Talking All Things Cardiopulm
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Talking All Things Cardiopulm
Episode 77: All Things Pulmonary Rehab
Join me today as we discuss all things pulmonary rehab, its structure, accepting diagnoses, benefits and even its continued underutilization.
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Rachele Burriesci:We just celebrated our seven year wedding anniversary. We had a staycation type weekend, super low-key, but I think, exactly what we both needed and of course, we decided to start to tackle another DIY project. I think we have a problem, but seven years married 13 together flies by when you're doing DIY. That could be its own logo. I think We've had this plan to do a paver patio on the side of our covered structure and it's just an awkward space and it has a super huge drop off in the yard which just adds to the difficulty level. Plus, there's like a sprinkler system and we have to reroute some downspouts, so just like an awkward spot, but it would also be awkward being grass because it gets really muddy in that area. So, something that we've been planning to do literally for over a year. We did a small paver project last spring and we bought pavers for both of those projects but hadn't tackled the second project. It just got too hot too fast and it definitely takes a lot of planning and so it just so many different. You know kind of lessons in DIY in the world of planning and foresight and being able to see the whole picture but still being able to pinpoint detail just is so important.
Rachele Burriesci:So we did some dirt deliveries this weekend. We rented a Home Depot pickup truck, we drove out and got ourselves some fill dirt and as they were loading it, we usually over or, yeah, we usually overestimate and, you know, get a little too much. I think the last time we had a dirt delivery I was very surprised by how big the pile of dirt was in the dump truck that came to drop it. So we were like we're gonna, we're gonna do it ourselves, save ourselves a delivery fee and we'll just, you know, take care of it. And as soon as he did the first load it was the amount that we were asking for I had that feeling that we were going to be under and I should have made the judgment call there. But as soon as we got home we were right. We were just short, so we ended up having to do another delivery.
Rachele Burriesci:But we're really making progress now and sometimes it really is just getting started. Making that first move, thinking about the overall plan, getting the things in place, getting that ground level, is going to be the biggest, probably time consuming, piece of it. But once that gets started, then, like everything else will start to fall into place. But once that gets started, then like everything else will start to fall into place. So, whatever it is that you're doing planning, sometimes you just have to throw yourself into it, make the first move and start going and everything else will come together because you can sit and plan and think for literally over a year, but it's not until you jump in headfirst that things start to get going. And so all these little lessons are lessons to myself as well, and so hopefully that is helpful for you in some aspect of your life. And if you are going to do a paper patio and you have questions, feel free to reach out, because this is now number two and we're getting a little bit more savvy in our construction planning.
Rachele Burriesci:All right, so today I wanted to talk about pulmonary rehab, One of my favorite patient populations, one of my favorite programs I used to run. Both cardiac and pulmonary rehab hold a very special place in my heart and was just so fun to run it. It was just a really great program. You see so much improvement in your patients and in pulmonary rehab specifically, you tend to have repeat customers because sometimes you are utilizing pulmonary rehab to maintain a level of aerobic capacity so that you can potentially become a transplant candidate or you're waiting for that transplant call. So pulmonary rehab and cardiac rehab have a tremendous amount of similarity. There are obvious difference in the clientele, primarily pulmonary diagnoses versus cardiac, but pulmonary rehab has a little bit of the cardiac piece as well. So overall overarching picture pulmonary rehab governing bodies similar to cardiac rehab is run by AACVPR and on the pulmonary rehab side, ats, american Thoracic Society, is the second kind of governing body of this program.
Rachele Burriesci:The diagnoses are pulmonary specific, pulmonary specific. So your COPD population, including emphysema, chronic bronchitis, asthma, bronchiectasis, cystic fibrosis, all fall into that obstructive approved category. There is a number of restrictive diseases that are included in this as well, ild being top of that restrictive disease list, but also things like obesity-related restrictive disease is an approved diagnosis, as well as neuromuscular conditions like post-stroke. A lot of post-surgical patients post-vets surgery, pre and post-lung transplant is on the list, people who have ventilator dependence or had a long-term stay where they were on a ventilator for a prolonged period of time. And now COVID-19 is a new, newer diagnosis that was added to the approved pulmonary diagnosis list in pulmonary rehab. I think it was last year. I updated my pulmonary rehab lecture when I was working with two mentees and I just kind of wanted to dig back in and see if there had been any changes, because I hadn't run pulmonary rehab since 2017. So when I went in, there wasn't tremendous changes. The big one was COVID-19 is an official approved diagnosis Now I believe it was as of 2022, it was approved, but something that was new as of 2021 was this idea of essential components that should be incorporated into pulmonary rehab, based on ATS guidance.
Rachele Burriesci:So they claim to have 13 essential components. One it should be center-based and it should have an assessment by a healthcare professional. I would be curious to see if there is change in terminology with this one, because center-based typically indicates that it is on a specific campus, right. So whether you're in a hospital setting but it's an outpatient program, but you are physically in person, is typically the verbiage for center-based Telehealth. Cardiac rehab has really made some impact and some stretch across the country. I'm starting to hear that it's happening in the pulmonary rehab world as well, but in general, pulmonary rehab is still less utilized than cardiac rehab and we know cardiac rehab is underutilized. So I'm curious if the center-based terminology will change in future updates. But that is still how it's written.
Rachele Burriesci:There should be some sort of exercise test at the time of assessment and or a field test, so they're written as two separate categories, but typically they go hand in hand. When we ran pulmonary rehab, six-minute walk test pre and post was standard of care and I really like this, and I think part of the difference between pulmonary rehab and cardiac rehab is there's a little bit more hands-on in this situation. In cardiac rehab, the patients typically go out for a sub-max exercise stress test. Where pulmonary rehab in-house, you are performing that pre and post six minute walk test and that just gives you a little bit more ability to create rapport with your patient and also to see that change right After you have worked with them for X number of weeks.
Rachele Burriesci:There should be some sort of quality of life measure, and so one of the there are plenty of quality of life measurements out there. A very common one used in pulmonary rehab is the St George questionnaire. We use this one as well, but there are a number that are specific to different diagnoses. For instance, there's an asthma quality of life scale. There's now a COVID-19 quality of life scale, so there is quite a few out there that can be used, but St George questionnaire is actually a very well-known quality of life measurement that has been used in pulmonary rehab. We should be doing some sort of dyspnea assessment, and that can just be the use of a scale, some sort of nutritional status evaluation and a little bit different nuance with nutrition in the pulmonary world is. A lot of times we have low BMI in this population, so making sure that they're having enough caloric intake. It can be important due to dyspnea and just overall shortness of breath with eating. Occupational status evaluation A lot of our patients were still working, even in factories on the line.
Rachele Burriesci:Endurance training strength training should be part of the program itself. Endurance training strength training should be part of the program itself. There should be some sort of exercise. The exercise program should be individually prescribed and tailored to that person, not just a group, you know group type exercise that should be specific to the individual. That program should then be progressed and there should be a team right so there's a team of healthcare professionals with experience in exercise prescription and progressed, and there should be a team right, so there's a team of healthcare professionals with experience in exercise prescription and progression. And number 13 is that their healthcare professionals are trained to deliver these components.
Rachele Burriesci:So in my opinion, there's a little bit of overlap in some of these essential components and I think we're missing a huge one. And I actually was a little surprised by this. Breathing exercises, or, you know, respiratory muscle training and any sort of verbiage in that category is not listed as an essential component, which kind of was surprising to me. In the pulmonary rehab program that I helped run, we did breathing exercises every session and I think it's such a huge valuable piece for these patients who A may have never been taught this, may have never had an assessment outside of PFTs and just really don't know how to coordinate their breath with activity, which is one of their primary quality of life triggers. Right, they are unable to do blank without feeling short of breath. They might feel embarrassed to do blank because of their shortness of breath, and that tends to be a question on that self-assessment questionnaire. So really surprising to me that breathing exercises is not on that list.
Rachele Burriesci:And what is even more surprising is I had a client recently who ended up going into a pulmonary rehab program and after assessing and just kind of checking in to see how things were going, he informed me that they didn't do any sort of breathing exercises. They did do the endurance training piece but there was no education on breathing. There were no breathing exercises to start the session. So from my understanding it is not necessarily a standard across the board. So that's always interesting when you start learning about other people's programs because you know you know your own program that you were in and you're reading AACB PR guidelines and all of all of the pieces that come together and it feels like that should be high priority and in my opinion it is. And so if you are in a pulmonary rehab program, we have access to observing a pulmonary rehab program. These are things that you want to kind of pay attention to and if you have any influence in these programs, we should definitely be incorporating breathing exercises, pre-activity, as well as education on how to utilize them during that. Endurance training and even strength training, right. So super important there. Very similar to cardiac rehab.
Rachele Burriesci:Lots of benefits for pulmonary rehab. Biggest ones are obvious improve exercise capacity, reduce dyspnea, improve health-related quality of life and reduce hospital admissions are actually listed as benefits Working in that environment. You see this. You can really see the change pre and post six-minute walk test. You also see the change in confidence so that patients know how to navigate their shortness of breath.
Rachele Burriesci:One of the biggest mistakes that pulmonary patients tend to make is that because they're fearful of becoming dysmyc or they're fearful of running out of air, they tend to speed up to get the activity over. And one of the big education points is actually to teach them to do the opposite to pace, to decrease speed so they can go a further distance, or maybe take a rest break before you are in panic mode, and so that's just a big education point. And a hard thing to train because patients want to get it done. They have that fear and that fear is really hard to overcome. But when they start to understand that they can do more for longer, when they change X, y, z, they start to become more confident in their abilities and so sometimes just being able to see that is huge. A lot of times too, patients end up coming off their oxygen, and I'm going to say that as sometimes and it's not always the goal, right, but sometimes they're utilizing less oxygen and that can be a huge progression for a patient. So everyone is different and I will say that in the pulmonary population, sometimes being able to maintain aerobic capacity, strength, oxygen levels is the goal, and that's not a bad goal. If you can maintain this for this many years without having a decline, without having multiple readmissions into the hospital, that is huge, and I think I've mentioned this before, but the word maintenance kind of gets thrown around like it's a bad word.
Rachele Burriesci:Maintaining can be a great thing. One population in particular that has to maintain their overall ability is patients that are pre-lung transplant. I remember having a specific patient who was just trying to get on the transplant list. I think he ended up coming through our pulmonary rehab about six times and he was able to maintain and in some bursts of sessions or, you know, times through cycles through, made improvements in his ability. But he was one that had a couple other comorbidities that was holding him back from being listed, and so he was really playing the waiting game of getting approval and it was so important for him to maintain his ability, his physical capacity, so that if he became a transplant candidate, that wouldn't undercut his ability. I actually left before he was transplanted and I don't remember if he ended up being listed or not, but you know that is a very common story in pulmonary rehab, where you're maintaining so that you can get a lung transplant, and so that can be a really huge, important role as well. So making improvement is great, but sometimes maintaining can be just as beneficial. But sometimes maintaining can be just as beneficial. And, if I haven't said it yet, pulmonary rehab is a level one, evidence-based program specifically for COPD. So improvement in dyspnea, improvement of aerobic capacity, decreased hospital readmission has been proven, especially in the COPD population.
Rachele Burriesci:One of the things that I thoroughly enjoyed was doing the pulmonary rehab eval. So a person gets, a person gets what is the word referred for pulmonary rehab, and they're going to enter the next cycle in and we do a full evaluation. So one of the things that I loved about the program that I was at was that the PTs ran both cardiac and pulmonary rehab and we had oversight from a cardiologist, we had oversight from our pulmonologist, but we were the main healthcare professional running the day-to-day program, performing the evaluation as well as the post-assessment and running the group programs. Just such an awesome experience. It's not that common anymore for PTs to be the lead in pulmonary rehab or cardiac rehab. We have a lot of nursing run programs, exercise physiologist run programs, and so if you have the want to be in this type of program setting, this would be a great place to try to insert yourself. But I will be very honest with you, it's much less common. So one of the things that I hold near and dear to my heart was the experience I had at the VA, because I think we have such a special approach or I think our approach really can be beneficial for cardiac and pulmonary patients outside of nursing, outside of exercise physiology, and so I think as a profession, we just have to keep pushing for the things that are in our scope of practice and be at the forefront of that. But one of the things I loved about the evaluation process was that you can do a full of the things I loved about the evaluation process was that you could do a full pulmonary assessment and this was my favorite part and I think why chest wall assessment and auscultation and diaphragm assessment is such a huge part of my evaluation process. But if you had a student, this is like the perfect population that you can actually assess E to A changes and fremitus and media percussion and just really utilize all the skills that you have learned in real time and be able to hear differences across different patients based on their diagnosis, and so that was the coolest part for me. So typically you do some sort of chest exam, which typically includes auscultation, chest wall assessment, diaphragm assessment, posture assessment, assessment of range of motion, mmt six minute walk test is performed in this time frame, as well as the St George questionnaire and then you start to even do education at this appointment, because being able to utilize the RP and RPD scale can be very beneficial for them moving forward in class as well as then performing the six-minute walk test. So very important to do a thorough evaluation so that you have a good pre and post information. Chart review is also super important in this population, right?
Rachele Burriesci:Not everyone is in for the same diagnosis. Not everyone has the same set of comorbidities. So, understanding their diagnosis, when was their last PFTs? Do you have a trend of PFTs Like are they already on a decline or in a severe category? What's their home oxygen prescription if they are on oxygen? And anytime you're looking at home oxygen prescription, you're looking at the level of oxygen that they are on at rest as well as with exercise, and this usually runs right into an education piece anyway. Do they own a pulse ox? Do they titrate based on dyspnea or do they titrate based on pulse oximetry? Hopefully it's the latter, right, and that's something that you want to be educating on, and it's something that is not always educated on, and a lot of times you might also come into situations where the patient isn't getting enough oxygen, where maybe they're on six liters with exercise but their portable concentrator only goes up to six pulsed or four pulsed and they're literally not getting enough. And there have been a number of situations where those patients come up to the PT department, which is usually quite a distance from the front entrance, and they're desatting into the 80s right so right out the gate. There is a lot of education that can happen, a lot of communication with the primary physician or the pulmonologist and so just really important information program overall and patients do great with it.
Rachele Burriesci:The other piece of chart review is really understanding, or even just evaluation is understanding their prior level of function. You get a lot of variability in this patient population, typically more deconditioned than cardiac rehab. So that's a blanket statement I usually say is your patients are typically lower level in pulmonary rehab compared to cardiac rehab. And then just what's their overall social history is obviously an important piece of any chart review as well as any evaluation process, like what is their support system at home? Are they able to get to their appointments in that home? Are they able to get to their appointments and what does that look like? So the pulmonary rehab class structure very much mirrors what cardiac rehab typically looks like with the addition of breathing exercises. So the warmup should be somewhere around that five to 10 minute mark and similar to cardiac rehab where you're doing active warmup. One of the biggest pieces in this patient population is to do breathing exercises as a warmup, especially that first session where maybe they've never been taught this stuff before.
Rachele Burriesci:The breathing exercises is typically a combination of pursed lip breathing, maybe using some form of a pinwheel, as well as paired breathing activities with upper extremity. Sometimes that can be progressed into standing, depending on what your class looks like or the individuals in the class. Sometimes you do it all in sitting positions, sometimes you do it all in sitting positions and also understanding what diagnoses exist in your class, because not everyone is going to benefit from the same breathing exercises. So if you have a class that is primarily obstructive lung disease, then you can typically coordinate the exercises together and run it as a group. But if you have a lot of restrictive lung disease patients, you might have to really adjust what you're doing. They tend to not do as well with that prolonged, extended exhale, with pursed up breathing, but some actually do just fine with it. So you have to really make sure that you're individualizing that piece as well. Make sure that you're individualizing that piece as well. Obviously, before anything even starts, warm-up wise, you're doing a full assessment of vitals so important to do this before a program like this.
Rachele Burriesci:I do have to say that both cardiac and pulmonary rehab usually the patients that were taken to the emergency room occurred before the first anything happened. Sometimes they come in and they just happen to be standing poorly that day, or blood pressure is out of control or something weird happened with their medication, and you can catch those things right out the gate. So never skip right, never skip vital sign assessment, and I'm going to say that across the board. Skip vital sign assessment and I'm going to say that across the board, not just in pulmonary and cardiac rehab all across the board, because sometimes you just catch those things that are either a brewing or are at a pivotal point of tipping the line. And, like I said, most of the patients that we've brought to the emergency room from either cardiac or pulmonary rehab occurred before anything even happened, before the first warmup was even performed. So vital sign assessment is so important.
Rachele Burriesci:And then it's a circuit training. Right. We did 10 minute intervals, three 10 minute intervals on different devices. So maybe a new step an arm bike, a treadmill. In pulmonary rehab we had a lot of patients who could not tolerate treadmill walking, just too fast paced for their level of oxygen needs or their dyspnea. So we did a lot of level ground walking with those patients. Right, don't just skip it and do seated exercise. Walking is probably one of their main goals. So instead of doing treadmill walking you can do interval level ground walking. It takes more supervision. It's going to take another person to literally walk with the patient and guard potentially person to literally walk with the patient and guard potentially. But it might be more beneficial for the patient than treadmill walking, or safer for that matter. So, usually some form of aerobic circuit training, typically three sets of 10.
Rachele Burriesci:And then you're reassessing, at that five minute mark, vital signs, specifically SpO2, dyspnea, rpe scale, um, because you want to make sure that your person is tolerating. Do they need to be up, titrated on their oxygen? Do they need to um pace their breathing more effectively? Do they need to add in a rest break versus doing 10 minutes continuous, right? So, making sure that there is appropriate supervision, that there is adjustment to the person's program, and maybe it's the opposite. Maybe it's too easy, right. Maybe we need to increase the resistance, maybe we need to increase the speed, and so you can have two ends of the spectrum in any of these programs. Strengthening equally is important, right? So we know that endurance training, strength training are very beneficial to improve overall aerobic capacity, improve overall efficiency, improve gas exchange at the lung and peripherally, making them more efficient overall. And so this is one of those big education points With pulmonary rehab likely 99% you are not improving the lung function itself, you're improving the physical function to overcome said dyspnea.
Rachele Burriesci:The person becomes stronger, the person becomes more efficient in gas exchange. We're not changing the lung disease, we're improving the efficiency of the human. And so what typically happens when you're not exercising is that you have a further decline in strength, endurance, oxygenation because you do less and less and less. As you start to build back up, the body becomes more efficient in its process. So you can do more for longer on maybe the same or less oxygen with less dyspnea. That is the goal. So patients tend to do better. Over time you can see their overall confidence improve. You can see the level of fear decrease. As I mentioned earlier, they might require less oxygen to do the same amount of activity or they maintain the same amount of oxygen and able to do more. Both can be beneficial.
Rachele Burriesci:But strength training is part of this overall program because we know strength training is one of those pillars that really help improve the overall picture, become more efficient. So typically strength training is based on proximal major muscle major muscles, typically done sets of 10 and incorporating paired breathing in with that activity. Like every exercise program, we should have a cool down period somewhere around that five minute mark again, can incorporate breathing exercises again and always ending with vital sign reassessment. So that's a huge, with vital sign reassessment. So that's a huge, just general overview of what pulmonary rehab looks like. You're going to have a pre-post eval program last somewhere around eight weeks plus, typically two to three times a week, very similar to cardiac rehab, and in that time, outside of the exercise program, there are also education classes and this education class is typically performed by an interdisciplinary team to help your patients understand their lung disease. So every program is a little bit different but overall education classes can be overview of lung anatomy and physiology, overview of obstructive and restrictive lung diseases, the effects of aging. I think this is just a big, important education piece for patients with lung disease.
Rachele Burriesci:The most common statement that I hear from a person with emphysema is I turned 65 and everything went downhill. And it's just that pivotal point where disease and age kind of hits this peak and the decline happens right. So we have changes with our lungs as we age and they very much mirror what obstructive lung disease looks like. So if you have obstructive disease and you are aging, there's going to be this point where all of a sudden we have more symptoms. And that's typically when the person comes in. They may have not seen the decline, the slow, steady, you know increase in shortness of breath. They've just may have not noticed it. But now, when it comes to the point where they're actually dysmec with doing a flight of stairs, walking a block, it becomes more apparent and obvious. So just having an education point about what's happening in your body as you age as well as what is happening with this disease and why do they notice that, like you know, 62, 65, 68, all of a sudden I've heard that statement over and over from patients. So it's good to educate and so that they can understand that this is something that is going to continue to happen, and exercise is one of those things that can help stunt or at least make you more efficient in the process, which then leads into the benefits of exercise and the benefits of breathing exercise.
Rachele Burriesci:Usually they have a pharmacist that comes in to do a medication overview. What type of inhalers are you on? Who is on a steroid? Who needs to make sure that they're rinsing their mouth after using this inhaler to prevent oral thrush? Are we utilizing our inhalers correctly? Do we need a spacer? What is a spacer? Right? So lots of different pieces there that can be super beneficial for patients.
Rachele Burriesci:From a medication perspective. One of the biggest education points and I think this really is specific to my COPD years is the use of certain inhalers even though they don't feel different in the moment. Right? So we know, if we're on a short acting bronchodilator and you are having bronchoconstriction and you take that inhaler, that person is going to feel better, that person's going to feel different. But when we're talking about other medications, like teotropium, they take this medication and don't necessarily feel any different, and so that typically leads to patients stopping these inhalers. It is a super important education point to educate these patients that these medications are preventative and help your lungs be less reactive and you're not going to feel any different in the moment, but it might help a trigger when you're at least expecting it, or at least maybe help decrease the inflammation in the lungs so that they're less reactive, whichever med they're on. Right, that education is a little bit different, but if they're not feeling any different, it is very common for these patients to stop medications. So very important education point for you to be a part of on a daily basis, because you are exercising with patients who should be taking their inhalers and if you're noticing changes in a negative way, one of the questions you might have to ask is did you take your normal medications today?
Rachele Burriesci:Stress management is another education class that is very common in pulmonary rehab. Stress from shortness of breath is a real thing. Fear of shortness of breath is a real thing. The panic that can occur when you run out of oxygen or that you run out of breath or that you're not going to have a place to sit in time is a real fear that can then spiral into worsening of that shortness of breath and lead to emergency type scenarios. So lots of different techniques can be taught in stress management class, anything from meditation to breathing exercises to calming techniques if you're having an episode, but stress is a really big component. Here we have the big, obvious one that I haven't mentioned yet smoking cessation. Smoking is still a very common practice. I'm actually always surprised by this. Sometimes we're driving and I'll see someone smoking out of their car and I'm just surprised sometimes that it's still a thing because there is so much education as to the disease process that occurs. So smoking cessation is typically an education piece, especially if the person has a history of smoking or is actively smoking or is trying to create a quit date, which is sometimes the first step in this process.
Rachele Burriesci:Energy conservation another big education component usually a class on what to do, on how to conserve your energy. This can be a class taught by OTs. It can be a class taught by PTs. This is one that kind of, depending on your facility, could really go to different healthcare professionals, but this might include things like sitting to prep your meals, sitting to wash your dishes, placing chairs throughout your house, maybe having a rollator as a just-in-case device so that if you're walking you don't have to panic, you have a seat built in with you. So lots of different things, including pacing, can be included in energy conservation. Sometimes there's a nutrition class where we actually bring in a nutritionist, a dietician, that comes in and discusses good, healthy options, as well as maybe having more frequent, smaller meals for patients who are dysmyc with eating, and then oxygen use. This is so, so, so important.
Rachele Burriesci:I actually had a patient last year who I saw in their home and before we even, you know, did our assessment, I think we were doing education on oxygen concentrators for about 20, 30 minutes and I learned a lot in that time because I have never been a part of the delivery of these devices. But essentially he received his oxygen concentrator, really wasn't given any instruction on use. He was given, you know, like a pamphlet, and he had like four different devices in his house. One was a concentrator that had appropriate level of oxygen amount. One wasn't even close One floor. He had two concentrators splitting into one tubing and he was primarily not on the correct dosage of oxygen that was required. So that was one, you know, example of oxygen education. We discussed appropriateness of maintaining SpO2 levels above goal and utilizing and having access to the right machines to provide said amount of leaders, and so we had conversations and then he ended up ordering something else and we had to discuss with the doctor to make sure that we had the right equipment for him.
Rachele Burriesci:Because if you're living at, you know an SpO2 in the high 70s when you should be, you know SpO2 greater than 88% because you physically don't have the oxygen available. That's going to lead to a hospital admission and possibly you know, a more severe situation. So really important to discuss oxygen as a medication, its importance of its use. You kind of get two ends of the spectrum with oxygen use and maybe I'll make this a conversation at one point. But I usually see one of two things. One, you have the patient who cranks up the oxygen anytime they feel more short of breath and they might not be able to tell you how high they put it to and they'll turn it down once they feel better. Right, those patients are typically not assessing SpO2. They're primarily using their subjective feelings to up titrate or down titrate. And then the other common patient story that you'll hear is they wear their oxygen but they typically take it off to walk across the house, go out to the community, walk in the grocery store, but when they come home they wear it, or they, you know they wear it at night.
Rachele Burriesci:The education piece for that patient is if you need it at rest, you need it with exercise, and so that's usually a hard one to kind of get through as well. There's a lot of perception with wearing oxygen. Actually, one of the questions on the St George questionnaire is do you feel embarrassed by wearing oxygen? Do you feel embarrassed by coughing fit? Do you feel embarrassed when you're short of breath? And that is a very highly rated question for yes. So there is definitely a subjective perception with wearing oxygen. But it's also one of those pieces where you have to educate that you will be able to do more and last longer without having the fear of running out of air if you actually utilize your oxygen appropriately and you're not always playing catch up. So sometimes you have the patient who's over oxygenating and sometimes you have the patient who's not using their oxygen when they actually need it. So those are like the extreme pictures. Obviously you'll have people in the middle and sometimes you have people who can teach you stuff about their oxygen, who are just like very on top of it know their diagnosis, understand the lung disease picture itself, understand their SpO2 goal, know how to up, titrate, down titrate, have an SpO2 reader on them. You'll see everything, but the extremes are always the places where you end up having to do a lot more education and where I think you can make a huge difference, especially if the person is either over oxygenated or under oxygenating, because you can really make a difference in that person's life with that education piece. So those are usually the standard.
Rachele Burriesci:Go to a class type education. In our facility we had a certain group come in and it was like a cycle. This was a 12-week cycle, then the next group will come in another 12 weeks, and so they had an education class after each exercise class and it was very structured in that way. Other programs are more fluid. Where it is there's a group, but it's more individualized and maybe the education is given on an individual basis. So there will be differences in how that education is delivered.
Rachele Burriesci:But I liked the group setting. There's pros and cons to it, but it gave the patient some camaraderie and you know, sometimes people were willing to ask questions and some people were more fearful, so they were able to learn from each other and that usually spurred conversation oh, I have that same issue, what do you do for that? And so it sometimes helped to kind of put the barrier down versus like just spitting information. It allowed for discussion, and I think that can be very empowering for patients to have that camaraderie in a setting and just know that other people in the same picture that you are and be able to talk amongst each other. And one of the things I liked about those classes was the family member could come, and so sometimes the family members would have the ability to talk to other family members and that alone, like you just don't feel. They didn't feel alone. They felt like they were a part of something, and so that can be very beneficial, you know, from a quality of life piece as well.
Rachele Burriesci:In the exercise classes there's usually some sort of education undertone, and we had different education topics that typically were discussed during warmup. Sometimes it was about breathing exercises, how to activate your diaphragm, how to improve your chest wall mobility while performing those exercises. Sometimes it was about scales, like the RPD and RPE scale, where you could discuss when you should be stopping your exercise, and so then patients would again be able to ask questions in the group setting, and maybe someone would be afraid to ask a question, but someone else you know wasn't, and so they both learned from that education topic. Pacing was a big education topic, typically discussed throughout each exercise day, a lot of times discussed individually, but we also discussed it as a group, usually during, again, like a warm-up period or maybe like the first cycle of circuit training.
Rachele Burriesci:We talked a lot about the differences between shortness of breath and increase in respiratory rate, and I think this is an important education topic, especially with patients who are so fearful of becoming shorter breath, and I think that's sometimes why people hold back from exercising. Right, they're like well, when I exercise I get shorter breath. But shortness of breath is a perception. Respiratory rate is objective, right, increased respiratory rate is going to happen when you do activity. Shortness of breath is the perception that you're not going to be able to catch your breath and sometimes just having that dialogue can be empowering to the patient. Right, like it's okay that my breathing is getting more labored or increased. I still feel comfortable, and so just little nuances that can really make a difference in your person's comfort level with doing different activities.
Rachele Burriesci:Weather Weather was a big education piece and we discussed both hot and cold, regardless if we were in winter or summer. But obviously if we were in winter we would spend some time on that first Because, for instance, I was in Michigan at the time. It gets real, real cold in Michigan where typically we would say, you know, don't exercise outdoors less than 50 degrees. I mean that's like early October or September. So you know, really having the conversation about covering your mouth when you're in colder temperatures exercising indoors, if you don't have exercise equipment, go to a big box store that is going to be heated or cooled and temp controlled. Same for summer, right, differences in humidity and heat and that effect on breathing. So making sure that patients are utilizing their inhalers, maybe that they're covering their mouth when they're in the cold, maybe that they're taking more rest breaks in the summer, or that they're scheduling their exercise either early morning, at late at night. So just different pieces that maybe they have never been educated on before. Maybe they need a reminder or just understanding why because that tends to be a huge one when I go outside and it's cold, I feel it right away. Why do I feel it right away? Well, that's going to cause some bronchoconstriction. When it's really humid, I feel like I just can't get any air in. Why? Well, the pressure gradient is much higher and so you have to pull more air in or do more work to create that negative pressure to pull more air in. And just having those little pieces of conversation can be very helpful in empowering them to understand what is happening Allergies, time of year, spring and fall.
Rachele Burriesci:What are your triggers? Understanding that every person is different, whether they're asthmatic, whether they have seasonal allergies or whether they have indoor allergies, what that looks like. A lot of times I would have patients download a weather app or a seasonal app and it would say, like pollen is high, just having that information, because, well, the temperature is fine outside, but when I go outside, I start to, I start to cough or I start to feel short of breath. Why, well, are you allergic to pollen? Are you allergic to mold? Are you? Oh, what's the other big one? There's another seasonal flower type deal. It'll come to me in a minute. Or dust, right, like? We had a lot of patients who were in construction. We discussed wearing a mask. Are you sanding while you're painting? Are you masking when you're doing that? No, I don't wear a mask. That could be a big trigger every time you do this, then you have these symptoms.
Rachele Burriesci:So, being a part of the conversation, giving them education, sometimes it's hard, right, because it's their occupation. Well, what can we do differently so that you can continue to work but do it safely? Smoking was also typically in that mix, but that one can be hard as a group setting and that kind of thing, because not everyone is a smoker. So then it becomes, you know, having that conversation to a group who might not need it. So those tend to be done on a more individual basis, especially if having a quit date was part of the assessment.
Rachele Burriesci:One of the things that I didn't mention was stages of change. So during the assessment, typically you ask questions about where they are in their process. Are they ready to start exercising, are they ready to quit smoking? And a lot of times you would have patients that say I'm never going to quit, so don't ask me again. And sometimes you have to table those conversations to keep rapport and actually make improvements in other areas, and maybe you readdress it at a later time or you let it be. Sometimes you have patients that say I want to quit but I don't know where to start, and so you can start having the conversations about making a quit date, maybe discussing with their physician about alternate type of suppression type medications, and so you can start having those conversations on a smaller level so that it then snowballs into something more long lasting.
Rachele Burriesci:And then another big piece of education is when to go to the doctor and how to avoid getting sick. So this was a really important conversation, especially in the winter months when you have like flu season, making sure patients are getting vaccinated, staying away from sick family members, maybe masking in high population type settings if they can't avoid it, washing hands. That was a very big conversation. That was all pre-COVID, right. So you can think about the education that can be added to that too. Maybe in certain time periods, like December to February, you're masking when you're in public or you're more aware of individuals who might be sick, or maybe you're not going to bigger venues when you're in this timeframe. So lots of different education pieces that can be incorporated during the exercise session as well as more structured in a like classroom type setting. Both are beneficial and the overlap is really nice and you can give different perspectives and you can have patients kind of give their own perspective on the matter or family members, for that matter, can weigh in as well and then at the end of your program or class you tend to do a post-assessment, and so post-assessment should mirror anything that you did in pre-assessment.
Rachele Burriesci:So if you did a six-minute walk test, you're doing a repeat six-minute walk test. If you did a St George questionnaire, you're repeating your St George questionnaire. If I could do this again, I would probably add in hand grip strength as well as MIP and MEP. But sometimes they get PFTs pre and post, and so then that would trump your MIP and MEP. Um, but making sure that your reassessment mirrors your evaluation is so important. Um, what? Even you know whether or not you're doing research or not. It's just very beneficial for program analysis as well as patient understanding, right? Nothing better than to give your like post-assessment paper to your person who just finished pulmonary rehab and they see that they have a 100 meter improvement in their six minute walk test, and then you can discuss that greater than 30 meters is considered significant. Or maybe they had a change in their oxygen prescription. Maybe they're now on room air at rest and only wear one liter with exercise. Whatever it might be, even if they didn't change their distance, maybe they're on less oxygen, or maybe they're on the same oxygen but improved their distance One of the biggest things that we saw in pulmonary rehab and I'm going to say anecdotally because I never ran numbers on this was improvement in blood pressure and heart rate response to exercise as well, not just distance improvement, as well as SpO2, right?
Rachele Burriesci:So maybe on their first six-minute walk test they had to sit three times and their oxygen dropped below 90%. On retake they didn't have to sit and their oxygen stayed above level. Even if the distance didn't have to sit and their oxygen stayed above level, even if the distance didn't improve significantly, that level of change is going to translate into quality of life. So lots of differences that you can see across the board and as you are involved in programs like this and see those changes, you can really help the patient see the improvement, because sometimes they don't see it and I think if you're in the world of PT, you you know, you you kind of see this across the board in different settings. I think in outpatient I saw more where patients like I don't feel like I'm I'm getting any better or I don't feel like I'm any better than when I started. And then you look at those pre and post numbers and they're significant improvement.
Rachele Burriesci:Sometimes, subjectively, patients don't notice that they're less short of breath or they can go a further distance. You know, fill in the blank, whatever it might be, so huge change that can happen with pulmonary rehab. The other thing and I just want to finish this and make this one more make one more point about this Sometimes there isn't any improvement, and that is okay. Sometimes the patient repeats their six-minute walk test and it's about the same, but that person is on a transplant list and that person is waiting for lungs and that person needs to maintain that distance to get those lungs. That is of equal importance. And sometimes that person doesn't prove, but either way, no matter how you're looking at it, they're maintaining and that gives them the hope for the next step and that is equally important. Maintaining strength, maintaining endurance when the next plan of care is for transplant is so important, and I do not want to undervalue maintaining aerobic capacity and strength in that patient population, because that is a huge feat. So so much benefit to pulmonary rehab.
Rachele Burriesci:If you have patients who can benefit from pulmonary rehab, recommend it. Pulmonary rehab is underutilized, much more so than cardiac rehab, and cardiac rehab is underutilized. We're not getting these patients into these programs enough. These programs are not being utilized enough and there are fewer and far between. So they have to be recommended to go to these programs for these programs to exist. So if you have a patient who can benefit, at least put the words out there. Maybe reach out to the physician, maybe search in your area what pulmonary rehabs exist and give that information out, because your patient will benefit long term. All right, if you have any questions about pulmonary rehab, you know where to reach me. Shoot me a text. I'll have the number written below or a DM on Instagram. And if you are someone who is babysitting for their CCS or wanting more information on a more one-on-one type basis, I do mentoring on a one-on-one basis, so click that link below and sign up. All right, I hope you all have a wonderful day and whatever you have to do, get after it.
