Patients who have been hospitalized for COPD exacerbation or pneumonia are great candidates for the SNF. They usually present with muscle weakness and pulmonary weakness, and have a high chance of returning home within a few weeks.
When a patient is on condensed O2, there are a handful of components we need to keep in mind:
- what is the blood/oxygen saturation at rest?
- what is the blood/oxygen saturation with activity?
- can the patient safely ambulate around the cannula tubing?
- can the patient appropriately don/doff the cannula?
- is the patient compliant with O2 use?
- does the patient show an appropriate inhalation? exhalation?
- does the patient have good peripheral circulation?
- has the patient been on condensed O2 at home?
- will the patient be returning home with condensed O2?
- is the patient symptomatic when the blood/oxygen saturation is low?
Before we get into the intervention techniques, let’s review the basics.
A normal blood/oxygen saturation is typically in the 95-98% range. I usually say, 90% and above is good, 93% and above is better. Most of my pulmonary patients arrive to our facility on 1-2 liters of condensed O2, meaning that the oxygen tank is distributing 1-2 liters of oxygen per minute.
If a patient is experiencing shortness of breath, the best and quickest way to increase the blood/oxygen saturation is through pursed-lip breathing techniques; in through the nose, out through the mouth. So we instruct the patient to breath in as if they were smelling a flower, and breath out as if they were blowing out a birthday candle.
Why does pursed-lip breathing work?
Our lungs thrive on moist air, and our nose is much better at moistening the air than our mouths are. So we take a deep breath in through the nose to fill the lungs with fresh, moist air.
The exhale is just as important as the inhale because we need to rid our lungs of all the stale, dead air to make room for that fresh, moist air. So image a garden hose. A standard garden hose with no head attachment can be used to water your garden, but the water just sort of piddles out the end of the hose. The same things happens when we exhale through a wide open mouth. Yes the air comes out, but just in a little piddle. The second you add an attachment to the head of the garden hose, the water can be released much farther and at a much greater velocity. This is what happens when we exhale through pursed lips. The pressure behind the air enables us to rid the lungs of as much dead air as possible.
Pursed lip breathing only works as well as the diaphragm does.
Even if the patient demonstrates excellent pursed lip breathing, a shallow pursed lip breath will not show pulmonary improvements. This is why it is equally as important to instruct the patient to engage the diaphragm. This can be done by placing on hand on the sternum and one hand on the upper abdomen. If you stand in front of the mirror and breath normally with your hands in this position, you should notice that the hand on your upper abdomen moves up and down, while the hand on your sternum remains stationary. This is what we want. Because in reality, the lungs are only able to inflate and deflate if the pressure within the chest cavity changes. The pressure in the chest cavity only changes if the diaphragm appropriately contracts and relaxes. Hence, pursed lip breathing + diaphragmatic breathing = the perfect deep breath.
So then how do we teach these techniques to our patients?
I have a few ideas. Well we can start with an incentive spirometer; a simple device used to facilitate deep inhalation and exhalation.
In my short experience, exhalation is much more difficult than inhalation for most patients. So I try multiple activities that facilitate a full, deep exhalation:
- place some medicine cups in a row upside-down on a table and instruct the patient to propel the cups across the table by blowing through a drinking straw; if the exhale is strong, the air from the end of the straw should propel each cup across the length of the table in one attempt
- inflate a balloon
- blow bubbles
- fill a basin with a small amount of water and some liquid soap and blow bubbles into the water through a straw (aka create a bubble mountain in the basin)
Upper body exercises are also a great way to open up the chest cavity and increase pulmonary endurance.
My favorite upper body exercise for pulmonary endurance is what I refer to as a resistive beach ball volley. I instruct the patient to hold a Wate Bar horizontally at roughly chest-height. Then gently toss a beach ball, instructing the patient to bounce the beach ball off the center of the Wate Bar.
If a patient is planning to return home without condensed oxygen, we need to facilitate the titration process.
Titration is a fancy way to say ‘ween off condensed oxygen’. Essentially, this is done by performing total body exercise and functional ambulation with a decreased level of condensed oxygen.
So for example: we have a patient who came into the facility on 2 liters. So we titrate by performing an upper body exercise routine on 1 liter of oxygen, consistently testing the blood/oxygen saturation after each exercise. If done in slow, steady increments, the patient should eventually build up the pulmonary endurance to maintain a blood/oxygen saturation of 93% or higher on room air.
If a patient will be returning home on condensed oxygen, then we need to facilitate safety and independence with tank and cannula management.
This means teaching the patient to ensure that the foot area is clear of tubing before ambulating, knowing how to set the oxygen levels, and how to read the pressure gauge. Patients who have chronic pulmonary conditions may qualify for a portable oxygen concentrator which can be less cumbersome and more manageable than a typical oxygen tank. In either case, as with any safety measure, we need to ensure that the patient has consistently demonstrated safety with oxygen management before discharge home.
Do you have a favorite exercise to facilitate pulmonary endurance?