a. Personal grooming

b. In-home activities

c. Out-of-home activities

See Chapter 1 for the discussion on interviewing a patient about sputum production. The patient with chronic and severe cardiopulmonary disease may describe a very restricted and limited lifestyle. Extra O₂ may have only limited benefit. The patient with chronic, but moderate, cardiopulmonary disease can live a somewhat limited but full lifestyle. Extra O₂ may help greatly at times when the patient becomes short of breath. The otherwise healthy patient with an acute cardiopulmonary disease should describe a previously full and enjoyable lifestyle. Extra O₂ may be needed now, but it is hoped that it will not be needed upon recovery.

a. Perform overnight pulse oximetry (Code: IB9q) [Difficulty: ELE: R; WRE: Ap, An]

b. Interpret the results of overnight pulse oximetry (Code: IB10q) [Difficulty: ELE: R, Ap; WRE: An]

While it less expensive to perform overnight pulse oximetry in the home than polysomnography in the hospital, most patients who are suspected of having sleep-disordered breathing will be evaluated in the hospital. See the discussion on sleep-disordered breathing and overnight pulse oximetry in Chapter 18.

c. Initiate treatment for sleep disorders (e.g., CPAP) (WRE code: IIIK9) [WRE difficulty: Ap, An]

See Chapter 18 for the discussion on treatment for sleep disorders. CPAP systems are presented in Chapters 15 and 18.

a. Initiate and adjust sleep apnea monitors (WRE code: IIIK2) [WRE difficulty: Ap]

b. Perform apnea monitoring (Code: IB9p) [Difficulty: ELE: R, Ap; WRE: An]

Apnea monitoring is indicated in an infant who has documented periods of apnea of prematurity resulting from an immature central nervous system. This condition is most commonly seen in infants younger than 35 weeks’ gestational age. The usual monitoring guidelines include apneic periods that last longer than 20 seconds and are associated with bradycardia with a heart rate of less than 100 beats/min. Hypoxemia is often demonstrated by cyanosis, pallor, or documented desaturation through pulse oximetry. In addition, the infant may show marked limpness, choking, or gagging. Other conditions such as intracranial hemorrhage, patent ductus arteriosus, upper airway obstruction, hypermagnesemia, infection, and maternal narcotic agents, for example, should be ruled out before apnea of prematurity is confirmed. If this is the infant’s problem, it is usually outgrown by the time the infant is 40 weeks’ postconceptional age. Home apnea monitoring is not indicated in normal infants, in preterm infants without symptoms of apnea, or to test for sudden infant death syndrome (SIDS). See Box 17-1 for guidelines on starting and stopping home apnea monitoring.

Apnea monitors currently in use sense respiratory efforts through the changing electrical impedance measured through the chest wall as the infant breathes. Impedance is resistance to the flow of electricity through the skin and other organs. The monitor transmits a small, constant electrical current that results in a voltage across the two electrodes on the infant’s chest. As the infant breathes and the chest wall expands and contracts, a resulting change in voltage occurs. This fluctuation is measured and interpreted as inhalation and exhalation. Similarly, smaller voltage changes are measured with each heartbeat. This is measured and interpreted as the heart rate.

The following are desirable features on a home apnea monitor: (1) ability to store and display events for later analysis, (2) identification of breathing patterns and apnea periods, (3) identification of heart rate patterns, (4) estimation of tidal volume, and (5) identification of hypoxemia by pulse oximetry. Assembling a home apnea monitor involves placing the electrodes properly on the infant’s chest, turning on the monitor, and setting the proper high and low limits for the alarms.

Two electrodes are usually placed where the greatest amount of movement occurs during breathing. Most often, this is on the infant’s upper chest between the nipples and armpits (Figure 17-1). With older infants, the electrodes might have to be placed on the sides over the lower ribs. Occasionally one electrode is placed on the chest and the other on the infant’s abdomen. Some monitoring systems require that a Velcro belt be placed around the infant over the electrodes to secure their positions. (Obviously this works only if both electrodes are on the chest.) Other systems employ electrodes with an adhesive. In either case, for best results, the infant’s chest should be washed with mild soap and water and dried before the electrodes are placed. This results in the best electrical conduction. Do not use baby oils, lotions, or powders over the electrode sites. Attach the lead wires to the electrodes. These connect to the patient cable that is then connected to the monitor. Occasionally static electricity causes some interference with the signal. A third chest electrode is then added to act as a ground wire.

Figure 17-1 Block diagram for impedance apnea and heart rate monitor.

(From Lough MD. In Lough MD, Williams TJ, Rawson JE, editors: Newborn respiratory care, St Louis, 1979, Mosby.)

The monitor should be plugged into a working electrical outlet and turned on. Set the unit to charge the internal battery so that it can be made portable for later use. Confirm that the infant’s respiratory and heart rates are being sensed and displayed. If pulse oximetry is a feature on the unit, the probe should be properly placed on the infant, and an Spo₂ value should be displayed. Set the high and low alarm values according to the physician’s orders or established protocols. For example:

Multiple alarms provide for a greater margin of patient safety. They also indicate what physiologically deteriorates first in the infant. These backup alarm systems are important because the apnea monitor senses chest wall movement, not air movement. It is possible for the infant to have an upper airway obstruction and continue to make breathing attempts; therefore the apnea monitor will not alarm because the chest wall is moving. The bradycardia or desaturation alarms will signal that the infant is in trouble.

It is critically important that the parent(s) know(s) about the infant’s medical condition. They need to understand how the monitor functions and what to do if the alarms sound. They should demonstrate their knowledge of the monitor’s functions and be given written instructions about the monitor. The parents should not be more than 10 seconds away from the infant at any time, which means that the infant will not be apneic for more than 30 seconds (20-second alarm delay and 10 seconds for the parents to respond). The parents must know how to give tactile stimulation to the infant, use the manual resuscitator, call for emergency help, and perform infant cardiopulmonary resuscitation.

c. Interpret apnea monitoring results (Code: IB10p) [Difficulty: ELE: R, Ap; WRE: An]

Alarm situations fall into two basic categories: patient alarms and equipment alarms. Patient alarms mean that the infant either is apneic, has a heart rate below or above an acceptable level, or is desaturated. One, any two, or all three alarms may be triggered. Other than the audible alarm, a visual alarm flashes to show the problem(s), and the recording device keeps track of the events. The parents should be instructed first to care for the infant, and then, when the infant is back to normal, the alarms can be reset.

Three types of equipment alarms are found: electrode or lead problem, low battery, or monitor failure. The unit should have different visual and audible alarms for equipment failure so that the family does not mistakenly believe that the infant is in trouble. An electrode or lead problem alarm usually occurs because the electrode fell off of the infant or the lead became disconnected. The family should be taught how to fix these types of problems. A low battery alarm indicates that time is limited for the monitor to function on battery power. The family should be instructed to plug the monitor into a functioning electrical outlet, and the unit should be set to recharge the battery. A monitor failure alarm indicates a serious internal problem with the monitor. It is not functioning properly and should not be used. The family should be instructed to observe the infant continuously and call the home care company for a replacement monitor.

Apnea monitors in current use record and store the alarm situations discussed previously. The information can usually be downloaded into a computer for a visual display of breathing and heart rate patterns, equipment problems, and the dates and times of their occurrences. The therapist or physician should review all these data to determine what kinds of problems the patient experienced.

a. Personal grooming

b. In-home activities

c. Out-of-home activities

If necessary, review the discussion on sputum production in Chapter 1. The patient with chronic and severe cardiopulmonary disease will describe a very restricted and limited lifestyle. Extra oxygen may have only a limited benefit. The patient with chronic, but moderate, cardiopulmonary disease is able to live a somewhat limited but full lifestyle. Extra oxygen may help greatly at times when the patient becomes short of breath. The otherwise healthy patient who has an acute cardiopulmonary disease should describe a previously full and enjoyable lifestyle. Extra oxygen may be needed now but not on recovery.

a. Perform a 6-minute walk (Code: IB9h) [Difficulty: ELE: R; WRE: Ap, An]

A 6-minute walk procedure involves the therapist having a patient walk as far as possible in 6 minutes and noting the distance covered. (Or, the distance that can be covered in a 12-minute walk test.) A timed walk test is easy to perform, is generally well tolerated, and directly relates to pulmonary rehabilitation activities. See the discussion on stress testing in Chapter 18 for information on evaluating a patient before a walk test and contraindications to exercise testing that may apply to a patient performing a timed walk.

Ideally, repeated tests should be performed at the same time each day and at least 2 hours after a meal. Basic equipment for the walk test includes a straight hallway at least 100 feet long that is marked at intervals for distance, a stopwatch, and a pulse oximeter. Record the temperature in the hallway. Be aware of two outside factors that can alter a patient’s performance. First, the so-called practice or learning effect can alter performance. The practice effect means that with repeated attempts, the patient will probably walk farther each time. Therefore the patient should perform at least two 6-minute timed walks that are measured and reported. The patient may rest for about 15 minutes between each walk test. Second, positive encouragement and feedback from the respiratory therapist can boost the patient’s walking distance. Therefore when and how encouragement is given need to be standardized with all patients. See Box 17-2 for a recommended 6-minute walk protocol.

b. Interpret the results of a 6-minute walk (Code: IB10h) [Difficulty: ELE: R, Ap; WRE: An]

Research has shown that patients participating in a pulmonary rehabilitation program will usually show an increase in their timed walk distance. The following indicates that the patient is making progress:

The following indicate that the patient’s health is deteriorating:

c. General considerations in a graded exercise program

Note: While the following information is not specifically listed as testable by the NBRC, past Written Registry Examinations have included questions pertaining to it.

The patient’s physical condition must be evaluated before designing an exercise program. Besides chronic obstructive pulmonary disease (COPD), the patient may have other conditions that further limit his or her ability to safely participate in a rehabilitation program. See Box 17-3 for the suggested assessment parameters. If the patient is too ill or too limited in ability, he or she should not be placed into a rehabilitation program.

Although the patient’s physical condition is the most important factor to evaluate from a safety point of view, other aspects of the patient’s life also must be reviewed. These include a nutritional evaluation, a psychosocial evaluation, and a vocational evaluation. Because these areas are beyond the scope of practice of most respiratory therapists, the physician must refer the patient to other experts. In addition, any patient who is still smoking must be enrolled in a smoking cessation program.

Similar to preparing a patient for home care, all aspects of the patient’s physical condition information must be evaluated. Each patient must have an individualized program and be physically and emotionally prepared to begin the rehabilitation program. As discussed next, the patient is placed into either an open- or a closed-end program format. The starting and ending points of the program are determined based on the patient’s physical condition, heart rate target, and stress test results.

A graded exercise program is an individually structured sequence of events that is designed to safely increase the patient’s exercise tolerance. It is a critical component of any pulmonary rehabilitation program. In 1942 the Council of Rehabilitation defined rehabilitation as “the restoration of the individual to the fullest medical, mental, emotional, social, and vocational potential of which he/she is capable” (Hodgkin, 1993). In 1974 The American College of Chest Physicians’ Committee on Pulmonary Rehabilitation adopted the following:

It further states: “In the broadest sense, pulmonary rehabilitation means providing good, comprehensive respiratory care for patients with pulmonary disease.”

The patient with pulmonary disease who is inactive because of his or her condition experiences a slow deterioration in overall body function. It is well-known that physical activity is important for general health. Box 17-4 lists the effects of inactivity.

The remainder of this discussion focuses on how to start a patient in a graded exercise program and to monitor the patient’s progress. (Note that the education of the patient about normal and abnormal lung function, respiratory care procedures, and medications, for example, is addressed in earlier sections of this book and in other textbooks dedicated solely to pulmonary rehabilitation.)

d. Benefits of an exercise program

The benefits of the exercise program must be stressed to the patient to gain his or her acceptance of it. If the patient does not believe that the program will make his or her life better, it will not be followed. In 1981 the American Thoracic Society Executive Committee adopted the following as principle objectives of pulmonary rehabilitation:

Most authors agree with the following general therapeutic goals:

Note that the benefits did not list an improvement in the patient’s cardiopulmonary condition. Numerous studies have documented that pathologic changes seen in COPD do not improve despite the patient being in a rehabilitation program. It is important that the therapist correct any misunderstanding of this.

e. Individualized graded exercise program

The program format and features may vary considerably. Minimally, the patient’s physician should specify four parts to the exercise prescription: mode, intensity, duration, and frequency. The following program formats and suggestions are typical of what might be ordered.

f. Program format

There are two basic types of formats. Each has its own advantages and disadvantages depending on the limitations and preferences of the patient. The open-end format allows the patient to enter and progress through the program at his or her own pace. Because each patient’s goals are individualized, the time of their accomplishment is relatively unimportant as long as progress is being made. The program facilitator (often a respiratory therapist) acts as a coordinator. This may include ensuring that educational materials are available for the patient, exercise equipment is available, and the patient’s questions are answered. The patient may stay in the program until the last goal is achieved. The advantages of this program are that it is self-directed and can be adjusted if the patient has a schedule conflict. The disadvantage of this program is that no group support or involvement with other people who have COPD is included.

The closed-end format involves the program facilitator setting up a formal schedule of educational topics and exercise sessions. These group events commonly last from 1 to 3 hours and may occur from one to three times per week. The whole program can vary in length from 8 to 16 weeks, depending on the content. These events are attended by a group of patients who share a common problem and have common goals to address. One major advantage of this program is that most patients do better when they have peers to ask for emotional support. The facilitator will probably find that it is easier to schedule speakers when a established time frame can be set. The disadvantages of this program relate to the loss of individual goals and attention. If a patient misses a session, he or she will have to wait for the topic to be repeated at the next program. If the group is too large, the facilitator may not have time to help a patient with an individual goal.

g. Strength training

Many patients are so weak from years of relative inactivity that they must regain muscle strength before pursuing increased endurance. The specific muscle groups that need strengthening can be determined by physical examination. In general, the large muscle groups of the legs and arms and inspiratory muscles must be strengthened.

Before beginning strength training, the patient must perform calisthenics for about 10 minutes as a “warm-up.” It is important to stretch the muscles and joints and increase circulation before starting more vigorous activity. See Figure 17-2, groups 1 to 7, for a series of progressively more demanding calisthenic exercises. All patients should at least be able to perform the calisthenics shown in groups 1 and 2 for a warm-up. The patient must focus on breath control (pursed-lip breathing) during the warm-up period to avoid dyspnea.

Figure 17-2 Modified calisthenic exercises. In all groups, the figure to the left is the starting point. The figures to the right show the sequence of steps in the exercise. The patient can adjust the pace of exercises to either increase or decrease the energy that is expended. In general, most patients choose 10 to 15 repetitions per minute. Exercises shown in groups 1 and 2 are useful during the warm-up period of either a strength or an endurance program. Exercises shown in groups 3 and 4 are more demanding and can be used for muscle reconditioning by many patients in an endurance program. The most demanding exercises are those shown in groups 5, 6, and 7. Patients with only moderate disability may be able to progress to this level for further muscle conditioning.

(From May DF: Rehabilitation and continuity of care in pulmonary disease, St Louis, 1991, Mosby.)

Group 1 Exercises

Group 2 Exercises

Group 3 Exercises

Group 4 Exercises

Group 5 Exercises

Group 6 Exercises

Group 7 Exercises

Arm and leg strengthening can be done in a variety of ways for about 10 minutes. Typically, a 1- or 2-lb weight is used. Barbell weights can be held as the arms are moved to the back, front, sides, and overhead to strengthen the arms, shoulders, and chest and back muscles. Ankle weights can be worn. The legs are then moved to the back, front, and sides; the legs can be lifted with the knees bent; or the initial calisthenics can be repeated with added weight. The abdominal muscles can be strengthened by having the patient lie on his or her back and placing a 2-lb weight on the abdomen. The patient then concentrates on maintaining breath control against the added weight.

Inspiratory muscle strengthening is done in two ways. First, the patient is told to take in a deep sigh and hold it for a brief time. This both stretches the rib cage and increases the workload of the primary and secondary inspiratory muscles. The deep sigh should be repeated several times. Second, the patient uses a specific inspiratory muscle training device. The PFLEX device is popular because it is inexpensive and can be gradually adjusted to increase the workload as the patient improves. Review the discussion in Chapter 7 and see Figure 7-1.

Finally, the patient should spend about 10 minutes in “cool-down” activities. This may involve more light calisthenics or slow walking. The cool-down period allows the body to return to a slower metabolic rate while still maintaining good circulation to the arms and legs. This helps to eliminate any lactic acid that might have accumulated in the muscles during the more vigorous exercise. Increased lactic acid may cause some muscle aches after exercise. Inform the patient that some muscle soreness may be felt the next day. It can be relieved by taking an antiinflammatory medication such as aspirin if the physician approves. See Box 17-5 for specific guidelines for a strength training program.

BOX 17-5 Guidelines for Strength and Endurance Training

Modified from May DF: Rehabilitation and continuity of care in pulmonary disease, St Louis, 1991, Mosby.

STRENGTH TRAINING

This involves a low number of repetitions of a high-intensity activity, such as lifting weights.

A warm-up period involving calisthenics should be carried out for about 10 min.

The following strengthening program should last about 10 min:

Three sets of 10 to 15 repetitions of an activity should be performed.

Each set is followed by a rest period of a few minutes.

The patient should work at 85% to 90% of the maximum capacity of the muscles being exercised.

Follow with a cool-down period involving calisthenics for about 10 min.

The patient should exercise every other day (for example, Monday, Wednesday, and Thursday).

This program may precede or be done simultaneously with an endurance program.

It takes 4 to 8 weeks for improved strength to be realized.

ENDURANCE TRAINING

This involves a high number of repetitions of a relatively low-intensity activity, such as walking.

A warm-up period involving calisthenics should be carried out for about 10 min.

The patient should do the following:

Exercise continuously for about 20 to 30 min.

Exercise at a level that results in the target heart rate being maintained.

Follow with a cool-down period involving calisthenics for about 10 min.

The patient should exercise every other day (for example, Tuesday, Thursday, and Saturday).

This program may follow or be done simultaneously with a strength program.

It takes 4 to 8 weeks for improved endurance to be realized.

It is helpful, but not necessary, for the patient to have access to professional body building equipment found in many gymnasiums. In addition, a physical therapist is helpful in designing a training program.

1. Analyze available information to determine the patient’s pathophysiologic state (Code: IIIH1) [Difficulty: ELE: R, Ap; WRE: An]

The respiratory therapist should have a solid understanding of the pathophysiology of commonly found cardiopulmonary and cardiovascular conditions. These include, but are not limited to, asthma, emphysema, chronic bronchitis, pneumonia, pulmonary fibrosis, cystic fibrosis, right and left heart failure, stroke, and neuromuscular disease. The scope of this text prevents a full discussion of these conditions; the reader is referred to the many excellent pathology textbooks that are available.

In addition, review the information presented in Chapters 1, 3, 4, and 5. These chapters discuss bedside patient assessment, blood gas interpretation, pulmonary function testing, and hemodynamic monitoring that the NBRC has determined to be testable on the Entry Level Examination and Written Registry Examination. Be prepared to evaluate areas such as vital signs, breath sounds, blood gas values, pulmonary function results, and cardiac study results to determine the patient’s condition.

2. Develop the home care and pulmonary rehabilitation protocols (Code: IIIH6b) [Difficulty: ELE: R; WRE: Ap, An]

3. Apply the home care and pulmonary rehabilitation protocols (Code: IIIH8) [Difficulty: ELE: R, Ap; WRE: Ap]

4. Monitor the outcomes of home care and pulmonary rehabilitation protocols (Code: IIIH7b) [Difficulty: ELE: R, Ap; WRE: An]

Respiratory care protocols may be used at home as well as in the hospital. An oxygen therapy protocol can be implemented that uses the patient’s pulse oximetry values to adjust the oxygen percentage or flow up or down. For example, keep the patient’s Spo₂ less than 95% but greater than 85%. A second protocol may be using inhaled sympathomimetic bronchodilators based on the patient’s peak flow results.

The patient’s physical condition must be evaluated before designing a home care or rehabilitation program. Besides the primary diagnosis, the patient may have other conditions that further limit his or her ability to participate safely. If the patient is too ill or too limited in ability, he or she should not be placed into a home care or rehabilitation program.

Although the patient’s physical condition is the most important factor to evaluate from a safety point of view, other aspects of his or her life also must be reviewed. These include a nutritional evaluation, a psychosocial evaluation, and a vocational evaluation. Because these areas are beyond the scope of practice of most respiratory therapists, the physician must refer the patient to other experts.

Be prepared to evaluate the patient’s condition and make suggestions for changing goals or methods, for example. The therapist must have a thorough understanding of the patient’s condition and individual goals to evaluate his or her progress toward meeting them. Objectively consider the patient’s physical, emotional, and social condition. The therapist also must listen to the patient’s subjective opinion about his or her situation. Be prepared to make recommendations to the patient and attending physician for modifying the goals depending on the patient’s changing condition.

5. Record and evaluate the patient’s response to the treatment(s) or procedure(s), including the following:

6. Communicate information