Evidence based case study in management of acuteExacerbations of COPD.

Introduction:

Chronic pulmonary diseases have become increasingly one of the most common chronic lung diseases and a major cause of morbidity and mortality in modern world. It is characterized by airflow limitation that is not fully reversible.

Chronic Obstructive Disease is a leading cause of the death in the worldwide (Calverley et al, 2003). The condition can result in loss of work quality and quality of the life can be significantly effected (Barnes, 1999). In UK 27,478 men and woman die because of the chronic obstructive lung diseases and most of the death ( more than 90%) was in  the age of above 60 years old(British Thoracic Society. 2006).

Rehabilitation for patients with chronic lung diseases is well established and widely accepted as means of enhancing standard therapy in order to improve symptoms and maximise the patients function (Siafakas et al, 1995; Ries, 1990; Casaburi, 1993; Fishman, 1996). In 1974, the American College of Chest Physicians (ACCP) focused in there definition of Pulmonary rehabilitation on three important features and they suggested that Successful pulmonary rehabilitation depends on three importance features, Individuality of each case, Multidisciplinary team approach and attention to physiopathology and psychopathology of each case.

One of the main problems with COPD patient is the increase in the pulmonary secretions leading to increase in shortness of breath. These two factors affect the patient’s function and quality of life.  For exacerbation, Physiotherapy is often required to help clear secretions and reduce WOB, including non-invasive ventilation to prevent intubation (Alexandera, 2001).

There are various techniques, which can be used in physiotherapy to improve patient’s condition. The research suggests that the postural drainage is beneficial in clearing  the chest from secretions (Clarke,1989;Faling,1986), respiratory muscle relaxation manoeuvre is effective for improving the pulmonary function of pulmonary emphysema patients (Fujimoto et al, 1996), relaxation can help reduce dyspnoea and anxiety in chronic obstructive pulmonary disease (COPD) patients (Louie, 2004).

Case description :( case history, physical examination, and intervention)

Patient is a 67-years-old woman with acute exacerbation in Chronic Obstructive Pulmonary Disease (COPD). She complained of increased shortness of breath with loose, non-productive cough. A febrile on auscultation, bilateral rales, rhonchus, and expiratory wheezing. Patient said she is on bronchodilators and low-dose steroid. Patient said she has been suffering from this problem since 10yrs and has been on medication since. She does not do any exercises and her general practitioner who she usually sees has never mentioned about seeing any physiotherapist. Recently during this episode of acute exacerbation, she was advised by the hospital doctor to see a physiotherapist.

The strategy in this case study used was the problem-solving model, which included following six steps;

Step 1: Patient assessment,

Step 2: defining the problem,

step3: determining the goals,

step4: identifying appropriate techniques,

Step 5: applying the techniques,

step6: re-evaluation of the patients situation(Donna,1987).

Evaluation and assessment:

Accurate assessment is the key player of physiotherapy and forms the bases of rational practice. A Problem based assessment leads to reasoning in the pulmonary rehabilitation. As result, a thoughtful evaluation will guide to both effectiveness and efficiency  because time will be saved by avoiding unnecessary treatment (Physiotherapy in Respiratory Care An evidence-based approach to respiratory and cardiac management).

Ward reports and medical notes of the patient were evaluated to know about;

·         The past and present relevant history.

·          social history , accommodation

·         Conditions required precautions in relation to certain treatments e.g. light-headedness ,bleeding disorders or swallowing disorders

·         Recent cardiopulmonary  resuscitation to examine the X-ray in case of gastric aspiration or fracture

·         Checking for possibly of bony metastases, long-standing steroid therapy that this leads to risk of osteoporosis and checking for the history of radiotherapy over the chest. These all findings contraindicate percussion or vibration over the ribs.

·         The patient’s experience increased shortness of breath and the assessment indicate airway secretion.

A part of the patient evaluation was subjective assessment and that was by listening to patient’s problem in her own words. Following symptoms were checked:

Respiratory symptoms by looking for the how long the symptoms been troublesome.

·         Frequency, duration, and the severity.

·         Any pain, chest pain, musculoskeletal pain or cardiac pain.

·         Checking functional limitations including the daily living.

·         Observation to check the breathing rate and pattern before the patient a ware of the physiotherapist’s presence to avoid any role-play.

·         General appearance , colour, hand checked which is a good and rich source of information like cold hand indicate a poor cardiac output, oedema, jugular venous pressure, chest shape.

Objective measurement:

Exercise testing was used to monitor the progress of the patient due following few reasons:

·         Lung function tests are not a good predictor of exercise capacity (Bradley et al, 1999).

·         The laboratory tests are for physiological measurement rather than monitoring of patients progress.

·         The patients own estimate of exercise tolerance is not objective (Hough, 2001).

Exercise testing:

As long as the patient was not suffering from acute breath illness, exercise testing was used as an objective measure to monitor the progress. Oximetry on exercise testing was used which is advisable to measure the level of oxygen during the exercise (Martine et al, 1992). Because the patient was in acute exacerbation condition, only simple stair climbing testing was used and count the number of steps can be climbed up and down in 2 minute and rest allowed but included within the 2 minutes.  Each minute was passed the patient was informed about the time. The result of the test was only 10 steps per 2 minutes. Exercise testing revealed increased shortness of breath and from assessment of patient, it was clear that she had airway secretions.

Defining the problem:

Shortness of breath was probably due to increased secretions with the patient and so physiotherapy was planned after the use of bronchodilators. Percussion can trigger bronchospasm in patients with asthma and in this case would benefit to have maximum bronchodilator prior to treatment. (Donna 1987)

Determining the Goals:

Promote airway clearance; encourage relaxation and breathing exercise; encourage exercise to promote airway clearance.

Identifying Appropriate Techniques:

Due to short shortness of breath, modified positioning was used for postural drainage as per the patients comfort, turning the patient side to side to prevent any shortness of breathiness (Hough 1991). Trendelenberg position was also used with percussion and vibration was gently applied due to consideration that the patient was on long-term steroid therapy. Emphasis was placed on both lower lobes as no specific area of pathology was described. Relaxation exercises were done for upper chest and neck to increase the ventilation, abdominal areas. Patient was also taught home postural drainage to help in early recovery.

Walking and cycling was encouraged, as it is most widely used modalities of exercise training in chronic obstructive pulmonary disease rehabilitation (Vallet et al, 1997). Patient was given endurance (aerobic) training program for 4-12 weeks (Casaburi et al, 1997; Wijkstra et al, 1996), and she attended supervised training sessions 2-5 times a week. Each session duration was 20-30 minute.

Applying techniques:

Techniques for vibration and postural drainage (Gumery et al 2001) were applied with consideration to the contraindications and patients condition and motivation. As the patient was on long term of cortico- steroid treatment, possibility of osteoporosis was considered which may led to fracture while doing tapping in postural drainage.

Re-evaluation:

The patient was re-evaluated after the secretions were mobilised and on observation, patients breathing was found to be more effective. The progress was slow as the patient was reconditioned. Patient was encouraged to remain active to help in early recovery. Patient and family was given education about restoration and maintenance of exercise tolerance and basic self-management. Home visits were made to check for adequate heating, and health or safety hazards. In addition, this visit was also supportive for the family.

The exercise was prescript for the patient to keep the patient fit and increase the vital capacity. The mode of the exercise was related to the patient’s life style and the patient was encouraged to use stationary bike. The bike was suggested as it supports 85% of the body weight, and large muscle groups can be exercised with less strain than walking (Bach and Haas, 1996, p.309). Furthermore, exercise programs for the muscles of ambulation were prescribed as they are a part of virtually every program of pulmonary rehabilitation (Ries, 1990; Casaburi, 1993; Carter et al, 1992; Olopado et al, 1992). Over the period of rehabilitation, the patient also said that her functional capabilities improved and this helped her to great extent in her ambulation. Exercises were also given for muscles of the shoulder girdle as these muscles can help provide support to pull on the ribcage (Criner et al, 1988). Patient was encouraged to resume her sports hobbies – bowling to combine exercise and recreation.

Patient was scheduled for a follow up appointment after 6 weeks of rehab and treatment to monitor the patient’s progress. (Broussard 1979; Fujimoto et al. 1996; Gift, Moore, and Soeken, 1992; Louie, 2004). Patient was also provided with breathlessness rating scale to check her breathlessness after each session of exercise.

On the follow up appointment subjective and objective re assessment was done. Patient as observed to check the breathing pattern and frequencies, auscultation was done to check the chest for any signs of secretion and obstructions. The patient was sent to take x-ray to check the clarity of the chest. Stair climb test was done and there was a good progress in the patient’s condition as the result was increased significantly from 10 steps in 2 minute before 6 week to 25 step.

Improvement was also seen on the self reported and measured breathlessness rating scale where the patient scored 2 whereas she scored 4 during initial assessment and also the recovery rate post exercises reduced from 5-10mins to 2-5mins and the patient also reported that she was doing fine the day and was comfortable.

Summary:

From the above case study, it can be derived that patients suffering with similar conditions can benefit from appropriate exercise and active lifestyle. It is very important to keep encouraging the patients and educating them regarding the condition and help those to self manage.

Although suggestions for appropriate management can be made based on available evidence, the supporting literature is spotty.

References

1.   Alexandra Hough 2001,Physiotherapy in Respiratory Care An evidence-based approach to respiratory and cardiac management, third edn, Nelson Thomas Ltd, United Kingdom.

2.   Back, J. R. & Haas, F. pulmonary rehabilitation. Phys.Med.Clin.North Am [7], 205-406. 1996.

3.   Barnes PJ 1999,Managing chronic obstructive pulmonary diseaseScience Press, London.

4.   Bradley, J., Howard, J., & Wallace, E. 1999, "Validity of a modified shuttle test in adult cystic fibrosis",Thorax, vol. 54, pp. 437-439.

5.   British Thoracic Society 2006,The Burden of Lung Disease, Second edn.

6.   Broussard, R. 1979, "Using relaxation for COPD",Am.J.Nurs, vol. 79, no. 11, pp. 1962-1963.

7.   Calverley PM & Walker P 2003, "Chronic obstructive pulmonary disease",Lancet, vol. 362, pp. 1053-1061.

8.   Carter R, Coast JR, & Idell S 1992, "Exercise training in patients with chronic obstructive pulmonary disease",Med Sci Sports Exerc, vol. 24, pp. 281-291.

9.   Casaburi R & Petty TL 1993,Principles and practice of pulmonary rehabilitationWB Saunders, Philadelphia.

10.   Clarke, S. W. Rationale of airway clearance. Eur.Respir.J.Suppl 7, 599-603. 1989.

11.   Criner GJ & Celli BR. Effect of unsupported arm exercise on ventilatory muscle recruitment in patients with severe chronic airflow obstruction. Am Rev Respir Dis 138, 856-861. 1988.

12.   Donna L & Frownfelter 1987,Chest Physical Therapy and Pulmonary Rehabilitation an Interdisciplinary Approach.2 edn, Year Book Medical, INC, Chicago.

13.   Faling, L. J. 1986, "Pulmonary rehabilitation--physical modalities",Clin.Chest Med, vol. 7, no. 4, pp. 599-618.

14.   Fujimoto, K. e. a. 1996, "Effects of muscle relaxation therapy using specially designed plates in patients with pulmonary emphysema",Intern.Med, vol. 35, no. 10, pp. 756-763.

15.   Gift, A., Moore, T., & Soeken, K. 1992, "Relaxation to reduce dyspnea and anxiety in COPD patients",Nurs.Res, vol. 41, no. 4, pp. 242-246.

16.   Gumery, L., Proyer, J., Prasad, S. A., & Dodd, M. clinical guidelines for Physiotherapy Management of Cystic Fibrosis.  2001. CSP.

17.   Louie, S. W. 2004, "The effects of guided imagery relaxation in people with COPD",Occup.Ther.Int, vol. 11, no. 3, pp. 145-159.

18.   Martin D, Powers S, Cicale M, Collop N, Huang D, & Criswell D 1992, "Validity of pulse oximetry during exercise in elite endurance athletes",J Appl Physiol, vol. 72, no. 2, pp. 455-458.

19.   Olopade CO, Beck KC, & Viggiano RW 1992, "Exercise limitation and pulmonary rehabilitation in chronic obstructive pulmonary disease",Mayo Clin Proc, vol. 67, pp. 144-157.

20.   Ries AL 1990, "Position paper of the American Association of Cardiovascular and Pulmonary Rehabilitation: scientific basis of pulmonary rehabilitation",J Cardiopulmonary Rehabilitation, vol. 10, pp. 418-414.

21.   Siafakas NM, Vermeire P, & Pride NB 1995, "Optimal assessment and management of chronic obstructive pulmonary disease (COPD):  the European Respiratory Society Task Force",Eur Respir J, vol. 8, pp. 1398-1420.

22.   Vallet G, Ahmaidi S, & Serres I 1997, "Comparison of two training programmes in chronic airway limitation patients: standardized versus individualized protocols",Eur Respir J, vol. 10, pp. 114-122.

23.   Wijkstra PJ, van der Mark TW, & Kraan J 1996, "Effects of home rehabilitation on physical performance in patients with chronic obstructive pulmonary disease (COPD)",Eur Respir J, vol. 9, pp. 104-110.