1. WMMC Pulmonary Rehab Rick Kenney, MSM, RRT, RCP Director Respiratory Care Services

2. WMMC Pulmonary Rehabilitation Program (PR)

3. Making Friends in PR

4. WMMC GYM Strength training is an essential part of PR

5. Definition of PR According to the 2006 American Thoracic Society/European Respiratory Society statement on PR, “PR is an evidence-based, multidisciplinary, and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities. Integrated into the individualized treatment of the patient, PR is designed to reduce symptoms, optimize functional status, increase participation and reduce health care costs through stabilizing or reversing systemic manifestations of the disease”

6. AACVPR Statement Pulmonary rehabilitation is an integral component of comprehensive medical therapy for patients with chronic respiratory disease. In Genreal, PR provides the greatest improvements in symptoms, exercise capacity, and health-related quality of life of any therapy available for patients with COPD. In light of this PR is now prominently placed in virtually all major guidelines for treatment of COPD

7. Condition’s Appropriate for PR

8. Obstructive Diseases COPD (including alpha-1 antitrypsin deficiency) Persistent asthma Bronchiectasis Cystic Fibrosis Bronchiolitis obliterans

9. Restrictive Diseases Interstitial diseases – Interstital fibrosis – Occupational or environmental lung disease – Sarcoidosis Chest wall diseases  Kyphoscoliosis  Ankylosing Spondylitis Neuromuscular diseases Parkinson’s disease Postpolio syndrome Amyotropic lateral sclerosis Diaphragmatic dysfunction Multiple sclerosis Posttuberculosis syndrome

10. Other Conditions Lung cancer Primary pulmonary hypertension Before and after thoracic and abdominal surgery Before and after lung tranplantation Before and after lung volume reduction surgery Ventilator dependence Pediatric patients with respiratory disease Obesity-related respiratory disease

11. Patient Assessment Patient interview Medical Hx Physical exam Diagnostic tests Symptom assessment Musculoskeletal and exercise assesment

12. Patient Assessment (cont.) Activities of daily living Nutrition assessment Education assessment (understanding disease) Psychosocial assessment Goal achievement Pain assessment

13. Pulmonary Rehab Consent

14. Plan of Care After the intial evaluation is done the therapist and patient come up with goals and objectives the patient wants at the end of the program. Once done Dr. Abboy will meet with the patient to give the go ahead for this individual plan of care.

15. Education Collaborative self-management education is an essential component of comprehensive PR. Self-management education promotes learning by doing and taking advantage of teachable moments. Recommended content should be patient-specific, yet it is imperative to include early recognition and treatment of exacerbations, including the use of an action plan, for all patients. (AACVPR 4 th edition)

16. Chronic Bronchitis/Emphysema

17. PR Exercise Tests 6 minute walk test: Walk with patient and monitor heart rate and oxygen saturations. Documents distance walked, oxygen sats, and dypsnea.

18. Exercise Assesment Muscle strength and endurance Joint range of motion limitations Postural abnormalities (example: Kyphoscoliosis) How is the patient with oxygen equipment Subjective endurance and work tolerance Dyspena Lack of understanding of fitness and exercise Fear of exertion Ability to pace activities and energy conservation Balance abnormalities, gait instability, or increased risk of falling Pain levels and locations Ability to perform ADL’s (household chores, grooming, climbing stairs)

19. Exercise Program The importance of an exercise training program cannot be overemphasized. But before a safe exercise program can be provided, a through assessment needs to be done to evaluate exercise tolerance, formulate and appropriate exercise training prescription, detect exercise-induced hypoxemia or bronchospasm, and detect occult cardiac or other nonpulmonary limitations to exercise. The benefits of exercise training are well documented and include decreased dyspnea, increased physical capacity, and improved quality of life. Exercise is an essential component of a comprehensive PR program AACVPR 4 th Edition

22. PR is for any age

23. COPD Age Group From COPD.com

24. COPD and Gender From COPD.com

25. Psychosocial Needs A strong, trusting bond must be established with patients early in PR to ensure successful outcomes. Patients experiencing substantial impairments in psychosocial functioning need to be referred to a mental health provider. Smoking cessation is part of PR. A combination of behavioral and pharmacological approaches is recommended to maximize success with long-term smoking cessation.

26. Interdisciplinary Approach Core Team Members: The Patient/Family Medical Director – Dr. Ramadas Abboy Department Director – Rick Kenney Department Assistant – Tara Chadwick Respiratory Therapists William Rodriguez Johanna Reyes Should include as needed: Behavioral Health Case Managers Diabetes Educator Dietician Nurse Pharmacist Physical/Occupational Therapy

27. Restrictive Lung Disease Patients with restrictive diseases are seen one-on-one per CMS guidelines. Because the disease process is more advanced and requires strict monitoring of the patient while in our care.

28. Obstructive Lung Disease This patient can be seen in a group setting. Benefits of group setting is “competition” among other group members by pushing each other to do better

29. WMMC Patient Work Out Warm up stretching Upper extremities – with or without weights – Biceps – Triceps Lower Extremities o Leg lifts o Squats Arm ergometer Stationary Bike Treadmill NuStep Cool down period

30. Extreme Monitoring Of The Patient

31. We are here to save the day!!!

32. Admitting your patient into Outpatient Pulmonary Rehab at WMMC A prescription from MD Pulmonary Function Test (within 1 year Insurance Card List of current medications Complete ALL paperwork Not Smoking

33. WMMC PR Patients 70 Year old Female Persistent Asthma HTN/Status Post CABG Multiple ER visits before = Zero visits since PR Six Minute Walk – More than doubled their distance! Comments from patient: “need more tissue. A assest to your PR department is William”

34. WMMC PR Patient 72 Year old Female Persistent asthma/chronic bronchitis Admitted 3 times in early 2013 (less than 30 days x 2) Six Minute Walk – Doubled distance No admissions or ED visits since PR Patient Comment: “I am very happy that with God’s grace this therapy has made me feel a lot better. My therapist explained everything very well. Thank you so much”

35. Contact WMMCPulmonary Rehab Internally Ext. 2789 Externally (323) 268-5000 Ext 2789 Fax: 323-881-8609 Hours of operation Monday – Thursday 0700 – 1630 Closed Fridays and Holidays

36. Eric Lawson, former Marlboro Man, dies of smoking-related disease A smoker since age 14, actor appeared in print Marlboro ads from 1978 to 1981

37. Famous People

38. Questions?