Occupational Therapy for COPD in Acute Care / Acute Rehab / SNF / Home Health

Background

  • Chronic Obstructive Pulmonary Disease (COPD) is an umbrella term used to describe progressive lung diseases including emphysema, chronic bronchitis, and refractory (non-reversible) asthma.
  • Therapeutic air exchange cannot occur
  • Breathing becomes more difficult
  • Results in decreased ability to participate in ADLs, IADLs, etc.
  • Can cause the heart to become enlarged
  • Can cause hypertension
  • Can cause cognitive impairment
  • Possible psychosocial (anxiety & depression) involvement

Vital Signs

  • Beware of the dangers of over-supplementing oxygen.
  • In patients with COPD, “titrate their oxygen” and aim for an oxygen saturation target of 88-92%.
    • Provides adequate tissue oxygenation while avoiding the complication of hyperoxic hypercapnia by giving the minimum amount of oxygen needed to stay above severe hypoxemia.
    • Giving patients with COPD lots to oxygen tells their breathing mechanism that they have a lot of oxygen and they should slow their breathing. They retain COand their body gets worse.
  • Normal oxygen saturation does not rule out respiratory failure.
    Do not rely on the oxygen saturation to warn you of impending respiratory failure.
    • Hemoglobin may remain saturated with oxygen despite hypoventilation causing rising levels of carbon dioxide.
    • The oxygen saturation may not fall below 90% until the patient is already in serious trouble, especially if the patient is on supplemental oxygen.
    • Respiratory rate, pCO2, and level of consciousness should all be assessed routinely.
    • At a minimum, it is also necessary to record the respiratory rate, and if they are having supplemental oxygen.

Oxygen Delivery Methods for OTs

  • Room Air
  • Nasal Cannula (most common) – with or without a humidifier
  • High Flow Nasal Cannula (HFNC)
    • HFNC allows for high flow due to air being heated and humidified.
    • Isn’t just a standard nasal cannula cranked up to very high flow rates.
    • Takes gas and can heat it to 37oC with a 100% relative humidity.
    • Can decrease airway inflammation, maintain mucociliary function, improve mucous clearance and reduce the caloric expenditure in acute respiratory failure.
    • In patients with acute respiratory failure, the percentage of gas we rebreathe gets larger, and as a result, we can rebreathe larger amounts of carbon dioxide as we draw our breaths from a mixed reservoir from our upper airway.
    • HFNC gives a continuous flow of fresh gas at high flow rates replacing or washing out the patient’s pharyngeal dead-space (the old gas low in oxygen and high in CO2). Each breath that the patient now re-breathes will be washed out of carbon dioxide and replaced with oxygen-rich gas improving breathing efficiency.
    • Cons: cannot be hooked up to portable tank to mobilize patient due to high flow rate
  • Oxygen Mask
  • CPAP & BiPAP

Breathing Techniques

  1. Pursed lip breathing
  2. Diagram breathing
  3. Pacing (stop, rest, continue)

Interventions

  • Stress management
  • Therapeutic breathing
  • Pacing/Planning/Prioritizing/Positioning
  • Energy conservation
  • Oxygen safety, contraindications, and use
  • Body mechanics

Tips

  • Carry a portable pocket-sized pulse oximeter to use in a tight squeeze.
  • Use extension tubing if possible.
  • Double-check oxygen tank level prior to mobilizing.
  • Ensure nasal cannula is fitted incorrect orientation (prongs facing DOWNWARD and towards the patient), often patients may re-don them incorrectly.
  • To facilitate breathing, position patient upright in bed in fowler’s instead of supine.

Sources:

https://www.copdfoundation.org

https://journals.lww.com/em-news/Fulltext/2011/02000/Titrated_Oxygen_Better_than_High_Flow_for_Patients.3.aspx

https://acphospitalist.org/archives/2009/12/tech.htm

rebelem.com/high-flow-nasal-cannula-hfnc-part-1-how-it-works/