Transcript Section_3_Pulm_Rehab_Home_Care

Initiation and Modification of
Therapeutic Procedures
Initiate and Conduct Pulmonary Rehabilitation
and Home Care
You should be familiar with the following areas of pulmonary rehabilitation;
Purpose and goals of pulmonary rehabilitation.
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Improving patient’s exercise tolerance
Reducing level of perceived dyspnea
Improving health-related quality of life
Reducing emergency department visits and hospital admissions
Reducing the overall costs of health care
Patient selection.
Key components of a program:
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Multidisciplinary approach
Education and related counseling
Multiple forms of treatment, including breathing retraining and physical conditioning
Flexible specific approaches to meet the patient’s varied needs
Medical direction and involvement
Documentation
Patient Selection
Pulmonary rehabilitation will not reverse the disease process or
increase life expectancy.
Candidates for pulmonary rehab are patients with
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COPD
Asthma
Bronchiectasis
Cystic Fibrosis
Interstitial lung disease, including pulmonary fibrosis and sarcoidosis
Those undergoing lung volume reduction surgery
Cardiopulmonary exercise testing is an essential aspect of initial
enrollment screening, monitoring progress, and measuring
rehabilitation outcomes, and provides for:
 Differentiation between pulmonary and cardiac causes of dyspnea
 Determination of the degree of oxygen desaturation that occurs with
physical exertion
 Establishment of baselines for patient’s levels of physical conditioning
 Determination of a patient’s target heart rate, to be used in the physical
reconditioning
 Enabling physicians and practitioners to follow patient progress
 Possibly excluding patients from pulmonary rehabilitation.
Program Components
Patient Education
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Purpose of pulmonary rehab and the patient’s role
Cardiopulmonary anatomy and physiology
Cardiopulmonary pathophysiology
Breathing techniques and retraining
Stress management and relaxation
Physical reconditioning
Cardiopulmonary pharmacology
Home care
Chest physiotherapy
Nutrition and diet
Specific strategies for maximizing ADLs
Instructional Strategies:
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Be prepared and knowledgeable about topic(s)
Create a comfortable learning environment
Encourage family and caregiver participation
Appeal to varied learning styles (visual, hands-on)
Encourage questions
Keep sessions short, break it down into brief segments
Use understandable (lay)terms
Distribute written supplemental material
Reinforce concepts and follow up
Smoking Cessation and Nicotine
Intervention
Smoking cessation essential to help control disease progression and
obtain full benefits of rehabilitation.
Methods may include:
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Individual counseling
Group sessions
Nicotine replacement therapy (gum, patches, lozenges, and/or spray)
Other pharmacologic intervention such as varenicline (Chantix)
Hypnosis
Follow-up and long term support
Medications:
 Varenicline (Chantrix)
 Buproprion (Zyban)
 Nicotine gum, inhaler, nasal spray, patch
Respiratory Home Care
Respiratory home care includes prescribed respiratory care services in
a patient’s personal residence.
Most common services:
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Patient assessment and monitoring
Diagnostic and therapeutic modalities and services
Disease management
Patient and caregiver education
Patient follow-up
Most common therapeutic modalities delivered in the home:
 Supplemental oxygen therapy
 Invasive and noninvasive mechanical ventilation (positive and negative
pressure)
 Continuous positive airway pressure (CPAP) and bi-level positive airway
pressure (BiPAP)
 Apnea monitors
 Other modalities, including aerosol therapy and secretion clearance
methods
Home Oxygen Therapy
Unique aspects of home O2 therapy:
Patient must qualify for health insurance reimbursement of costs by
meeting criteria related to accepted diagnosis and blood oxygen
levels (SpO2 or PaO2) on room air.
 COPD or other chronic pulmonary disorders: SpO2 of 88% or less, or a
PaO2 of 55 mmHg or less
 Chronic lung disorder with a secondary diagnosis such as pedal edema
or cor pulmonale: SpO2 of 89% or less, or a PaO2 of 56 – 59 mmHg
Types of systems:
Oxygen concentrators: most cost-efficient supply method for
patients in alternative settings who need continuous low-flow O2
Liquid Oxygen: 1 cubic foot of liquid = 860 cubic feet of gas, 1 pound
of liquid = 344 liters of gas
Compressed Oxygen Cylinders: primarily used for ambulation (small
cylinders) or backup to main liquid or concentrator systems
Portable Oxygen Systems: Smaller cylinders, refillable portable liquid
units, portable concentrators
Home Oxygen Therapy (cont.)
Oxygen Appliances:
 Simple low-flow devices (nasal cannula @ flow less than 4 LPM)
 Transtracheal catheter use for patients who:
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Cannot be adequately oxygenated with standard therapy
Do not comply when using other devices
Experience complications from nasal cannula use
Prefer the cosmetic appearance
Need increased mobility
 Oxygen conserving systems: pulse dose and demand flow systems
Home Mechanical Ventilation
Ventilator-dependent patients who have
1. Underlying cardiopulmonary conditions of COPD or compromised cardiac status or
2. Neuromuscular disease or spinal cord trauma
Goals of home mechanical ventilation
1. Sustain and extend life
2. Enhance the quality of life
3. Reduce morbidity
4. Improve or sustain physical and psychological function of all ventilator-dependent
individuals and enhance growth and development in pediatric patients
5. Provide cost-effective care
Prerequisites for patient discharge to home:
1. Patient and caregiver desire to go home
2. Patient is clinically stable for at least 2 weeks
3. Patient has been on continuous ventilation for at least 30 days with unsuccessful
weaning
4. Patient is free of cardiac monitoring
5. Patient has a tracheostomy in place, unless using noninvasive ventilation
6. Patient demonstrates control of any seizure activity with medication protocol as
prescribed
7. Patient is free of IV medications of an acute care nature such as vasodilators or betablockers
8. Family members and/or caregivers are willing and capable to accept home care
responsibility
9. Patient has had a complete medical and financial assessment by the case manager
(post acute)
Home Mechanical Ventilation
(cont.)
Patients should not be considered for home ventilatory support if:
1. They require more than 40% O2 or more than 10 cmH2O PEEP
2. They need continuous invasive monitoring
3. Their tracheostomy is still fresh (for invasive support only)
4. The home physical environment is deemed unsafe by the discharge
team
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Fire, health, or safety hazards
Unsanitary conditions
Inadequate heating, ventilation, or electrical service
Additional considerations for home care ventilation
1. A backup ventilator should be available for patients who:
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Cannot maintain spontaneous ventilation for 4 or more consecutive hours
Live in an area where a replacement ventilator cannot be provided within 2
hours
2. Caring for a ventilator-dependent patient in the home is a laborintensive undertaking and involves extensive education and training of
the family and/or caregivers, including infection control measures
3. Additional equipment needed may include hospital bed, supplemental
oxygen, suction equipment, and related supplies
4. Arrangements must be in place for emergency situations, including
power outages
Other Respiratory Home
Equipment and Modalities
Nasal CPAP: to treat sleep apnea-hypopnea syndrome
Apnea Monitoring:
 Primary indication: neonates at risk of recurrent apnea, bradycardia,
and hypoxemia after discharge
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Infants
Infants
Infants
Infants
Infants
Infants
receiving aminophylline or caffeine therapy for a history of apnea and bradycardia
with bronchopulmonary dysplasia requiring O2 therapy, CPAP, or ventilatory support
with gastro-esophageal reflux (GERD) if symptomatic with color and tone change
of substance-abusing mothers if clinically symptomatic
with a tracheostomy or anatomic abnormalities at risk for airway compromise
with neurologic or metabolic disorders affecting respiratory control
Key elements prior to discharge
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Family conference to discuss ongoing management and 24-hr monitoring
Emergency procedures, including CPR for parents and caregivers
Notification and communication with primary caregiver
Monitor setup, including electrode placement, cable and wire connections, and alarm
settings
Alarm evaluation and response
Monitor troubleshooting
Psychosocial support, including social services involvement, as appropriate
Home care company contact information for questions and equipment ordering
 Post-discharge considerations
 Family/caregivers’ competency and confidence with all procedures
 Family/caregivers’ stress level, coping mechanisms, and need for
community resources
 Ongoing insurance/payer eligibility and related issues
 Active phone service and e-mail service
 Notification of utility company(s) and paramedics
 Discontinued after
 Infant demonstrates negative pneumocardiogram or when apnea data
logs reveal no events during a prescribed time frame
 Usually 2 – 4 months after discharge
Infection Control
Patient and caregiver education
 Friends or relatives with respiratory infections should be discouraged
from visiting the patient
 Proper hand washing or disinfecting lotions should be applied to the
hands before and after handling patients or home respiratory
equipment
 Disinfection of most home respiratory supplies such as nebulizers,
humidifiers, and connectors may be achieved in the following manner:
 First wash them with soap and warm water
 Soak them in a 50-50 solution of white vinegar and water for a minimum of 30
minutes
 Rinse with water
 Leave them to air dry on a clean surface
 Standard precautions, including gloves and eye/facial protection
should be used as appropriate
 Sterile water should be used in large-volume nebulizers, although
distilled water is acceptable for humidifiers
 Wherever practical, disposable equipment (ventilator circuits) should
be used
 Nondisposable equipment should be scrubbed to remove organic
material, then thoroughly washed, rinsed, and allowed to air-dry in a
clean location
Common Errors to Avoid on the Exam
 Never explain planned goals and activities associated with
pulmonary rehabilitation to the patient in highly technical or
“textbook” terms. Instead, use understandable terms.
 Never inform a patient that pulmonary rehabilitation reverses the
underlying disease process. Instead, communicate the essential
aim of returning the patient to the highest functional capacity.
 Remember that pulmonary rehabilitation patients will never
realize improvement in their pulmonary function capacity but will
tend to experience a greater level of activity.
 Participants in pulmonary rehabilitation should not just attend
regularly scheduled classes. They also need to participate
actively by exercising at home in accordance with their plan and
maintaining a log or diary of activity.
 Avoid harsh criticism of patients who relapse from smoking
cessation.
More Common Errors to Avoid on the
Exam
 Home oxygen instructions should never include how t0
change the flow such changes require a a physician’s order.
 Sterile water is not needed for most home care humidifiers.
Distilled water is generally adequate.
 Sterilization is generally not needed for infection control in the
home setting.
 To deliver an FiO2 greater than 0.21, most home ventilators
bleed in oxygen from a concentrator or liquid system.
 Never set up highly active oxygen-dependent patients on a
concentrator, which is more suitable for those with restricted
activity.
Exam Sure Bets
 Always use the cardiopulmonary exercise stress test to
screen patients for pulmonary rehabilitation.
 Always have patients in pulmonary rehabilitation warm
up before performing strengthening and aerobic
activities to help avoid injury.
 The physical reconditioning component of pulmonary
rehabilitation should always include aerobic and
strength-training exercises.
 Always encourage patients in a smoking cessation
program and consider multiple approaches such as
medication(buproprion SR, vareniclene, nicotene
replacement) and counseling
More Exam Sure Bets
 Patients enrolled in pulmonary rehabilitation will almost
always experience a reduction in respiratory symptoms,
increased exercise tolerance, and fewer
hospitalizations.
 Patients with a pulse oximetry reading of less than 88% or
a PaO2 of less than 55 mmHg will generally always
qualify for home oxygen therapy through Medicare and
most other health payers.
 Always consider recommending oxygen conserving
devices for highly active patients; however, those with
limited mobility should generally be set up on a
stationary system using an oxygen concentrator.
 Always supply a backup system for home oxygen and
ventilator-dependent patients.
More Exam Sure Bets
 Education of home oxygen patients should always focus on
safe use, maintenance, cleaning, and fire precautions.
 During a home visit, always check the equipment’s
functioning and cleanliness, determine the patient’s
compliance with therapy, assess the patient, and modify
goals as necessary.
Reference:
Certified Respiratory Therapist Exam Review Guide, Craig Scanlon,
Albert Heuer, and Louis Sinopoli
Jones and Bartlett Publishers