Unique therapy strategies can help patients in home care with COPD

By Joseph "Jay" Cigna, PhD, MSPT

Chronic obstructive pulmonary disease (COPD) is a leading cause of death and disability in the United States. In the year 2000, the National Center for Environmental Health estimated that COPD was responsible for 119,000 deaths, 726,000 hospitalizations, and 1.5 million hospital emergency department visits.

Patients with COPD often cycle between acute care episodes and home health care episodes. The National Center for Health Statistics (2005) estimates that 5 percent of all patients admitted for home care services have COPD. Use of health care resources and mean costs per case are approximately twice that of individuals without COPD.¹ Rehabilitation programs for patients with COPD have demonstrated effectiveness not only in reducing costs but also in improving quality of life.²

Patients with COPD experience limitations in airway flow rates, dyspnea, coughing, abnormal sputum production and an inability to tolerate normal functional activities.³ As COPD progresses, walls of the lung's alveolar sacs are destroyed, reducing gas exchange between the small airway passages and the blood. In addition, bronchioles lose their elasticity, causing them to collapse during exhalation, trapping air and secretions. As patients with COPD cough repeatedly but ineffectively, lung secretions collect and promote the development of pneumonia.

Home Care Options

Prior to treatment, evaluate the patient's respiratory history. Include questions about the course of his COPD, smoking history, the type and effectiveness of medical management and the use of supplemental oxygen (O₂). Assess the patient's degree of dyspnea (or breathlessness) on a scale of 1-10, with 1 being very slight and 10 being maximal.

Determine the patient's current attitude and motivation towards self-managing the disease and actively participating in the rehabilitation program. Lung auscultation, palpation, physical characteristics of the chest and the environment in which the patient lives will help to direct the treatment options.

The goal of medical management is dyspnea relief and to help improve activity tolerance, sleep quality and overall quality of life.³ Bronchodilators are prescribed to relax smooth muscles of the bronchi and open constricted airway passages. Medications include anticholinergic bronchodilators such as Ipratropium bromide and Tiotropium bromide, long-acting beta2-agonist bronchodilators such as Formoterol and Salmeterol, short-acting beta2-agonist bronchodilators such as Albuterol and Metaproterenol, and methylxanthine bronchodilators such as Aminophylline and Theophylline. Corticosteroids are often prescribed to help relieve the inflammation and swelling of lung tissues.

In addition, patients are often prescribed antibiotics to control lung infections and mucolytics to reduce the thickness of mucous secretions. It is important to understand the function of medical management in order to adjust homecare treatments and avoid potential interactions that could alter the effects of the medication.

Supplemental O₂ is used to improve sleep, activity tolerance, cognitive function and to reduce breathlessness. A portable pulse oximeter measures the O₂ saturation of the blood. The goal is to maintain the O₂ saturation above 90 percent. Oxygen can be delivered through air concentrators, compressed O₂ in cylinders or in a liquid-oxygen device, depending on patient needs such as mobility and COPD severity. Routinely review the proper use of flow meters and regulators with the patient and any caregivers.

Chest Physical Therapy

Chest physical therapy (CPT) is a useful technique to treat patients with compromised airflow and pulmonary secretion clearance.⁴ The main components of CPT used to treat patients with COPD are positioning, along with manual, coughing and breathing techniques.

Patients can be placed in several of 11 classic positions–supine, prone, side-lying, upright and Trendelenburg–that allow gravity to promote drainage of secretions that have settled into the lung segments. Lung auscultation using a stethoscope allows the clinician to listen for sounds that may be present such as rhonchi or wheezes or absent in cases of effusion or atelectasis.

The most commonly used manual techniques are percussion, vibration and rib-springing. Percussion is performed using a cupped hand to make a clapping sound over the external surface of the back, sides and chest. Percussions are applied from 100 to 400 times per minute, exerting enough force to dislodge secretions but not in a manner that causes pain, increases bronchospasm or causes bruises in patients medically managed with anticoagulants such as warfarin. Vibration and rib-springing are manual techniques used during the expiratory phase in frequencies of 12 to 20 Hertz.

Manual techniques are contraindicated in patients with untreated pneumothorax, marked thrombocytopenia or rib fractures, and must be exercised with caution in patients with osteoporosis.

During home care treatments, instruct patients to use a controlled cough with a forced expiratory technique known as "huff coughing." Huff coughing begins with a slow, maximal inspiration, breath-holding for several seconds, then a forced expiratory phase consisting of one or two forced exhalations ("huffs").

Huff coughing avoids the dynamic airway collapse, bronchoconstriction and fatigue associated with uncontrolled, forceful coughing. Huff coughing saves energy and O₂ as well as helps to clear the airway of secretions more effectively.

Just as important as coughing techniques are breathing techniques.^5,6 Pursed lip breathing prevents dynamic airway collapse and air entrapment using a slow, controlled exhalation. During dyspneic episodes, pursed lip breathing helps reduce breathing difficulty by maintaining lung pressure.

First, instruct patients to inhale through the nose. The instructional phrase most often used is "smell the roses." Next, have the patient exhale slowly through pursed lips. The instructional phrase is "blow out the candles."

Lower chest expansion uses the lower excursion of the diaphragm into the abdomen to increase inspiratory capacity, avoiding overuse of upper chest and neck muscles. With the patient in supine position and the abdomen free to move, the therapist places one hand on the upper chest to determine the contribution of the chest muscles during breathing. The therapist then places the other hand at the level of the navel on the abdomen. The therapist should have the patient breathe in slowly through the nose and try to push the therapist's hands out with the abdomen. As the patient exhales through pursed lips, the therapist lets his hand move back to the abdomen.

Therapists use manual techniques with postural drainage to promote movement of secretions. Secretions dislodged from the small sacs into the larger airway passages can be removed by coughing techniques. Expectorated secretions can be inspected for quantity, color, consistency and odor.

Pulmonary Rehabilitation

Pulmonary rehabilitation (PR) for the home care patient who has COPD is a treatment with demonstrated success.^7,8 PR combines exercise training with educational programs to help patients with COPD control symptoms, improve quality of life and their participation in activities of daily living. The main components of PR used to treat patients with COPD are endurance exercises, conditioning exercises, postural reeducation and education.

Determine baseline exercise capacity with a timed distance walk such as the 3-, 6- or 12-minute walk test. Measure distance, heart rate, O₂ saturation and ratings of dyspnea or breathlessness using a scale of 1-10 as mentioned above.

Patients should exercise at an intensity that encourages proper energy conservation techniques to improve their capacity to perform activity yet limit the amount of dyspnea that they experience. The duration of the exercise will gradually be progressed as the patient's physiology adjusts to the exercise. The frequency of exercise is based on the patient's condition at initial examination. Patients should attempt to exercise three to five times per week.

In home care, it is not always necessary for the clinician to attend each session. Sessions with the PT should be used to monitor progress and adjust the exercise prescription as necessary. Walking, stair climbing and using a pedaler or stationary bike are different modes of exercise that can be used. Reevaluate at the middle and end of the PR program. Encourage other members of the homecare team as well as family to assist and reinforce the exercise program prescribed.

Strengthening exercises can progress from unresisted activities to exercise using a resistive band or light weights. Respiratory muscle training should also be included in the program to strengthen the inspiratory musculature.⁹

Patients with COPD often report increases in dyspnea when performing upper extremity activities such as lifting, bathing and grooming. In the struggle to breathe, the patient recruits the accessory muscles of respiration, compromising the use of the upper extremities, which share many of the same muscle attachments. Upper extremity exercises have been demonstrated to improve the condition of patients with COPD.¹⁰

Include postural reeducation exercises when appropriate to correct abnormalities that develop from relying on accessory muscles to aid ventilation. Correcting the forward head, elevated shoulders and protracted scapulae will improve the patient's condition, especially any complaints of neck and back pain. Maintenance of proper posture will also benefit patients when doing their breathing techniques.⁴

COPD is mainly associated with smoking; however, only about 20 percent of patients are able to maintain long-term smoking cessation. As many patients with COPD who smoke find it difficult to quit, it is important to educate them on the risks associated with smoking. Educating patients and their families about the techniques for smoking cessation as well as the dangers of smoking with O₂ therapy benefits not only patients but family members and health care providers as well.

All home care clinicians can become proficient in developing programs that will help patients with COPD. The recent creation of the Global Initiative for Obstructive Lung Disease (GOLD) report (http://www.gold.com) highlights the importance for home care practitioners to develop effective treatments to help reduce the progression of this disease. Clinically appropriate, evidence-based rehabilitation home health care programs not only help reduce health care costs but also reduce the impact of this disease on patients.

References

1. Mapel, D., Hurley, J., et al. (2000). Health care utilization in chronic obstructive pulmonary disease: A case-control study in a health maintenance organization. Archives of Internal Medicine, 160, 2653-2658.

2. Bourbeau, J., Julien, M., et al. (2003). Reduction of hospital utilization in patients with chronic obstructive pulmonary disease. Archives of Internal Medicine, 163, 585-591.

3. Celli, B., MacNee, W., & ATS/ERS committee members. (2004). Standards for the diagnosis and treatment of patients with COPD: A summary of the ATS/ERS position paper. European Respiratory Journal, 23, 932-946.

4. Irwin, S., & Tecklin, J. (2004). Cardiopulmonary physical therapy (4th ed.). St. Louis, MO: Mosby.

5. National Emphysema Foundation. (2005). Pulmonary Health/Exercise & Care. Retrieved from the World Wide Web, www.emphysemafoundation.org/pulhthex.aspx#EXERCISE1.

6. Dechman, G., & Wilson, C. (2004). Evidence underlying breathing retraining in people with stable chronic obstructive pulmonary disease. Physical Therapy, 84,1189-1197.

7. Ferrari, M., Vangelista, A., Vedovi, E., Falso, M., Segattini, C., Brotto, E., Brigo, B., & Lo Cascio, V. (2004). Minimally supervised home rehabilitation improves exercise capacity and health status in patients with COPD. American Journal of Physical Medicine and Rehabilitation, 83, 337-343.

8. American College of Chest Physicians/American Association of Cardiovascular and Pulmonary Rehabilitation Pulmonary Rehabilitation Guidelines Panel. (1997). Pulmonary Rehabilitation. Joint ACCP/AACVPR evidence-based guidelines. Chest, 112, 1363-1396.

9. Covey, M., Larson, J., et al. (2004). High-intensity inspiratory muscle training in patients with chronic obstructive pulmonary disease and severely reduced function. Journal of Cardiopulmonary Rehabilitation, 21, 231-240.

10. Lebzelter, J., Klainman, E., et al. (2001). Relationship between pulmonary function and unsupported arm exercise in patients with COPD. Monaldi Archives for Chest Disease, 56, 309-314.

Joseph Cigna is a physical therapist for Partner's Homecare in the metropolitan Boston area. He has more than 20 years of experience in health care practice, teaching and research with interests in gerontology and the role of rehabilitation in the management of chronic diseases.