Initiation and Modification of Therapeutic Procedures

1. Initiation and Modification of Therapeutic Procedures Initiate and Conduct Pulmonary Rehabilitation and Home Care

2. You should be familiar with the following areas of pulmonary rehabilitation; • Purpose and goals of pulmonary rehabilitation. • 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: • 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

3. Patient Selection Pulmonary rehabilitation will not reverse the disease process or increase life expectancy. Candidates for pulmonary rehab are patients with • 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.

4. Program Components Patient Education • 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: • 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

5. Smoking Cessation and Nicotine Intervention Smoking cessation essential to help control disease progression and obtain full benefits of rehabilitation. Methods may include: • 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

6. Respiratory Home Care Respiratory home care includes prescribed respiratory care services in a patient’s personal residence. Most common services: • 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

7. 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

8. Home Oxygen Therapy (cont.) Oxygen Appliances: • Simple low-flow devices (nasal cannula @ flow less than 4 LPM) • Transtracheal catheter use for patients who: • 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

9. Home Mechanical Ventilation Ventilator-dependent patients who have • Underlying cardiopulmonary conditions of COPD or compromised cardiac status or • Neuromuscular disease or spinal cord trauma Goals of home mechanical ventilation • Sustain and extend life • Enhance the quality of life • Reduce morbidity • Improve or sustain physical and psychological function of all ventilator-dependent individuals and enhance growth and development in pediatric patients • Provide cost-effective care Prerequisites for patient discharge to home: • Patient and caregiver desire to go home • Patient is clinically stable for at least 2 weeks • Patient has been on continuous ventilation for at least 30 days with unsuccessful weaning • Patient is free of cardiac monitoring • Patient has a tracheostomy in place, unless using noninvasive ventilation • Patient demonstrates control of any seizure activity with medication protocol as prescribed • Patient is free of IV medications of an acute care nature such as vasodilators or beta-blockers • Family members and/or caregivers are willing and capable to accept home care responsibility • Patient has had a complete medical and financial assessment by the case manager (post acute)

10. Home Mechanical Ventilation (cont.) Patients should not be considered for home ventilatory support if: • They require more than 40% O2 or more than 10 cmH2O PEEP • They need continuous invasive monitoring • Their tracheostomy is still fresh (for invasive support only) • The home physical environment is deemed unsafe by the discharge team • Fire, health, or safety hazards • Unsanitary conditions • Inadequate heating, ventilation, or electrical service Additional considerations for home care ventilation • A backup ventilator should be available for patients who: • Cannot maintain spontaneous ventilation for 4 or more consecutive hours • Live in an area where a replacement ventilator cannot be provided within 2 hours • Caring for a ventilator-dependent patient in the home is a labor-intensive undertaking and involves extensive education and training of the family and/or caregivers, including infection control measures • Additional equipment needed may include hospital bed, supplemental oxygen, suction equipment, and related supplies • Arrangements must be in place for emergency situations, including power outages

11. 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 • Infants receiving aminophylline or caffeine therapy for a history of apnea and bradycardia • Infants with bronchopulmonary dysplasia requiring O2 therapy, CPAP, or ventilatory support • Infants with gastro-esophageal reflux (GERD) if symptomatic with color and tone change • Infants of substance-abusing mothers if clinically symptomatic • Infants with a tracheostomy or anatomic abnormalities at risk for airway compromise • Infants with neurologic or metabolic disorders affecting respiratory control • Key elements prior to discharge • 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

12. 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

13. 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

14. 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.

15. 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.

16. 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

17. 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.

18. 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.

19. Reference: Certified Respiratory Therapist Exam Review Guide, Craig Scanlon, Albert Heuer, and Louis Sinopoli Jones and Bartlett Publishers