2.  Definition: › Process › Facilitates moving patients from one level of health care setting to another The process of discharge planning begins the moment a person (patient) enters a particular health care setting.

3.  Provides the foundation for quality post- acute (subacute) care.  Guides multidisciplinary team in transferring patient from health care facility to alternative care site.  Ensures safety and efficacy of continued patient care.  Aims to contain health care costs & improve patient outcomes.

4.  Attempts to reduce hospital length of stay (LOS).  Attempts to reduce unplanned readmission to hospital.  Improves coordination of services following discharge from hospital.

5.  Discharge planning should ensure that patients are discharged from hospitals at an appropriate time in the course of their care.

6.  Indications: › For all respiratory patients being considered for discharge or transfer to alternative health care settings.  Contraindications: › NONE

9. Arrange services:  Home care  Nursing home  Rehabilitative care  Out-patient medical treatment  Hospice Hospital discharge planning is usually conducted by the hospital’s Social Services Department.

10. CAVEATS and PROVISOS Facilities with the most vacancies may not be desirable. Facilities located too far from family home should not be recommended. Patient/legal representative must consent to placement.

11.  Multidisciplinary Team › Utilization review › MD › Discharge planning (social service) › Respiratory therapy › Nursing › Dietary/nutrition › Physical/occupational therapy › Psychiatry/psychology › DME/home care company

12. MULTIDISCIPLINARY TEAM  Utilization review: recommends consideration of patient discharge, & documents patient’s in-hospital care  MD: writes order for discharge  Discharge planning: ensures that patient can be discharged to subacute care setting  RT: provides respiratory care plan and follow- up

13. MULTIDISCIPLINARY TEAM  Nursing: composes nursing plan ; assesses patient status; provides follow-up  Dietary: assesses & determines nutritional needs  PT/OT: recommends modalities/procedures  Psychiatry/psychology: emotional status/counseling/support  DME/home care: equipment/supplies/emergencies RE: equipment

14. Site & Support Service  Goals & needs of patient determine appropriate site for discharge.  Resources at proposed site must meet patient needs. › Competent staff › Respiratory/ventilatory needs › Other health care services

15.  Home discharge: › Caregivers’ abilities to learn/perform must be evaluated. › Caregivers’ competencies must be documented. › Caregivers must provide 24-hour coverage. › Multiple caregivers (professional & non- professional) required.

16. Confirmation of Skills among Nonprofessionals verbal communication demonstration return-demonstration

17. Qualities Required of DME company’s accreditation status cost & scope of services dependability/location/availability (24/7)

18. HOME ENVIRONMENT no fire, health, or safety hazards adequate heating, cooling, & ventilation adequate electrical supply capable of supporting RT & ancillary equipment

19. RT HOME EQUIPMENT CONSIDERATIONS available space electrical power supply amperage/grounded outlets absence of hazardous appliances

20. Possible Complications of Discharge Planning: Patient discharged before full implementation of plan Natural course of the disease (e.g., patient dies) Factors beyond control of discharge planners

22.  About 46 million American adults smoke cigarettes, but most smokers are either actively trying to quit or want to quit.  Nicotine content in cigarettes has slowly increased over the years.  One study found an average increase of 1.6% per year between the years of 1998 and 2005.

24. CAD/CV disease atherosclerosis MI COPD lung CA

25.  After 1 year off cigarettes, the risk of CAD is reduced by half.  After 15 years of abstinence, the risk is similar to that for people who've never smoked.  In 5 to 15 years, the risk of stroke for ex- smokers returns to the level of those who've never smoked.

26.  Male smokers who quit between ages 35 to 39 add an average of 5 years to their lives.  Female quitters in this age group add 3 years.  Men and women who quit at ages 65 to 69 increase their life expectancy by 1 year.

27.  Crosses BBB in 10-20 seconds after inhalation.  Induces euphoria & acts as its own reinforcer.  Leads to nicotine withdrawal syndrome when absent.  It’s a stimulant and it’s a depressant.  Elimination half-life is about 2 hours.  Metabolized by liver by P450 enzyme system.

28.  Increases levels of dopamine (relaxation & reward) & norepinephrine in brain.  These levels drop when smoker quits.  Body reacts by having nicotine withdrawal › Edginess › Hunger

29.  Reduces nicotine withdrawal & craving by supplying small amounts of nicotine.  Contains about ⅓ to ½ the amount of nicotine found in cigarettes.

30.  Forms of NRT: › Nicotine gum › Nicotine patch › Nicotine nasal spray › Nicotine inhaler

31.  Nicotine patches & nicotine gum are available over-the-counter.  Nicotine nasal spray & nicotine inhaler are currently available only by prescription.  Provide a small amount of nicotine to relieve withdrawal symptoms when quitting.  No smoking while using NRT.  Goal is to be free of cigarettes and nicotine substitutes within 3 to 6 months.

32. NICOTINE GUM  Releases small amounts of nicotine, absorbed into the body through the mucous membranes of the mouth.  Chew 10 to 15 pieces of gum a day; some chew 30.

33.  1 piece at a time.  Chew slowly.  Sense peppery taste & feel tingle in mouth.  Park between cheek & gum of mouth.  Tingle gone.  Resume chewing until tingle returns.  Park gum in different area in mouth.  These steps repeated for 30 minutes.  Chewing NOT to be continuous.  NO swallowing saliva while chewing.  Nicotine NOT absorbed by GI system.  Chew daily for 2 to 3 months.  NO drinking fluids while or just after chewing.

34. NICOTINE PATCH  Applied to skin for about 24 hours.  No smoking while wearing patch.  May cause: › Headaches › Dizziness › Blurred vision diarrhea › Upset stomach

35. NICOTINE PATCH  Apply to clean, dry, non-hairy part of upper arm.  Avoid using creams & lotions.  Showering is permissible.

36. NICOTINE SPRAY  Prescription required.  No smoking while using spray.  Delivers nicotine through nose.  Dosage is flexible.  Nicotine cravings eliminated quickly.  Nicotine absorbed through mucous membranes in nasal cavity.

37. NICOTINE INHALER  Prescription required.  No smoking while using spray.  Delivers nicotine through mouth & throat.  Dosage is flexible.  10 puffs = 1 cigarette.

38.  Zyban (Wellbutrin) = bupropion hydrochloride  Non-nicotine prescription drug.  Increases level of dopamine & norepinephrine.  Zyban + NRT = more effective than either alone.  Taken BID (AM and PM).  1 week needed to reach therapeutic dose.  Set Quit Date 1 to 2 weeks after starting Zyban.  Average length of use: 7 to 12 weeks.

39.  Chantix = varenicline  Blocks pleasant effects of nicotine in brain.  Taken PO (per os) QD or BID with food & water.  Begin Chantix 1 week before Quit Date.  Taken for 12 weeks: › If smoking stopped after 12 weeks, another 12 weeks prescribed. › If smoking continues after 12 weeks, consult with MD for another plan.

40.  Ask: patient’s tobacco use & record response.  Assess: willingness & readiness to attempt quitting.  Advise: clear, nonjudgmental, and suggestions for quitting.  Assist: provide cessation plan to patient.  Arrange: schedule follow-up visits for discussion.

42.  Goals › Maximize patient’s functional ability › Minimize impact in  Patient  Family  Community › Improve quality of life › Control & alleviate symptoms

43.  Historical Perspective › 1951: Dr Barach recommended physical reconditioning for COPD patients  Walk without becoming dyspneic › Barach was ignored; O 2 therapy & bed rest prescribed  Skeletal muscle deterioration  Fatigue & weakness  Increased dyspnea  Homebound, room bound, bed bound

44.  Historical Perspective › 1962: Pierce confirmed Barach › Pierce found that exercising COPD patients  Decreased pulse  Decreased respiratory rates  Decreased minute ventilation  Decreased CO 2 production  Improved pulmonary function

45.  Historical Perspective › Paez demonstrated  Efficiency of motion  Decreased O 2 consumption › Smoking cessation included › Education added  Pathophysiology  Equipment  Medications

46.  Scientific Basis › Focus on patient › Include clinical sciences  Quantify degree of physiologic impairment  Establish outcomes for reconditioning › Include social sciences  Psychological  Social  Vocational

47.  Physical Reconditioning › Exercise increases energy demands  Increased circulation  Increased ventilation  Increased O 2 deliver  Increase CO 2 elimination › If O 2 demands NOT met  Blood lactate level increases  CO 2 increases as lactic acid buffered  Increased stimulus to breathe

48.  This point is called the “onset of blood lactate accumulation,” or OBLA  Abrupt rise in PaCO 2 & minute ventilation: called “ventilatory threshold”  Beyond V T, metabolism = anaerobic respiration (decreased NRG production efficiency, lactic acid rise, fatigue)

49.  Physical Reconditioning › MVV index of respiratory system’s ability to handle increased physical activity › MVV = FEV 1 x 35 › Normal: 60% to 70% of predicted MVV during max exercise › Indicates adequate respiratory reserve › Indicates ventilation NOT primary limiting factor for ending exercise

50.  Physical Reconditioning › MVV decreased with COPD › COPDs have limited exercise ability  Increased CO 2 production  Respiratory acidosis  SOB  O 2 consumption increases faster than normal

51.  Physical Reconditioning › Rehab programs must:  Physically recondition  Increase exercise tolerance

52.  Psychosocial Support › Indicators bettor predictors of frequency & LOS for COPD patients compared to PFTs › Psychosocial indicators better determine rehab program completion than physical reconditioning › COPD negatively affects person’s outlook on life › Can reduce motivation

53.  Psychosocial Support › Depression/hostility occur with acute & chronic disease › Economic loss & fear of death produce hostility › Interaction among patients is beneficial › Patient’s lacking social support at higher risk for re-hospitalization › Intolerance for physical exertion lessens social activity

54.  Psychosocial Support › Physical reconditioning & psychosocial support linked › Reducing exercise intolerance & improving cardiovascular response to exercise = independent, active lifestyle › Improve social importance & self-worth › Occupational training & job placement important

55.  Program Goals › Control respiratory infection › Basic airway management › Improve ventilation & cardiac status › Improve ambulation & other physical activities › Reduce medical costs › Reduce hospitalizations

56.  Program Goals › Reduce LOS when hospitalized › Reduce # of MD office visits › Provide psychosocial support › Occupational training/job placement › Family education, counseling, support › Patient education, counseling, support

57.  PROGRAM OBJECTIVES › Development of diaphragmatic breathing skills › Development of stress management and relaxation techniques › Involvement in a daily physical exercise regimen to condition both skeletal and respiratory-related muscles › Adherence to proper hygiene, diet, and nutrition › Proper use of medications, oxygen, and breathing equipment (if applicable) › Application of airway clearance techniques (when indicated) › Focus on group support › Provisions for individual and family counseling

58.  Chronic lung disease progressive & irreversible  Rehabilitation slows progressive deterioration  Rehabilitation does NOT alter progressive deterioration  Rehabilitation improves tissue utilization of O 2 by: › Increasing muscle use effectiveness › Promoting effective breathing techniques

59.  O 2 cost for given amount of ventilation is excessive  Training skeletal muscle groups alone NOT beneficial  Training respiratory related muscles improves exercise tolerance

60.  Evaluation of Rehabilitation Program Outcomes › Changes in exercise tolerance › Before and after 6 minute walking distance › Review of patient home exercise logs › Strength measurement › Flexibility and posture › Performance on specific exercises (e.g., ventilatory muscle, upper extremity) › Changes in symptoms › Dyspnea measurement comparison › Frequency of cough, sputum production, or wheezing › Weight loss or gain › Psychological test instruments

61.  Evaluation of Rehabilitation Program Outcomes › Other changes › Activities of daily living (ADL) changes › Postprogram follow-up questionnaires › Preprogram and postprogram knowledge tests › Compliance improvement with pulmonary rehabilitation medical regimen › Frequency and duration of respiratory exacerbations › Frequency and duration of hospitalizations › Frequency of emergency department visits › Return to productive employment

62.  Program Results › Evaluate  Patient  Program outcomes › Preprogram/current program status › Data  Physiological  Psychological  Sociological

63.  Potential Hazards › Cardiovascular abnormalities  Cardiac arrhythmias (can be reduced with supplemental O 2 during exercise)  Systemic hypotension › Blood gas abnormalities  Arterial desaturation  Hypercapnia  Acidosis › Muscular abnormalities  Functional or structural injuries  Diaphragmatic fatigue and failure  Exercise-induced muscle contracture

64.  Potential Hazards › Miscellaneous  Exercise-induced asthma (more common in young patients with asthma than in patients with COPD)  Hypoglycemia  Dehydration

65.  Patient Selection › Evaluation › Testing  Patient Evaluation › History (medical, psychological, vocational, social) › Questionnaire/interview form › Physical exam › CXR

66.  Patient Evaluation › CBC › Electrolytes › Urinalysis › PFTs (pre/post spirometry, volumes, D L CO) › Cardiopulmonary exercise evaluation  Quantifies initial exercise capacity  Provides basis for exercise prescription  Renders baseline data for assessing progress  Shows degree of hypoxemia/desaturation during exercise

67.  Patient Selection › Ex-smokers › Smoking cessation program for smokers  Patients Excluded › Concurrent problems limiting or precluding exercising › Condition complicated by malignant neoplasms, e.g., bronchogenic carcinoma

70.  Relative Contraindications to Exercise Testing › Patients who cannot or will not perform the test › Severe pulmonary hypertension/cor pulmonale › Known electrolyte disturbances (hypokalemia, hypomagnesemia) › Resting diastolic blood pressure > 110 mm Hg or resting systolic blood pressure > 200 mm Hg › Neuromuscular, musculoskeletal, or rheumatoid disorders exacerbated by exercise › Uncontrolled metabolic disease (e.g., diabetes) › SaO 2 or SpO 2 < 85% with the subject breathing room air › Untreated or unstable asthma

71.  Indications for Pulmonary Rehabilitation › Symptomatic patients with COPD › Patients with bronchial asthma and associated bronchitis (asthmatic bronchitis) › Patients with combined obstructive and restrictive respiratory defects › Patients with chronic mucociliary clearance problems (Kartagener’s syndrome, PCD, immotile cilia syndrome) › Patients having exercise limitations caused by severe dyspnea

72. Situs Solitus Situs Inversus

73.  Program Design › Open-ended format  Participate until predetermined objectives achieved  No set timeframe  Completed at patient’s pace  Good format for self-directed patients  Good format for schedule difficulties  Good format for individual attention  Lack group support/involvement

74.  Program Design › Closed design  Set timeframe (8 to 16 weeks; 1 to 3 sessions/wk)  Sessions last 1 to 3 hours  Presentations formal  Offer group support/involvement  Schedule determines program completion  Insurance coverage may dictate length for which person qualifies

75.  Session Example: Closed Design (1 day) ComponentFocus Time Frame EducationWelcome (group interaction)5 min Review of program diaries (past week’s activities)20 min Presentation of education topic20 min Questions, answers, group discussion15 min PhysicalPhysical activity/reconditioning45 min ReconditioningIndividual goal-setting/session summary15 min Total: 120 minutes (2 hours)

76.  Physical Reconditioning › Exercise prescription with target HR based on initial exercise evaluation › Target HR set using Karvonen’s formula › THR = [(MHR-RHR) x (50% to 70%)] + RHR › THR = target heart rate › MHR = maximum heart rate › RHR = resting heart rate

77.  Physical Reconditioning MHR = 150 bpm RHR = 90 bpm THR = [(150 – 90) x (0.60)]+ 90 = 126 bpm

78.  Exercise Prescription › Lower extremity aerobic exercises › Timed walking › Upper extremity aerobic exercises › Respiratory muscle training  Monitoring during Exercise › Pulse oximetry › Blood pressure › Heart rate

79.  Lower Extremity › Walking (treadmill/flat surface)  Goals for distance, time, grade on treadmill  6 minute / flat surface / increase distance › Bicycling (stationary)  Upper Extremity › Arm ergometers › Rowing machines

81.  Inspiratory resistance breathing device › Adjustable flow resistor › One-way valve › Inhale through restricted orifice (variable size) › Change inspiratory load › Exhalation through one-way valve

82. Inspiratory Resistance Breathing Device

83.  Instruction › Sit upright › Breathe slowly through device (10 to 12 bpm) › MIP < 30% of measured P i max, use next smaller orifice › Repeat effort until 30% is consistently achieved › 1 or 2 daily sessions for 10 to 15 minutes/session › When 30% is consistently achieved, increase resistance › Increase session time to 30 minutes