contact pulmonary rehabilitation staff if you are not feeling well &/or unable to make it to your scheduled class day at 209536-3726.  Always report any unusual symptoms which you experience before, during or after exercise, or that you notice in an exercising colleague.  Do not exercise within 2hours after eating a large meal, drinking alcoholic or caffeine containing beverages or smoking. Some of the components of the program are  Initial assessment of respiratory status  Patient training (education)  Exercise (monitoring of HR, SpO2, Pre-Post BP)  possible dehydration.  Do NOT exercise if you have fasted overnight or for longer than 5 hours during the daytime. Small snacks will give you energy your body needs for exercise.  NEVER exceed the prescribed level of exercise. If at any time you feel the exercise is too hard or too easy you will inform the Pulmonary Rehab staff immediately so adjustments can be made next session starts.  Keep all follow-up appointments with your family doctor and/or pulmonologist, 3. POTENTIAL BENEFITS While there is no guarantee that this program will benefit you directly in any way, widespread experience indicates substantial improvement in many areas, depending on the individual situation. These areas include: 1. 2. 3. 4. 5. 6. 7. Increased exercise capacity. Improved ability to perform activates of daily living. Decreased respiratory symptoms. Decreased anxiety and depression. Reduction in hospitalizations. Enhanced quality of life. Improved ability to be gainfully employed. 4. POTENTIAL RISK AND DISCOMFORTS Although the staff will make every effort to minimize risks during the sessions by performing a comprehensive preliminary assessment and by maintaining close observation during the sessions, there exists the possibility of unexpected changes during exercise. These include: 1. 2. 3. 4. 5. Equipment problems (e.g. falling off treadmill) Abnormal blood pressure response. Lightheadedness of fainting. Disturbance in heart rhythm. Chest pain, heart attack, or even death (rare). For increased safety, various vital signs, such as pulse, blood pressure, and oxygenation will be monitored on a prescheduled basis and/or as needed. Emergency equipment is available, and staff is trained to deal with unusual situations, which may arise. Adequate hydration before, during and is important after exercise to minimize who will continue to be responsible for medical care. 6. MEDICAL RECORDS / CONSENT; Your medical records will not be released to any other person without your consent. The information contained, therein, however, may be used for statistical or scientific purpose (as long as it does not identify my person or provide facts that could lead to my identification), or for insurance reimbursement. In the event I am injured or become ill while attending the program, consent is herby given to provide emergency treatment as deemed necessary by a physician until such time as other appropriate care can be arranged by my family and primary care physician. I acknowledge that I have read this form in its entirety, or that it has been read to me, that I have had the opportunity to discuss it with a rehabilitation team representative, and that I understand the nature of this pulmonary rehabilitation program. I accept the rules and regulations set forth, and consent to participate. I also agree to be treated for any complications or emergencies that may arise. I understand that I can withdraw from the program ay any time and that doing so will not effect further medical care. _________________________ Pt. Signature / Date ___________________________ Witness / Date Plan of Care • After the intial evaluation is done the therapist and patient come up with goals and objectives the patient wants at the end of the program. • Once done Dr. Abboy will meet with the patient to give the go ahead for this individual plan of care. Education • Collaborative self-management education is an essential component of comprehensive PR. Self-management education promotes learning by doing and taking advantage of teachable moments. Recommended content should be patient-specific, yet it is imperative to include early recognition and treatment of exacerbations, including the use of an action plan, for all patients. (AACVPR 4th edition) Chronic Bronchitis/Emphysema PR Exercise Tests 6 minute walk test: Walk with patient and monitor heart rate and oxygen saturations. Documents distance walked, oxygen sats, and dypsnea. Exercise Assesment • • • • • • • • • • • • Muscle strength and endurance Joint range of motion limitations Postural abnormalities (example: Kyphoscoliosis) How is the patient with oxygen equipment Subjective endurance and work tolerance Dyspena Lack of understanding of fitness and exercise Fear of exertion Ability to pace activities and energy conservation Balance abnormalities, gait instability, or increased risk of falling Pain levels and locations Ability to perform ADL’s (household chores, grooming, climbing stairs) Exercise Program The importance of an exercise training program cannot be overemphasized. But before a safe exercise program can be provided, a through assessment needs to be done to evaluate exercise tolerance, formulate and appropriate exercise training prescription, detect exercise-induced hypoxemia or bronchospasm, and detect occult cardiac or other nonpulmonary limitations to exercise. The benefits of exercise training are well documented and include decreased dyspnea, increased physical capacity, and improved quality of life. Exercise is an essential component of a comprehensive PR program AACVPR 4th Edition PR is for any age COPD Age Group From COPD.com COPD and Gender From COPD.com Psychosocial Needs A strong, trusting bond must be established with patients early in PR to ensure successful outcomes. Patients experiencing substantial impairments in psychosocial functioning need to be referred to a mental health provider. Smoking cessation is part of PR. A combination of behavioral and pharmacological approaches is recommended to maximize success with long-term smoking cessation. Interdisciplinary Approach Core Team Members: The Patient/Family Medical Director – Dr. Ramadas Abboy Department Director – Rick Kenney Department Assistant – Tara Chadwick Respiratory Therapists William Rodriguez Johanna Reyes Should include as needed: Behavioral Health Case Managers Diabetes Educator Dietician Nurse Pharmacist Physical/Occupational Therapy Restrictive Lung Disease Patients with restrictive diseases are seen one-on-one per CMS guidelines. Because the disease process is more advanced and requires strict monitoring of the patient while in our care. Obstructive Lung Disease This patient can be seen in a group setting. Benefits of group setting is “competition” among other group members by pushing each other to do better WMMC Patient Work Out • • Warm up stretching Upper extremities – with or without weights – Biceps – Triceps • Lower Extremities o Leg lifts o Squats • Arm ergometer • Stationary Bike • Treadmill • NuStep • Cool down period Extreme Monitoring Of The Patient We are here to save the day!!! Admitting your patient into Outpatient Pulmonary Rehab at WMMC  A prescription from MD  Pulmonary Function Test (within 1 year  Insurance Card  List of current medications  Complete ALL paperwork  Not Smoking WMMC PR Patients • • • • • 70 Year old Female Persistent Asthma HTN/Status Post CABG Multiple ER visits before = Zero visits since PR Six Minute Walk – More than doubled their distance! • Comments from patient: “need more tissue. A assest to your PR department is William” WMMC PR Patient • • • • • • 72 Year old Female Persistent asthma/chronic bronchitis Admitted 3 times in early 2013 (less than 30 days x 2) Six Minute Walk – Doubled distance No admissions or ED visits since PR Patient Comment: “I am very happy that with God’s grace this therapy has made me feel a lot better. My therapist explained everything very well. Thank you so much” Contact WMMCPulmonary Rehab Internally Ext. 2789 Externally (323) 268-5000 Ext 2789 Fax: 323-881-8609 Hours of operation Monday – Thursday 0700 – 1630 Closed Fridays and Holidays Eric Lawson, former Marlboro Man, dies of smoking-related disease A smoker since age 14, actor appeared in print Marlboro ads from 1978 to 1981 Famous People Loni Anderson Tallulah Bankhead Samuel Beckett Leonard Bernstein Walter Brennan William F. Buckley, Jr. Harry Carey Johnny Carson Fyodor Dostoyevsky - Russian Novelist (1821-1881) King Edward VII T. S. Eliot – Novelist/Publisher (1866 – 1965) Alan Ford - Actor King George V of England Arthur Godfrey Frank Gorshin – Actor (The Joker on tv show Batman) John Huston Don Imus Spike Jones Boris Karloff Dean Martin Robert Mitchum Garry Moore - Entertainer from the 50’s Alfred Newman – Composer (not the Mad comic book) Pat Nixon Johnny Paycheck Vincent Price Jerry Reed – Actor/Singer (best known as truck driver on Smokey and the Bandit) Del Reeves – Country/Western Singer R.J. Reynolds, Jr. R.J. Reynolds III Dusty Rhodes – Professional Wrestler Norman Rockwell Chris Schenkel - Sports Caster Allan Sherman – Musician and Comedian in 60’s/70’s Barbara Stanwyck - Actress (Big Valley) Maureen Stapleton - Actress Gene Tierney – Actress (40’s/50’s) Ernest Tubb – Country/Western Forrest Tucker – Actor (F-Troop) Christy Turlington – Model (father passed from lung cancer) Bill Wilson – Co-Founder of Alcoholics Anonymous Amy Winehouse – Diagnosed with emphysema at 24 Dick York – Actor (Husband on Bewitched) Questions?