Transcript Pulmonary Rehabilitation Disease Management Program

The Role of the
Respiratory Therapist
in the
Treatment of the PH Patient
Gerilynn L. Connors, RRT, BS, FAARC, FAACVPR
Clinical Manager, Pulmonary Rehabilitation
Inova Fairfax Hospital
Falls Church, VA
[email protected]
The Role of the Respiratory Therapist
From ICU to Home Care
OBJECTIVES:
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state how the Pulmonary Diagnostic Laboratory test patient’s
lung function, exercise capacity and determines what oxygen a
patient may need while flying
Understand how Pulmonary Rehabilitation can be an adjunct
treatment for the PH patient from the inpatient setting to the
outpatient setting
Know the important role the ICU Respiratory Therapist provides
for heart failure patients beyond Nitric Oxide (NO) to Inhaled
Epoprostenol
Understand the respiratory home care needs of the PH patient
from oxygen systems, delivery devices to CPAP
Understand how the Respiratory Therapist can be a vital team
member in the Pulmonary Hypertension Clinic
Medical Direction in Respiratory Care
The strength of a Respiratory Care Department,
Pulmonary Diagnostic Laboratory and
Pulmonary Rehabilitation Program is measured
not only by the Respiratory Therapist and
Managers who work in these departments but
the MEDICAL DIRECTORS who provide
guidance, support and evidenced based
direction.
Pulmonary Diagnostic Laboratory
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Pulmonary Function Test
— Pre/post spirometry
— Lung Volume
— Diffusion
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Exercise capacity Test
— 6 Minute Walk Test
— Pulmonary Exercise Stress Test
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Arterial Blood Gas
Oxygen Test for High Altitude (air flight, travel)
Air Travel for the Patient Requiring Oxygen –
the Pulmonary Diagnostic Laboratory
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Hypoxia-Altitude Simulation Test (HAST)
— Patient breaths 15.1% oxygen simulating aircraft conditions
— Determine what patients will develop severe hypoxemia
during air travel
— Able to identify patients at risk of flight-related
complications
— requiring supplemental oxygen during air travel
— Titration of oxygen during test to determine oxygen l/m in
aircraft
Calculation for Estimate of In-Flight PaO2
Predicted PaO2 at altitude = 22.8 – 2.74x + 0.68y
— A regression equation derived from HAST
— Used in normocapnic chronic airway obstruction
— X is anticipated cabin altitude in thousands of feet
— Y is resting PaO2 in mmHG at ground level, on room air
— Formula provides only a prediction of anticipated PaO2
— HAST is able to assess the cardiovascular and symptomatic
response plus determine supplemental oxygen need
Pulmonary Rehabilitation from the
Inpatient to Outpatient Setting
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Pulmonary Rehabilitation is an adjunct treatment for the PH
patient
Pulmonary Rehabilitation assess and treat may be appropriate
for the PH Inpatient
— New PH diagnosis
— New medication program
– Patients who begin IV PAH medications must be
monitored closely when beginning exercise due to
hypotension
— Exacerbation of PH
— Need to assess exercise function and provide advise for oxygen
delivery system and liter flow of home oxygen therapy
— Pre/Post lung transplant
Pulmonary Rehabilitation Definition ATS/ERS 2006
“Pulmonary rehabilitation is evidence-based, multidisciplinary, and comprehensive intervention for patients
with chronic respiratory disease who are symptomatic and
often have decreased daily life activities. Integrated into
the individualized treatment of the patient, pulmonary
rehabilitation is designed to reduce symptoms, optimize
functional status, increase participation and reduce health
care costs through stabilizing or reversing systemic
manifestations of the disease.”
— This definition applies to the pulmonary hypertension patient with
the ultimate goal of optimizing their quality of life through
assessment, education and therapeutic exercise.
— The PH patient’s success in PR starts with a strong partnership
between the referring PH Clinic and the local pulmonary
rehabilitation program.
Essential Components
of Pulmonary Rehabilitation
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Assessment
Education/Training
Therapeutic Exercise
Psychosocial Intervention
Long Term Adherence**
**with Prevention and Outcomes **
Assessment
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Respiratory Therapy
Assessment
Exercise Assessment (6 min.
walk test)
Hypoxemia: at rest and with
exercise
Nutritional Assessment
Other Assessments as
determined:
– physical therapy
– occupational therapy
– Social/ psychological
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PAH Specific
New York Heart Functional
Class/ Symptoms
Assessment
PA Pressures
Diagnostic Classification
Expected side effects of
medications/ INR (Prothrombin
time (PT) and its derived measures of
prothrombin ratio (PR) and international
normalized ratio (INR) are measures of
coagulation.)
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Patients understanding of
medications/ back-up
pumps
Lower baseline blood
pressures
Peripheral edema
PAH: Signs and Symptoms
Symptoms
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Syncope
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Palpitations
Signs
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Prominent Right Ventricular
Impulse
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Accentuated Pulmonic Valve
component (P2)
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Right-Sided third heart sound
(S3)
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Fatigue
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Dyspnea on exertion
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Anginal Chest Pain
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Hemoptysis
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Hepatomegaly
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Light headedness
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Peripheral Edema
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Jugular Vein Distention
Potential Side Effects of PAH Medications
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Cough
Headache
Flushing
Flu-like syndrome
Nausea
Jaw Pain
Trismus –”lock jaw” - any restriction
to mouth opening
• Hypotension
• Site Pain
PAH PR Assessment Cont.
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PR Assessment to include:
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WHO Clinical Classification of PAH
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WHO Functional Classification, Class I-IV
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Results of Rt. heart catheterization
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Important to record drug therapy, route given
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Symptoms: syncope, palpitations, fatigue, chest pain, light
headedness, edema, blood pressure
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Anticoagulation, INR
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Results of overnight oximetry or formal sleep study
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Are they a candidate for lung transplant?
Education/Patient Training
Normal Anatomy and
physiology
Chronic Lung Disease
Description and interpretation
of medical tests
Breathing Retraining
Bronchial Hygiene
Medications
Oxygen Therapy/Sleep
Disorders
Activities Of Daily Living
Eating Right
Preventing Infection
Leisure Activities
Coping With Chronic disease/
advanced directives
PAH Specific Education/Patient Training
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Identifying and self monitoring of PH symptoms
Recognizing symptom limited exercise
Know signs of right heart failure
Emergency procedures (pumps & lines)
Expected reactions to medications
Identifying symptoms/ understanding heart cath results
Pregnancy risks
Avoiding falls for the anti-coagulated patient
INR test results & frequency
Recognizing “symptom limited exercise”
Self monitoring of weight and edema
Weight and edema checks
Expected reaction to PH meds
Need for lifelong medication
Patients MUST bring their back up pump at all times
Lung transplantation
Exercise Testing
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6-minute walk test
Pulmonary Exercise Stress Test
Detect exercise-induced hypoxemia and determine
O2 titration
Establish a baseline for outcome determination
Evaluation of current functional activity level and
limitations, ADLS, pain, strength, range of motion,
posture, balance, gait, safety, and breathing pattern
Evaluation of PAH symptoms, chest pain, shortness
of breath, syncope, and fatigue
EXERCISE
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exercise training should be initiated in a supervised setting - PR
Patient has Fear of exertion
Patient should Never exercise alone
Always have back-up pumps and medications as prescribed
Know the safety measures for lines/pumps with exercise
equipment
Avoid exercises that increase intra thoracic pressure or valsalva
maneuvers
Detect exercise-induced hypoxemia, O2 titration (may require
high flow oxygen devices) goal is to keep patients ≥ 90% O2
saturation
Determine best home oxygen system, delivery device and flow
rate, especially when high flow oxygen required (beyond the
nasal cannula)
PH PR exercise documentation form to include PH symptoms,
vitals plus edema, daily weight
Collaborative partnership with PH Clinic and PR a must to
communicate concerns, issues, symptoms
Flolan® (epoprostenol)
Avoid activities that increase
intra-thoracic pressure or valsalva effort
PSYCHOSOCIAL INTERVENTION
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Quality of life testing (CAMPHOR)
Loss of job or income, disability
Family dynamics
Pregnancy issues
Impact of severe lung disease at relatively young
age
Genetic testing
Lack of visible signs of illness
Possible lung transplant evaluation
LONG TERM ADHERENCE
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Schedule and keep PH Clinic appts
Medications necessary for life
Attend PH support groups
Treatment of PH resulting in prolongation of life and
increased functional capacity
Exercise with a partner or in a supervised setting
Be connected with the National PH Association
Pulmonary Rehabilitation:
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PR is not just exercise or education but must have the essential
components
Typical PR program may meet three times a week, over an 8-12
week period of time, have approximately 10-15 hours of
education and 30 hours of therapeutic exercise.
The commitment by the PH patient is great but so are the
benefits.
The success of the PR program is also measured by the strength
of the PR’s Medical Director who guides the multi-disciplinary
team in evidence-based practice.
The PR goals for the PH patient are not that different from the
goals of PH medical management:
— improve cardiovascular endurance, increase exercise performance,
enhance ability to perform Activities of Daily Living (ADL), improve
quality of life, reduce hospitalizations, decrease symptoms,
especially dyspnea through breathing retraining and ensuring
adequate oxygenation at rest and with activity.
Positive Outcomes from Pulmonary Rehabilitation
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Patient will have a better understanding of how PH affects their
lungs, oxygen and exercise
Understand lung symptoms and decrease shortness of breath
through breathing retraining and ensuring adequate oxygenation
at rest and with activity
Increase exercise performance that translates into improvements
in activities of daily living
Improve cardiovascular endurance through a safe and supervised
exercise program
Improve quality of life through education and therapeutic
exercise
Exercise in a facility that allows the patient to feel secure and
safe because of the skill set of the pulmonary rehabilitation
respiratory therapist working with them
PR team communicates with referring MD and the PH clinic on
patient’s progress in PR
How to Locate a Pulmonary Rehabilitation Program
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American Association of Respiratory Care (AARC)
http://www.yourlunghealth.org/finding_care/qrc/pulm_care/index.cfm
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American Association of Cardiovascular and
Pulmonary Rehabilitation, (AACVPR)
http://www.aacvpr.org/Resources/SearchableCertifiedProgramDirectory/tabid/113/Default.aspx
Respiratory Home Care Needs of the PH Patient
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Oxygen Systems
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Oxygen Delivery Devices
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CPAP or Bi-Level Positive Airway Pressure to treat Sleep
Apnea
Oxygen Systems:
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Compressed gas
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Liquid oxygen
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Oxygen concentrator
Oxygen Delivery Devices
Delivery Device
Description
Liter Flow
Nasal Cannula
Delivers approx. 44%
O2 depending on liter flow,
patients respiratory rate, etc.
1-6 l/m
Oxymizer Pendant
or Mustache
Higher FiO2 achieved
1-12 l/m
http://www.chadtherapeutics.com/usa/Disposable-Conservers/Oxymizer.html
High Flow Cannula High flow without a face mask.
(various manufacturers) Patient can eat, drink etc.
6-15 l/m
Oxymask
1 - flush l/m
provide greater FiO2 at lower flows
http://www.southmedic.com/products/oxymask-adult.php
Respiratory Therapy in the ICU
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Know the important role the ICU Respiratory
Therapist provides for heart failure patients
beyond Nitric Oxide (NO) to Inhaled Epoprostenol
(iEPO)
Ventilated patients can be challenging to liberate
(wean) off mechanical ventilation and the ICU
Respiratory Therapist is a vital member of the ICU
team
Inhaled Nitric Oxide (iNO)
Objective:
— Decrease pulmonary artery pressure (PAP)
— Decrease pulmonary vascular resistance (PVR)
— Improve oxygenation
Patient Populations: adults and children
Indications: respiratory failure with mechanical ventilation,
secondary to diffuse parenchyma lung disease, severe respiratory
disease requiring FiO2 >70%, oxygenation index X Mean Airway
Pressure of >10, patients with congenital or acquired heart disease
with anatomic and/or physiologic abnormalities associated with
pulmonary artery hypertension or pulmonary vascular changes,
lung and cardiac transplant, LVAD
Benchmarking and Evidenced Based Data
Cost: Expensive
Going Beyond Inhaled Nitric Oxide (iNO) ……………………..
Inhaled Epoprostenol (iEPO)
Objective:
— treat pulmonary hypertension and right ventricular failure as
confirmed by rt. heart cath., echo, or direct visual inspection
during cardiac surgery
— Treat severe hypoxemia (PaO2/FiO2 ration < 200) unresponsive to
standard therapy in patients with ARDS
Patient Populations: adults and children,
Indications: lung, heart transplant, LVAD, ARDS
Inhaled Epoprostenol (iEPO)
— Comparable to the effect of iNO, clinical & hemodynamic response
good
— Lack of toxic reactions
— Easy administration
— Cost effective alternative
Benchmarking and Evidenced Based Data
The Respiratory Therapist and the
Pulmonary Hypertension Clinic
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Role the Respiratory Therapist has is dependent on
the facility and program needs as directed by the PH
Medical Director and Manager
Assessment and Education of the PH Patient
— clinic evaluation
– To include H & P
– physical exam
– medication review
— Diagnostic testing: 6 MWT and spirometry test
— Education of the PH patient on specific topics
References
CJ Dine, ME Kreider. Hypoxia Altitude Simulation Test. Chest.
2008;133;1002-1005.
Aina Akero, MD, Anne Edvardsen, Carl Christensen, et.al., COPD
& Air Travel. Oxygen Equipment and Preflight titration of
supplemental oxygen. Trial registry: Clinical Trials.gove; No.:
Identifier NCT01019538; URL: clinicaltrials.gov. Chest Journal
de Man FS, Handoko ML, Groepenhoff H, et. al., Effects of
exercise training in patients with idiopathic pulmonary arterial
hypertension. Eur Respir J 2009; 34: 669-675.
Shapiro S, Traiger GL, Exercise and Pulmonary Hypertension,
Chapter 32, pg 518- 528 in Hodgkin JE, Celli BR, Connors GL.
Editors. Pulmonary Rehabilitation: Guidelines to Success, 4th
Edition, Mosby Elsevier, 2009.
References Cont.
Mereles D, Ehlken N, Kreuscher S et al. Exercise and respiratory
training improve exercise capacity and quality of life in patients
with severe chronic pulmonary hypertension. Circulation 2006
October 3;114(14):1482-9.
Adamali H, Gaine SP, Rubin LJ. Medical treatment of pulmonary
arterial hypertension. Semin Respir Crit Care Med
2009;30:484-492.
Dose-Response to Inhaled Aerosolized Prostacyclin for
Hypoxemia Due to ARDS Chest March 2000 117:819;
10.1378/chest.117.3.819
Suhail Raoof, Keith Goulet, et.al., Severe Hypoxemic Respiratory
Failure: Part 2—Nonventilatory Strategies Chest June 2010
137:1437; 10.1378/chest.09-2416
References Cont.
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Kieter Wlamrath, Thomas Schneider, et. al., Direct
Comparison of Inhaled Nitric Oxide & Aerosolized
Prostacycline in Acute Respiratory Distress
Syndrome. Am J Respir Crit Care Med
1996;153:991-6.
Charl J. De Wet, David Afflect, et. al., Inhaled
prostacycline is safe, effective, and affordable in
patients with pulmonary hypertension, right heart
dysfunction, and refractory hypoxemia after
cardiothoracic surgery. J. Thorac. Cardiovasc. Surg.,
December 1, 2004; 128(6):949-950.
SUMMARY………………………………………...
Respiratory Therapist have a critical role
in optimizing the treatment and quality
of life for the PH patient from the ICU
to Pulmonary Rehabilitation to
Pulmonary Diagnostics to Home Care,
to the PH Clinic setting through
collaboration with the Pulmonary
Hypertension Specialist.
THANK YOU!!!!!!!
Gerilynn L. Connors, RRT, BS, FAARC, FAACVPR
Clinical Manager, Pulmonary Rehabilitation
Inova Fairfax Hospital
Falls Church, VA
[email protected]