Patient Evaluation

Pulmonary rehabilitation programs must have a qualified medical director, usually a pulmonologist, to provide overall medical direction of the program and to screen prospective patients.¹⁷ Patient evaluation begins with a complete patient history—medical, psychologic, vocational, and social. A well-designed patient questionnaire and interview form assist with this step. The patient history should be followed by a complete physical examination (see Chapter 15). A recent chest film, resting electrocardiogram (ECG), complete blood count, serum electrolytes, and urinalysis provide additional information on the patient’s current medical status (see Chapter 16).

To determine the patient’s cardiopulmonary status and exercise capacity, both pulmonary function testing and a cardiopulmonary exercise evaluation may be performed. Pulmonary function testing includes assessment of pulmonary ventilation, lung volume determinations, diffusing capacity (DLCO), and spirometry before and after bronchodilator use (see Chapter 19).

The cardiopulmonary exercise evaluation serves two key purposes in pulmonary rehabilitation. First, it quantifies the patient’s initial exercise capacity. This quantification provides the basis for the exercise prescription (including setting a target heart rate) and yields the baseline data for assessing a patient’s progress over time. In addition, the evaluation helps determine the degree of hypoxemia or desaturation that can occur with exercise; this provides the objective basis for titrating O₂ therapy during the exercise program. To guide practitioners in implementing exercise evaluation, the American Association for Respiratory Care (AARC) has published clinical practice guidelines on exercise testing for evaluation of hypoxemia or desaturation or both¹⁸ and pulmonary rehabilitation. Excerpts from these guidelines appear in Clinical Practice Guidelines 50-1 and 50-2.¹⁹

The exercise evaluation procedure involves serial or continuous measurements of several physiologic parameters during various graded levels of exercise on either an ergometer or a treadmill (Box 50-3). To allow for steady-state equilibration, these graded levels are usually spaced at 3-minute intervals. Work levels are increased progressively until either (1) the patient cannot tolerate a higher level or (2) an abnormal or hazardous response occurs.

Blood gas and arterial saturation measures are obtained at rest and at peak exercise. Samples from single arterial punctures are as good as samples drawn from indwelling catheters. If the peak exercise puncture is unsuccessful, a sample drawn within 10 to 15 seconds of test termination usually suffices. Owing to inherent problems, pulse oximetry has a limited but nonetheless important role in exercise evaluation. The best use of pulse oximetry is as a monitor to warn clinicians of gross desaturation events during testing. In addition, the pulse oximeter can be used to assess the patient’s response to supplemental O₂ during exercise.

Relative contraindications to exercise testing include the following:

Exercise evaluation also can help differentiate among patients with primary respiratory or cardiac limitations to increased work capacity. Table 50-1 summarizes these key similarities and differences. Besides helping to differentiate between the underlying cause of exercise intolerance, test results can assist in placing patients in the appropriate type of rehabilitation program.

TABLE 50-1

Exercise Parameters Distinguishing Cardiac and Ventilatory (Chronic Obstructive Pulmonary Disease) Limitations

Parameter*	Cardiac†	COPD†
Maximum	↓	↓
Maximum HR	N or ↓	↓
O2 pulse	↓	N
Maximum	↓	↓
	↓	N
PaO2	N	↓
PaCO2	↓	↑
	↑	↑
VT	↓	N

^*HR, Heart rate; , cardiac output; , ratio of ventilation to CO₂ production; , oxygen consumption; VT, ventilatory threshold.

^†N, Normal; ↑, increased; ↓, decreased.

Modified from Lane EE, Walker JF: Clinical arterial blood gas analysis, St Louis, 1987, Mosby.

To minimize patient risk during exercise evaluation, certain safety measures are implemented. First, the patient should undergo a physical examination just before the test, including a resting ECG. Second, a qualified physician should be present throughout the entire test. Third, emergency resuscitation equipment (cardiac crash cart with monitor, defibrillator, O₂, cardiac drugs, suction equipment, and airway equipment) must be readily available. Fourth, staff conducting and assisting with the procedure should be certified in basic and advanced life-support techniques. Last, the test should be terminated promptly whenever indicated.

With regard to test preparation, patients should fast 8 hours before the procedure. If the purpose of the test is to formulate an exercise prescription, the patient can take his or her regular medications. The patient should wear comfortable, loose-fitting clothing and footwear with adequate traction for treadmill or ergometer activity. The mouthpiece or face mask used during the test should be sized properly and fit comfortably with no leaks. Test conditions should be as standardized as possible to allow for comparison of results before and after rehabilitation periodically from year to year as the patient is treated and followed.

Patient Selection

Patients most likely to benefit from participation in pulmonary rehabilitation are patients with persistent symptoms caused by COPD who have low maximum O₂ uptakes at baseline. Pulmonary rehabilitation should be a part of the discharge planning process when a patient is released from the hospital after an exacerbation of the existing chronic respiratory condition. The feasibility of rehabilitation should be reviewed with the patient, physician, and respiratory therapist (RT). Other indications for pulmonary rehabilitation are listed in Box 50-4. Regardless of underlying conditions, patients also should be ex-smokers. Any patients who smoke should enroll in a smoking cessation program before starting pulmonary rehabilitation. Patients are excluded from pulmonary rehabilitation activities if (1) concurrent problems limit or preclude participation in exercise or (2) their condition is complicated by malignant neoplasms, such as lung cancer (see Box 50-4).

Objectively, candidates considered for inclusion in a pulmonary rehabilitation program generally fall into one of the following groups:²⁰

Groups or classes for pulmonary rehabilitation should be kept homogeneous. Placing individuals in a program who are at different stages of cardiopulmonary disability can be very defeating. Individuals with mild to moderate impairment may become discouraged on how severe lung disease can become, and individuals with severe impairment may feel they cannot keep up with or maintain the level of activity exhibited by others with less severe impairment. It is best to group patients together on the basis of severity and overall ability. In this way, patients can participate, compete, and progress together in the program without frustration, fear, or loss of motivation.

Format

Programs can use either an open-ended or a closed design, with or without planned follow-up sessions. With an open-ended format, patients enter the program and progress through it until they achieve certain predetermined objectives. There is no set time frame. Depending on his or her condition, needs, motivation, and performance, an individual patient can complete an open-ended program over weeks or months. This format is good for self-directed patients or patients with scheduling difficulties. It also may be the best format for patients requiring individual attention. The major drawback of the open-ended format is the lack of group support and involvement. In addition, insurance reimbursement may be a factor when the program is open-ended.

The more traditional closed design uses a set time period to cover program content. These programs usually run 6 to 16 weeks, with classes meeting one to three times a week. However, insurance coverage may dictate how many sessions make up the program. Medicare covers 36 initial sessions with possible coverage of another 36 sessions if the patient qualifies and would benefit from the additional rehabilitation sessions. Class sessions usually last up to 2 hours. Presentations are more formal, and group support and involvement is encouraged. A major drawback to this format is that the schedule determines program completion, rather than the objectives. However, most programs allow patients to reenroll if the anticipated improvements are not achieved.

Regardless of the format used, long-term improvements cannot be expected without planned follow-up.²¹ Follow-up must be ongoing and available to all patients who complete the program. Frequently, this essential element of the process is difficult, especially when it is not covered by most insurance plans, but program coordinators must ensure that it is routinely scheduled. Follow-up or reinforcement could be open-ended (available during regular rehabilitation sessions and offering open attendance) or could be scheduled weekly, monthly, bimonthly, or quarterly. The important thing is to have some type of follow-up available.^22,23

Content

The content of the rehabilitation program usually combines physical reconditioning with education activities. Table 50-2 outlines a sample session incorporating these two complementary components. Programs providing reconditioning or education alone are unlikely to be effective.

As shown in Table 50-2, the ideal rehabilitation session should last about 2 hours. Group size, available equipment, and group interaction dictate session length. Patients should arrive 10 to 15 minutes before a scheduled session to allow for informal group interaction and support. Classes should begin on time and conclude promptly as scheduled. Educational presentations should be brief and to the point. The use of audiovisuals or demonstrations should enhance understanding. To facilitate patient comprehension, the language should be simple, and unnecessary technical terms or concepts should be avoided. Handouts that enhance certain points made during a presentation are both useful and desirable. A folder or notebook in which program activities may be recorded and handout materials kept should be maintained by each patient.

Physical Reconditioning

The physical reconditioning component of the pulmonary rehabilitation program consists primarily of an exercise prescription with target heart rate based on the results of the patient’s initial exercise evaluation. For most patients, an initial target heart rate is set using Karvonen’s formula, or estimated as 20 beats/min greater than resting rate. Because of the severity of ventilatory impairment, some patients begin exercise reconditioning without a prescribed target heart rate.

 Rule of Thumb

To set a target heart rate for patient exercise, use Karvonen’s formula:

Target heart rate=[(MHR−RHR)×(50%−70%)]+RHR

where MHR is maximum heart rate at limit of exercise tolerance and RHR is resting heart rate.

A good target exercise heart rate for a patient with COPD with MHR of 150 beats/min and RHR of 90 beats/min would be [(150 − 90) × 0.60] + 90 = 126 beats/min.

Typically, the exercise prescription includes the following four related components:24,25

To ensure success with physical reconditioning, patients must actively participate both at the rehabilitation facility and at home. While exercising at the facility, patients should be monitored by pulse oximetry. Blood pressure measurements may also be made, but these are usually done at the start and end of each session unless a patient’s condition dictates otherwise. In addition, exercise sessions should be upbeat. Lively music helps to maintain a positive atmosphere. Clinicians must remember that these patients are ill and require a nurturing attitude from team members, family, and the group itself.

To ensure compliance with the program, a daily log or diary sheet is completed. Figure 50-5 depicts a sample log sheet that makes up a section of the patient manual. These log or diary forms are reviewed each time the patient attends a session. Based on this information, further individualized reconditioning goals are set.

Lower extremity exercises may include either walking or bicycling. Patients can walk on a stationary treadmill (with set goals for distance or time and grade) or on a flat, smooth surface. Patients can bicycle on an exercise cycle. With the treadmill or stationary bicycle, patients are required to cover a certain distance or duration every day that they are in the program. Commonly, the duration is set to 30 minutes daily, with patients encouraged to increase both their distance and equipment tension or resistance as tolerated. Patients with significant orthopedic disabilities can participate in aerobic aquatic exercises.

Walking also improves overall conditioning; this usually takes the form of a 6- or 12-minute walk performed once a day, depending on the patient’s condition and tolerance. These walk exercises are a convenient way for patients to carry out a well-defined amount of activity with increasing vigor and results over a number of weeks. During the 6 or 12 minutes, patients should walk on flat ground for as far as possible. If severe dyspnea occurs, they should stop and rest, with the rest time included as part of the time interval. After resting briefly, they should try to continue walking at a comfortable pace. The objective is to walk as far as possible during the allotted time. Landmarks such as telephone poles, city blocks, or actual distance measures can be used to quantify progress. Under adverse weather conditions, walking can be done indoors in shopping malls, stores, or long hallways. Patients should record their progress in their manuals or diaries.

Aerobic upper extremity exercises improve rehabilitation outcomes for patients whose regular activities involve lifting or raising the arms.24,26 Arm ergometers or rowing machines are available for this purpose; however, simple calisthenics using either a broomstick or free weights (by prescription and with training) are a satisfactory alternative. Upper body endurance generally is more limited, with many patients capable of only 2 to 3 minutes of daily activity to start. This limitation usually is related to the fact that patients may revert to using accessory muscles for breathing while doing the upper body exercise. Patients need to breathe diaphragmatically and perform the exercises at the same time. Arm exercises should get progressively longer, up to 20 minutes if possible. Upper body conditioning helps patients perform numerous useful activities at home and can increase overall physical endurance. As with other activity, patients should record daily results in their logs or manuals.

Although controversy exists, ventilatory muscle training probably can enhance the benefits of these more traditional exercises.²⁷ Ventilatory muscle training is based on the concept of progressive resistance. By imposing progressively greater loads on the inspiratory muscles (mainly the diaphragm) over time, the patient’s strength and endurance should increase. These improvements should increase the patient’s exercise tolerance.

Figure 50-6 shows a typical inspiratory resistance breathing device. The device is an adjustable flow resistor with a one-way breathing valve. The inspiratory load is created by forcing the patient to inhale through a restricted orifice. Varying the size of this orifice varies the inspiratory load, as do changes in the patient’s inspiratory flow. During expiration, gas flows unimpeded out the one-way exhalation valve. Other types of devices are also available. One model replaces the variable size orifice with an adjustable spring-loaded valve. This valve ensures a constant load regardless of how quickly or slowly the patient breathes.

Because variations in breathing strategy during ventilatory muscle training can affect outcomes, proper patient evaluation, training, and follow-up are required. The RT initially measures the patient’s maximum inspiratory pressure (PI_max) using a calibrated pressure manometer. The RT next compares the patient’s maximum with established norms (Table 50-3). This preliminary measure of inspiratory pressure helps to establish initial loads and provides the basis for the subsequent monitoring of patient progress.

Before beginning ventilatory muscle training, the patient should assume a position that relaxes the abdominal muscles, such as the position used for cough training. If using a flow resistive device, the RT begins at the maximum orifice setting, while measuring the inspiratory pressure generated through the monitoring or O₂ adapter (a second adapter may be needed if the patient is receiving supplemental O₂). The RT encourages the patient to breathe slowly through the device, at a rate no greater than 10 to 12 breaths/min. If the patient’s inspiratory pressure is less than 30% of the measured PI_max, the next smaller orifice is selected, with this procedure repeated until the 30% effort is consistently achieved.

At this point, the RT instructs the patient to exercise with the device in one or two regular daily sessions lasting 10 to 15 minutes. As the level of resistance becomes more tolerable over time, the patient should progressively increase session duration up to 30 minutes. A self-maintained log of treatment times can help motivate the patient and assist the RT in subsequent progress monitoring.

Educational Component

The educational portion of the program covers topics that are both useful and necessary to the patient. Table 50-4 lists examples of topics covered during a 12-week rehabilitation program. Recommendations regarding the best facilitators for each session are included. Naturally, other topics can be included depending on the program schedule, but in terms of relative importance, the ones listed in Table 50-4 generally have the highest priority.

The actual content of these sessions follows. These topics should be presented in an orderly, coherent fashion using supplementary audiovisual tools and demonstrations, where appropriate. Team members should allocate sufficient time both for the class sessions themselves and for setup and breakdown of equipment.

The program facilitator or leader must ensure that sessions begin on time and encourage maximum participation by each patient. If available, health care professionals such as dietitians, occupational therapists, physical therapists, and psychologists should be invited to present their respective topics and discuss the subject matter with the group. In addition to technical knowledge, session leaders must possess group facilitation skills and be able to motivate patients to participate both in class and at home and to adhere to program guidelines. This task is not an easy one, but it can be accomplished with patience and persistence. The desired end result is to help patients lead more productive lives with decreased hospitalizations.

Psychosocial and Behavioral Components

Psychologic and emotional stress is a common problem for patients with moderate to severe chronic lung disease. Pulmonary rehabilitation programs can bring in experts to implement psychosocial and behavioral therapies that provide patients with the opportunity to learn coping strategies. This component is most useful for patients with anxiety or depression or both.

Staffing

Pulmonary rehabilitation is a multidisciplinary endeavor. Team care is enhanced by involving various health care professionals in the planning, implementation, and evaluation components of the program (Figure 50-7). It is recommended that any staff conducting pulmonary rehabilitation program sessions be certified in basic life support or advanced cardiac life support through the American Heart Association. In addition to professional involvement, family members are needed to provide feedback and ensure that instructions and the exercise prescription are carried out at home.

Facilities

Location and quality of facilities can directly affect patient attendance. Patients are less likely to attend programs that are inaccessible to public transportation, have poor parking arrangements, or are physically difficult to reach. The facility must be wheelchair accessible. For elderly patients who do not drive, arrangements can be made with community organizations to provide transportation to and from the program. Ideally, the facility should provide two separate rooms for the program—one room for educational activities and one room for physical reconditioning. Rooms should be spacious and comfortable with adequate lighting, ventilation, and temperature control. Chairs should be comfortable with good back support. Restroom facilities need to be readily accessible. A room for individual counseling is helpful, but any private office would suffice. It is also preferable to have pulmonary function testing and blood gas analysis capabilities on site. If this space is used by other departments for other functions, proper scheduling of rehabilitation sessions needs to be considered.

Scheduling

Another aspect of program implementation involves timely scheduling of the rehabilitation sessions. With the open-ended format, patients can attend rehabilitation at a time convenient to them as long as the facility is open and staffed accordingly. With the closed format, sessions are scheduled one to three times per week for 1 to 3 hours, with programs running 8 to 16 weeks. The length of the program often depends on insurance coverage and expected reimbursement for sessions attended. Class times need to be scheduled when the largest number of patients can attend. Traffic patterns, bus schedules, and availability of rides are concerns that need to be discussed. The ideal situation involves a separate area set aside for pulmonary rehabilitation with a dedicated staff of professionals conducting the program; this makes scheduling for either open-ended or closed programs easier and more manageable. Sessions can be conducted in the morning, afternoon, or evening and on weekends if necessary. Proper scheduling helps to encourage participation and removes potential stumbling blocks, which could undermine the rehabilitation process.

Class Size

Class size is another issue that must be addressed. Theoretically, a rehabilitation program could be conducted with 1 participant or 15 or more, depending on available space, equipment, and staff. However, to foster group identity, interaction, and support, small group discussions are encouraged. The ideal class size should range from 3 to 10 participants. Keeping the class size manageable facilitates vital group interaction processes and allows for more individualized attention. These factors help sustain motivation, reducing the likelihood of participant attrition.

Naturally, economic concerns surface when class size is considered. Although program quality must be the first priority, program viability realistically depends on the number of participants. Programs generally should be conducted with a class size that is comfortable with regard to space and staffing and that is economically feasible. Such an approach helps ensure that programs produce meaningful patient outcomes.

Equipment

Both the instruction and the reconditioning component of the program require equipment. To meet the educational needs of the program, a blackboard or flipchart along with a PowerPoint projector, screen, overhead projector, and cassette or CD tape player are needed. A videotape or DVD player with monitor may also be helpful, especially if individualized instruction or commercially available programs are used. Also, slides, tapes, videos, and formal learning packages dealing with the educational topics covered during the rehabilitation program should be available for group and individualized presentation. These can be purchased from outside sources or designed and developed in-house.

For physical reconditioning, stationary bicycles, treadmills, rowing machines, upper extremity ergometers, weights, pulse oximeters, and inspiratory resistance breathing devices constitute the minimum equipment requirements. The quantity of equipment needed depends on class size, scheduling, and available space. Sufficient equipment should be on hand to keep all patients exercising and to monitor their activity. Emergency O₂ and bronchodilator medications should also be maintained in the rehabilitation area. Equipment guidelines for a class of 6 to 10 participants include the following: five stationary bicycles, two treadmills, two rowing machines, two upper extremity ergometers, five pulse oximeters for monitoring heart rate and O₂ saturation, one emergency O₂ cylinder (E), and bronchodilator medications. In addition, each patient should be supplied with an inspiratory resistance breathing device.

Because equipment can be expensive, care must be taken in its selection and purchase. Devices and appliances should be durable, easy and safe to use, simple to maintain, and not overly expensive. Initially, basic items are purchased. As a program develops and expands, equipment resources can be enhanced. Other program needs include the following:

By considering all of the factors needed for effective implementation of pulmonary rehabilitation, programs have lower patient attrition and a greater chance for overall success. As programs are conducted, regular evaluations must be made by both patients and staff. Needed changes should be implemented on an ongoing basis. Only in this manner can one expect continued refinement of the process and improvement in patient outcomes.