By Lorin G.

Last month I wrote a blog about chronic obstructive pulmonary disease (COPD). It’s a disease which consists of a combination of chronic bronchitis, the inflammation of the larger airways, and chronic emphysema, swelling of the alveoli or air sacks of the lungs.  It is the fourth leading cause of death in the United States.  Two days after writing that essay, a 49 year old patient (we will call him Howard) at the Skilled Nursing Facility where I work died of COPD.  In light of this, I think it is especially pertinent to revisit the subject of therapy and COPD to see what may have been done from our perspective to prevent or delay this event.

Howard was not quite the picture of optimal health – he was morbidly obese, had suffered from psychosocial disorders and was currently homeless.  He may have been a smoker before his admission to the SNF, but had not smoked for some time.  He was able to get out of bed and move to the toilet on his own, very slowly and precariously, or to his wheelchair.  Unfortunately Howard preferred to stay in bed the majority of his days, often stating that his knee hurt too much, possibly from osteoarthritis secondary to his obesity.  All these things are connected to Howard’s pulmonary condition and his overall prognosis.  The day of the poor man’s death, I worked with his 88-year old roommate at the SNF, who recalled that around 4 AM, Howard got up from bed to use the bathroom, returned to bed and started calling for help, stating he was dying because he couldn’t breathe. 

What therapeutic steps could have been taken in the days and weeks preceding this dire circumstance?  Unfortunately, depression can often be a factor in the psychosocial outlooks of people with COPD (2).  As occupational therapists, we can help people with depressive symptoms to feel better about themselves through a structured approach of journaling, reflection, education on COPD and depression, daily stretching and exercise.  At a SNF or other location, it’s also important to consult with a patient’s nurse or doctor to see if they’re taking any antidepressants and whether these mediations are having an appreciable effect. I’ve read different articles on obesity and occupational therapy that say that it is not really possible for us as therapists to push for tremendous weight loss as much as to help a patient with their every day needs and activities. 

Howard had been unemployed for about three years, but he was still at an age where he could work for his financial and psychosocial well-being.  One of the most important things to advocate for Howard with COPD was lifestyle change. Rather than living a sedentary existence, Howard could have been strongly encouraged to get out of bed at regular hours and discipline himself towards weight loss and more healthy exercise patterns.  To be fair, he was trying in many ways.  He could walk about 15 feet with physical therapy and was becoming more active with such activities as using the restorator (arm bicycle) and doing other therapeutic exercises to help increase his activity tolerance. Unfortunately, as the fates proved, these actions weren’t enough to save this poor man’s life.  What else could have been done?

I spoke with Dr. Henry Abrons, a family friend who is retired pulmonologist (3).  He stated that the morbidity rate for COPD patients by the time they are admitted to a hospital or SNF is extremely high.  So Howard didn’t have a lot of hope by the time I had met him at the SNF.  He had stopped smoking 3 years earlier, but weighed over 600 lbs and was homeless.  This combination of the pulmonary condition, weight, and psychosocial factors combine into the diagnosis of COPD.  According to Dr. Abrons, patients’ smoking history is defined in “pack-years”, the number of cigarette packs smoked each year for how many years.  Dr. Abrons stated that most of the time there are a lot of comorbidities with COPD, such as CHF, diabetes, or depression.   He stated that the definition of COPD as a disease is not terribly precise: it’s more of a syndrome or combination of chronic bronchitis, chronic emphysema and sometimes chronic asthma.  I asked him what COPD has to do with obesity and malnutrition or weight loss.  Morbid obesity limits a person’s ability to get out of bed, get dressed, move up and down stairs and generally complete activities of daily living.  Many individuals with COPD can also become undernourished and skinny because the abdomen can push up into the thoracic cavity which can cause a decrease in calorie consumption.

The Australian Lung Foundation offers a Pulmonary Rehabilitation Toolkit (4). They state, “A reduction in exercise tolerance is one of the main complaints of people with chronic lung disease.”  Occupational therapists, like myself, are not respiratory therapists, but we can play a crucial role as part of an interdisciplinary team in the treatment of COPD.   The Australian Lung Foundation recommends upper extremity exercises with low weights and high repetitions to help with the accessory muscles of the lungs like the biceps, triceps, pectoralis major, latissimus dorsi and trapezius.  Exercising these muscles is important in the rehabilitation of COPD more than a simple UBE (arm bike) because these muscles tend to help with functional activities like dressing and bathing.   Ambulation can also be helpful for the lower extremities as well as the muscles surrounding the lung.  They suggest having a person walk for about 10 minutes to the point of feeling moderately to severely breathless during walking or cycling.

The patient’s doctor and nurses should all be contacted early on when preparing for the rehabilitation of someone with COPD.  Do they have a schedule for medications like bronchodilators?  What about the need for supplemental oxygen?  When should it be given?  The treatment of people with COPD sounds like a true group effort between doctors, nurses, occupational therapists, physical therapists and others help encourage education, regular exercise, proper diet and the completion of normal daily activities. Overall, there wasn’t too much that could have been done for Howard by the time he checked into the SNF where I currently work under Jackson Therapy. 

Had he been seen by rehabilitation ten or twenty years earlier, there are therapeutic steps that could have been taken to extend Howard’s life.  These basic steps are:

1 – Becoming educated on COPD, obesity and their implications

2 – Stopping smoking

3 – Developing an appropriate exercise regimen

4 – Controlling caloric intake

In the setting where I work, the best things to do with a morbidly obese patient with COPD is to have compassion, build healthy habits of getting out of bed to perform ADLs, motivate to develop better exercise habits and educate people about the risks of smoking, COPD and a sedentary lifestyle.

References:

1.       “Chronic Obstructive Pulmonary Disorder” from Wikipedia, http://en.wikipedia.org/wiki/COPD, accessed on 7/4/11.

2.       Claudia Stahl, “Occupational Therapy in COPD”, from Wikipedia, http://occupational-therapy.advanceweb.com/Article/Occupational-Therapy-in-COPD.aspx, accessed on 7/4/11.

3.       Personal communications with Dr. Henry Abrons, MD on 7/12/11.

4.       Australian Lung Foundation, “Pulmonary Rehabilitation Toolkit”, accessed at http://www.pulmonaryrehab.com.au/index.asp?page=53, on 7/13/11.