The Role of the Respiratory Therapist in the Treatment of the PH Patient Gerilynn L. Connors, RRT, BS, FAARC, FAACVPR Clinical Manager, Pulmonary Rehabilitation Inova Fairfax Hospital Falls Church, VA gerilynn.connors@inova.org - PowerPoint PPT Presentation

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The Role of the Respiratory Therapist in the Treatment of the PH Patient Gerilynn L. Connors, RRT, BS, FAARC, FAACVPR Clinical Manager, Pulmonary Rehabilitation Inova Fairfax Hospital Falls Church, VA gerilynn.connors@inova.org

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The Role of the Respiratory Therapist in the Treatment of the PH Patient Gerilynn L. Connors, RRT, BS, FAARC, FAACVPR Clinical Manager, Pulmonary Rehabilitation – PowerPoint PPT presentation

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Title: The Role of the Respiratory Therapist in the Treatment of the PH Patient Gerilynn L. Connors, RRT, BS, FAARC, FAACVPR Clinical Manager, Pulmonary Rehabilitation Inova Fairfax Hospital Falls Church, VA gerilynn.connors@inova.org


1
The Role of the Respiratory Therapist in the
Treatment of the PH PatientGerilynn L.
Connors, RRT, BS, FAARC, FAACVPRClinical
Manager, Pulmonary RehabilitationInova Fairfax
HospitalFalls Church, VAgerilynn.connors_at_inova.o
rg
2
The Role of the Respiratory Therapist From ICU
to Home Care
3
OBJECTIVES
  • state how the Pulmonary Diagnostic Laboratory
    test patients lung function, exercise capacity
    and determines what oxygen a patient may need
    while flying
  • Understand how Pulmonary Rehabilitation can be an
    adjunct treatment for the PH patient from the
    inpatient setting to the
  • outpatient setting
  • Know the important role the ICU Respiratory
    Therapist provides for heart failure patients
    beyond Nitric Oxide (NO) to Inhaled Epoprostenol
  • Understand the respiratory home care needs of the
    PH patient from oxygen systems, delivery devices
    to CPAP
  • Understand how the Respiratory Therapist can be a
    vital team member in the Pulmonary Hypertension
    Clinic

4
Medical Direction in Respiratory Care
  • The strength of a Respiratory Care Department,
    Pulmonary Diagnostic Laboratory and Pulmonary
    Rehabilitation Program is measured not only by
    the Respiratory Therapist and Managers who work
    in these departments but the MEDICAL DIRECTORS
    who provide guidance, support and evidenced based
    direction.

5
Pulmonary Diagnostic Laboratory
  • Pulmonary Function Test
  • Pre/post spirometry
  • Lung Volume
  • Diffusion
  • Exercise capacity Test
  • 6 Minute Walk Test
  • Pulmonary Exercise Stress Test
  • Arterial Blood Gas
  • Oxygen Test for High Altitude (air flight,
    travel)

6
Air Travel for the Patient Requiring Oxygen
the Pulmonary Diagnostic Laboratory
  • Hypoxia-Altitude Simulation Test (HAST)
  • Patient breaths 15.1 oxygen simulating aircraft
    conditions
  • Determine what patients will develop severe
    hypoxemia during air travel
  • Able to identify patients at risk of
    flight-related complications
  • requiring supplemental oxygen during air travel
  • Titration of oxygen during test to determine
    oxygen l/m in aircraft

7
Calculation for Estimate of In-Flight PaO2
  • Predicted PaO2 at altitude 22.8 2.74x 0.68y
  • A regression equation derived from HAST
  • Used in normocapnic chronic airway obstruction
  • X is anticipated cabin altitude in thousands of
    feet
  • Y is resting PaO2 in mmHG at ground level, on
    room air
  • Formula provides only a prediction of anticipated
    PaO2
  • HAST is able to assess the cardiovascular and
    symptomatic response plus determine supplemental
    oxygen need

8
Pulmonary Rehabilitation from the Inpatient to
Outpatient Setting
  • Pulmonary Rehabilitation is an adjunct treatment
    for the PH patient
  • Pulmonary Rehabilitation assess and treat may be
    appropriate for the PH Inpatient
  • New PH diagnosis
  • New medication program
  • Patients who begin IV PAH medications must be
    monitored closely when beginning exercise due to
    hypotension
  • Exacerbation of PH
  • Need to assess exercise function and provide
    advise for oxygen delivery system and liter flow
    of home oxygen therapy
  • Pre/Post lung transplant

9
Pulmonary Rehabilitation Definition ATS/ERS 2006
  • Pulmonary rehabilitation is evidence-based,
    multi-disciplinary, and comprehensive
    intervention for patients with chronic
    respiratory disease who are symptomatic and often
    have decreased daily life activities. Integrated
    into the individualized treatment of the patient,
    pulmonary rehabilitation is designed to reduce
    symptoms, optimize functional status, increase
    participation and reduce health care costs
    through stabilizing or reversing systemic
    manifestations of the disease.
  • This definition applies to the pulmonary
    hypertension patient with the ultimate goal of
    optimizing their quality of life through
    assessment, education and therapeutic exercise.
  • The PH patients success in PR starts with a
    strong partnership between the referring PH
    Clinic and the local pulmonary rehabilitation
    program.

10
Essential Components of Pulmonary Rehabilitation
  • Assessment
  • Education/Training
  • Therapeutic Exercise
  • Psychosocial Intervention
  • Long Term Adherence
  • with Prevention and Outcomes

11
Assessment
  • PAH Specific
  • New York Heart Functional Class/ Symptoms
    Assessment
  • PA Pressures
  • Diagnostic Classification
  • Expected side effects of medications/ INR
    (Prothrombin time (PT) and its derived measures
    of prothrombin ratio (PR) and international
    normalized ratio (INR) are measures of
    coagulation.)
  • Patients understanding of medications/ back-up
    pumps
  • Lower baseline blood pressures
  • Peripheral edema
  • Respiratory Therapy Assessment
  • Exercise Assessment (6 min. walk test)
  • Hypoxemia at rest and with exercise
  • Nutritional Assessment
  • Other Assessments as determined
  • physical therapy
  • occupational therapy
  • Social/ psychological

12
PAH Signs and Symptoms
  • Symptoms
  • Syncope
  • Palpitations
  • Fatigue
  • Dyspnea on exertion
  • Anginal Chest Pain
  • Hemoptysis
  • Light headedness
  • Signs
  • Prominent Right Ventricular Impulse
  • Accentuated Pulmonic Valve component (P2)
  • Right-Sided third heart sound (S3)
  • Hepatomegaly
  • Peripheral Edema
  • Jugular Vein Distention

13
Potential Side Effects of PAH Medications
  • Cough
  • Headache
  • Flushing
  • Flu-like syndrome
  • Nausea
  • Jaw Pain
  • Trismus lock jaw - any restriction to mouth
    opening
  • Hypotension
  • Site Pain

14
PAH PR Assessment Cont.
  • PR Assessment to include
  • WHO Clinical Classification of PAH
  • WHO Functional Classification, Class I-IV
  • Results of Rt. heart catheterization
  • Important to record drug therapy, route given
  • Symptoms syncope, palpitations, fatigue, chest
    pain, light headedness, edema, blood pressure
  • Anticoagulation, INR
  • Results of overnight oximetry or formal sleep
    study
  • Are they a candidate for lung transplant?

15
Education/Patient Training
  • Normal Anatomy and physiology
  • Chronic Lung Disease
  • Description and interpretation of medical tests
  • Breathing Retraining
  • Bronchial Hygiene
  • Medications
  • Oxygen Therapy/Sleep Disorders
  • Activities Of Daily Living
  • Eating Right
  • Preventing Infection
  • Leisure Activities
  • Coping With Chronic disease/ advanced directives

16
PAH Specific Education/Patient Training
  • Identifying and self monitoring of PH symptoms
  • Recognizing symptom limited exercise
  • Know signs of right heart failure
  • Emergency procedures (pumps lines)
  • Expected reactions to medications
  • Identifying symptoms/ understanding heart cath
    results
  • Pregnancy risks
  • Avoiding falls for the anti-coagulated patient
  • INR test results frequency
  • Recognizing symptom limited exercise
  • Self monitoring of weight and edema
  • Weight and edema checks
  • Expected reaction to PH meds
  • Need for lifelong medication
  • Patients MUST bring their back up pump at all
    times
  • Lung transplantation

17
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18
Exercise Testing
  • 6-minute walk test
  • Pulmonary Exercise Stress Test
  • Detect exercise-induced hypoxemia and determine
    O2 titration
  • Establish a baseline for outcome determination
  • Evaluation of current functional activity level
    and limitations, ADLS, pain, strength, range of
    motion, posture, balance, gait, safety, and
    breathing pattern
  • Evaluation of PAH symptoms, chest pain, shortness
    of breath, syncope, and fatigue

19
EXERCISE
  • exercise training should be initiated in a
    supervised setting - PR
  • Patient has Fear of exertion
  • Patient should Never exercise alone
  • Always have back-up pumps and medications as
    prescribed
  • Know the safety measures for lines/pumps with
    exercise equipment
  • Avoid exercises that increase intra thoracic
    pressure or valsalva maneuvers
  • Detect exercise-induced hypoxemia, O2 titration
    (may require high flow oxygen devices) goal is to
    keep patients 90 O2 saturation
  • Determine best home oxygen system, delivery
    device and flow rate, especially when high flow
    oxygen required (beyond the nasal cannula)
  • PH PR exercise documentation form to include PH
    symptoms, vitals plus edema, daily weight
  • Collaborative partnership with PH Clinic and PR a
    must to communicate concerns, issues, symptoms

20
Flolan (epoprostenol)
21
Avoid activities that increase intra-thoracic
pressure or valsalva effort
22
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23
PSYCHOSOCIAL INTERVENTION
  • Quality of life testing (CAMPHOR)
  • Loss of job or income, disability
  • Family dynamics
  • Pregnancy issues
  • Impact of severe lung disease at relatively young
    age
  • Genetic testing
  • Lack of visible signs of illness
  • Possible lung transplant evaluation

24
LONG TERM ADHERENCE
  • Schedule and keep PH Clinic appts
  • Medications necessary for life
  • Attend PH support groups
  • Treatment of PH resulting in prolongation of life
    and increased functional capacity
  • Exercise with a partner or in a supervised
    setting
  • Be connected with the National PH Association

25
Pulmonary Rehabilitation
  • PR is not just exercise or education but must
    have the essential components
  • Typical PR program may meet three times a week,
    over an 8-12 week period of time, have
    approximately 10-15 hours of education and 30
    hours of therapeutic exercise.
  • The commitment by the PH patient is great but so
    are the benefits.
  • The success of the PR program is also measured by
    the strength of the PRs Medical Director who
    guides the multi-disciplinary team in
    evidence-based practice.
  • The PR goals for the PH patient are not that
    different from the goals of PH medical
    management
  • improve cardiovascular endurance, increase
    exercise performance, enhance ability to perform
    Activities of Daily Living (ADL), improve quality
    of life, reduce hospitalizations, decrease
    symptoms, especially dyspnea through breathing
    retraining and ensuring adequate oxygenation at
    rest and with activity.

26
Positive Outcomes from Pulmonary Rehabilitation
  • Patient will have a better understanding of how
    PH affects their lungs, oxygen and exercise
  • Understand lung symptoms and decrease shortness
    of breath through breathing retraining and
    ensuring adequate oxygenation at rest and with
    activity
  • Increase exercise performance that translates
    into improvements in activities of daily living
  • Improve cardiovascular endurance through a safe
    and supervised exercise program
  • Improve quality of life through education and
    therapeutic exercise
  • Exercise in a facility that allows the patient to
    feel secure and safe because of the skill set of
    the pulmonary rehabilitation respiratory
    therapist working with them
  • PR team communicates with referring MD and the PH
    clinic on patients progress in PR

27
How to Locate a Pulmonary Rehabilitation Program
  • American Association of Respiratory Care (AARC)
  • http//www.yourlunghealth.org/finding_care/q
    rc/pulm_care/index.cfm
  • American Association of Cardiovascular and
    Pulmonary Rehabilitation, (AACVPR)
  • http//www.aacvpr.org/Resources/SearchableCertifie
    dProgramDirectory/tabid/113/Default.aspx

28
Respiratory Home Care Needs of the PH Patient
  • Oxygen Systems
  • Oxygen Delivery Devices
  • CPAP or Bi-Level Positive Airway Pressure to
    treat Sleep Apnea

29
Oxygen Systems
  • Compressed gas
  • Liquid oxygen
  • Oxygen concentrator

30
Oxygen Delivery Devices
  • Delivery Device Description
    Liter Flow
  • Nasal Cannula Delivers approx. 44
    1-6 l/m
  • O2
    depending on liter flow,
  • patients respiratory rate, etc.
  • Oxymizer Pendant Higher FiO2 achieved
  • or Mustache
    1-12 l/m
  • http//www.chadtherapeutics.com/usa/Dispo
    sable-Conservers/Oxymizer.html
  • High Flow Cannula High flow without a face mask.
  • (various manufacturers) Patient can eat, drink
    etc. 6-15 l/m
  • Oxymask provide greater FiO2 at
    lower flows 1 - flush l/m
  • http//www.southmedic.com/products/oxyma
    sk-adult.php

31
Respiratory Therapy in the ICU
  • Know the important role the ICU Respiratory
    Therapist provides for heart failure patients
    beyond Nitric Oxide (NO) to Inhaled Epoprostenol
    (iEPO)
  • Ventilated patients can be challenging to
    liberate (wean) off mechanical ventilation and
    the ICU Respiratory Therapist is a vital member
    of the ICU team

32
Inhaled Nitric Oxide (iNO)
  • Objective
  • Decrease pulmonary artery pressure (PAP)
  • Decrease pulmonary vascular resistance (PVR)
  • Improve oxygenation
  • Patient Populations adults and children
  • Indications respiratory failure with mechanical
    ventilation, secondary to diffuse parenchyma lung
    disease, severe respiratory disease requiring
    FiO2 gt70, oxygenation index X Mean Airway
    Pressure of gt10, patients with congenital or
    acquired heart disease with anatomic and/or
    physiologic abnormalities associated with
    pulmonary artery hypertension or pulmonary
    vascular changes, lung and cardiac transplant,
    LVAD
  • Benchmarking and Evidenced Based Data
  • Cost Expensive

33
Going Beyond Inhaled Nitric Oxide (iNO)
..Inhaled Epoprostenol (iEPO)
  • Objective
  • treat pulmonary hypertension and right
    ventricular failure as
  • confirmed by rt. heart cath., echo, or
    direct visual inspection during cardiac surgery
  • Treat severe hypoxemia (PaO2/FiO2 ration lt 200)
    unresponsive to standard therapy in patients with
    ARDS
  • Patient Populations adults and children,
  • Indications lung, heart transplant, LVAD, ARDS
  • Inhaled Epoprostenol (iEPO)
  • Comparable to the effect of iNO, clinical
    hemodynamic response good
  • Lack of toxic reactions
  • Easy administration
  • Cost effective alternative
  • Benchmarking and Evidenced Based Data

34
The Respiratory Therapist and the Pulmonary
Hypertension Clinic
  • Role the Respiratory Therapist has is dependent
    on the facility and program needs as directed by
    the PH Medical Director and Manager
  • Assessment and Education of the PH Patient
  • clinic evaluation
  • To include H P
  • physical exam
  • medication review
  • Diagnostic testing 6 MWT and spirometry test
  • Education of the PH patient on specific topics

35
References
  • CJ Dine, ME Kreider. Hypoxia Altitude Simulation
    Test. Chest. 20081331002-1005.
  • Aina Akero, MD, Anne Edvardsen, Carl Christensen,
    et.al., COPD Air Travel. Oxygen Equipment and
    Preflight titration of supplemental oxygen.
    Trial registry Clinical Trials.gove No.
    Identifier NCT01019538 URL clinicaltrials.gov.
    Chest Journal
  • de Man FS, Handoko ML, Groepenhoff H, et. al.,
    Effects of exercise training in patients with
    idiopathic pulmonary arterial hypertension. Eur
    Respir J 2009 34 669-675.
  • Shapiro S, Traiger GL, Exercise and Pulmonary
    Hypertension, Chapter 32, pg 518- 528 in Hodgkin
    JE, Celli BR, Connors GL. Editors. Pulmonary
    Rehabilitation Guidelines to Success, 4th
    Edition, Mosby Elsevier, 2009.

36
References Cont.



  • Mereles D, Ehlken N, Kreuscher S et al. Exercise
    and respiratory training improve exercise
    capacity and quality of life in patients with
    severe chronic pulmonary hypertension.
    Circulation 2006 October 3114(14)1482-9.
  • Adamali H, Gaine SP, Rubin LJ. Medical treatment
    of pulmonary arterial hypertension. Semin Respir
    Crit Care Med 200930484-492.
  • Dose-Response to Inhaled Aerosolized Prostacyclin
    for Hypoxemia Due to ARDS Chest March 2000
    117819 10.1378/chest.117.3.819
  • Suhail Raoof, Keith Goulet, et.al., Severe
    Hypoxemic Respiratory Failure Part
    2Nonventilatory Strategies Chest June 2010
    1371437 10.1378/chest.09-2416

37
References Cont.
  • Kieter Wlamrath, Thomas Schneider, et. al.,
    Direct Comparison of Inhaled Nitric Oxide
    Aerosolized Prostacycline in Acute Respiratory
    Distress Syndrome. Am J Respir Crit Care Med
    1996153991-6.
  • Charl J. De Wet, David Afflect, et. al., Inhaled
    prostacycline is safe, effective, and affordable
    in patients with pulmonary hypertension, right
    heart dysfunction, and refractory hypoxemia after
    cardiothoracic surgery. J. Thorac. Cardiovasc.
    Surg., December 1, 2004 128(6)949-950.

38
SUMMARY...
  • Respiratory Therapist have a critical role in
    optimizing the treatment and quality of life for
    the PH patient from the ICU to Pulmonary
    Rehabilitation to Pulmonary Diagnostics to Home
    Care, to the PH Clinic setting through
    collaboration with the Pulmonary Hypertension
    Specialist.

39
THANK YOU!!!!!!!
  • Gerilynn L. Connors, RRT, BS, FAARC,
    FAACVPRClinical Manager, Pulmonary
    RehabilitationInova Fairfax HospitalFalls
    Church, VAgerilynn.connors_at_inova.org
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