Interventions

Reading Assignment

 Cameron & Monroe p. 372-384; Pagliarulo, Pg 254, Box 10-2, 259-263

 

 

 

 

Note: There is mention in the text of interventions specifically for those who are using mechanical ventilation equipment. We will be covering specific retraining and ventilator weaning considerations in PTA 205.

You should be able to recognize the signs and symptoms of over exertion in this population and make appropriate clinical decisions regarding exercise modification and termination.

 

  

 

 

Specific interventions, that can be a part of the PT plan of care, and delegated to the PTA may include:

• Breathing Exercises
• Diaphragmatic breathing

• Segmental breathing
• This is assisted or self-directed manual techniques to direct breath into targeted lung segments
• Autogenic drainage
• In a recent systematic review, autogenic drainage was associated with improved sputum production/improved airway clearance in patients with obstructive lung disease (cystic fibrosis) (Morgan, Osterling, Gilbert, & Dechman, 2015)
• A sample patient handout is provided here
• Incentive Spirometry reinforcement

• Pursed lip breathing

• Preventing and relieving episodes of dyspnea

• Respiratory resistance training

 

• Coughing and Airway Clearance

 

• airway clearance can be treated with hand-held devices, such as Flutter, Acapella, or Positive Expiratory Pressure. High frequency chest wall devices include a vest and a compressor and may be used in the home, especially by those affected by CF.

• directed coughing is reported as the most effective intervention for airway clearance, with questionable benefit provided with manual approaches and postural drainage. Current practice advocates teaching as many options for improving airway clearance as possible to promote optimal function (Fink, 2007; van der Schans, 2007)

 

• manual approaches (percussion and vibration)

• positional drainage
• there are specific guidelines for positioning that optimize drainage from involved segments

 

 

 

• Ther ex for endurance

Exercise is an effective intervention for improving function in patients with obstructive and restrictive lung disease.

Physiological monitoring, medication use, such as bronchodilators (inhalers), and patient education in exercise monitoring are key components to an effective exercise, and the evidence is clear that exercise can reduce anxiety, body weight, and general cardiopulmonary efficiency (Spruit, et al., 2016). Patients with severe restrictive lung disease have shown improvements in quality of life with exercise and appropriate ventilator support (Ho, et al., 2013).

In general, cycling induces less oxygen desaturation than walking in patients with COPD. Desaturation during small muscle mass exercise (e.g. arm exercise) is not very common. (Pothirat, et al., 2015)

Sample exercise program

• Patient and family education
• Home Safety/assessment
• Supportive and assistive device training, equipment training
• Discharge planning
• Energy conservation/management

 

 

 

 

References

Fink, J. B. (2007). Forced expiratory technique, directed cough, and autogenic drainage. Respiratory care, 52(9), 1210-1223.

Ho, S.-C., Lin, H.-C., Kuo, H.-P., Chen, L.-F., Sheng, T.-F., Jao, W.-C., … Lee, K.-Y. (2013). Exercise training with negative pressure ventilation improves exercise capacity in patients with severe restrictive lung disease: a prospective controlled study. Respiratory Research, 14(1), 22. http://doi.org/10.1186/1465-9921-14-22

Morgan, K., Osterling, K., Gilbert, R., & Dechman, G. (2015). Effects of autogenic drainage on sputum recovery and pulmonary function in people with cystic fibrosis: a systematic review. Physiotherapy Canada, 67(4), 319-326.

Pothirat, C., Chaiwong, W., Phetsuk, N., Liwsrisakun, C., Bumroongkit, C., Deesomchok, A., … Limsukon, A. (2015). Long-term efficacy of intensive cycle ergometer exercise training program for advanced COPD patients. International Journal of Chronic Obstructive Pulmonary Disease, 10, 133–144. http://doi.org/10.2147/COPD.S73398

Spruit, M. A., Burtin, C., De Boever, P., Langer, D., Vogiatzis, I., Wouters, E. F., & Franssen, F. M. (2016). COPD and exercise: does it make a difference?. Breathe, 12(2), e38.

van der Schans, C. P. (2007). Conventional chest physical therapy for obstructive lung disease. Respiratory care, 52(9), 1198-1209.

 

Role of the PTA

  

Communication with the interdisciplinary team is very important. Equipment needs, environmental assessments for activity modification, and assist and supervision recommendations are a critical component to an effective and safe pulmonary rehabilitation program.

 

Typical treatment goals

1. Increase aerobic capacity/endurance
2. Educate in safety, wellness and prevention through HEP and self-monitoring
3. Improve gas exchange through facilitated manual and exercise techniques
4. Education in specific techniques for airway clearance
5. Recommend equipment and modifications to minimize the work of breathing at home/work/school
6. Management of equipment for safety and vitality

Psychosocial considerations

1. Decreased endurance and impaired gas exchange can impact all activities of daily living and interfere with participating in community activities. Patients may be having difficulty with continence due to impaired endurance (inability to get to bathroom on time). Often this is undisclosed by the patient. Watch for weight loss. Patients who mouth breathe may experience decreased nutritional intake, thus affecting muscle performance and endurance. Again, PTAs can educate the patient on energy conservation and make recommendations for follow-up assessment from the health care team (OT, dieticians, wheelchair vendors, etc.)
2. Decreased pulmonary function often leads to anxiety. The perpetual state of breathlessness is a sympathetic nervous system activator. Sleep is often poor due to apnea and sleep position, thus affecting attention and concentration. PTAs can help guide patients back to their physicians if sleep and mood are a barrier to progressing in PT. Relaxation exercises can benefit in both improving tidal volume and self-managing anxiety and depression.
3. As with all impairments of endurance, sexual function and expression of sexuality can be negatively impacted by pulmonary dysfunction. You may be asked for advice on positions and modifications in order to safely engage in sex. Rely on your knowledge of positioning for dyspnea and positioning to collaborate on positions of maximal comfort and minimal stress/WB to thorax. Discuss optimal times of day/night based on pulmonary symptom presentation. Integrate principles of perceived level of exertion into teaching patients how to gauge risk with any activity (including sexual)
4. Children with pulmonary dysfunction require hours of self-care administered by parents/caregivers (inhalation therapy, postural drainage, vibration, etc) in addition to frequent medical appointments. Disability impacts both the child and the parent/caregiver. If you make recommendations for a home program, be sure you inquire about any existing home program and ask how much time is currently dedicated to providing "rehab" care. Make sure your recommendations can be reasonably provided by family members/caregivers and be prepared to offer alternatives to avoid overloading activities. Be prepared with information on parent support groups so you can facilitate sharing this information as you develop a relationship. Burn-out of caregivers is a very real problem.

 

 

  

Documentation

1. Informed consent
2. Time spent ( in minutes) and billing codes (in units)
3. Subjective complaints, symptoms, progress, questions
4. Observations at rest (posture, breathing patterns) and with exertion
5. Vital sign, pulse oximetry, and lung function (if available) at rest and with activity
6. Inclusion of formal assessments of response to work/exertion as needed
7. Objective data: may include rib/chest excursion, ROM, strength, lung function (incentive spirometer) activity tolerance (reps, sets, time, upright tolerance, distance, assistive devices and assist levels, use of oxygen/support equipment).
8. Patient instruction in some form of self-care related to impairment/functional limitation/disability and result of the instruction
9. Communication with family, interdisciplinary team, and/or PT and the result of the communication
10. Assessment of patient response, demonstrating skilled services and thread to the plan of care.
11. Signature and date

 

 

 

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