COPD and OT II – 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.
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.