Week 5 STARES - Joondalup Cardio

Situation
I had been treating a 58 yr old man who had been admitted for acute exacerbation of COPD with ↑SOB occurring of the previous 1/7. He had a history of bronchiectatsis & had been admitted 4 times previously in the last year for the same condition (“frequent flyer”). The patient appeared very fatigued & anxious and was regularly productive of thick grey sputum which was evident due to widespread crackles & wheezes on auscultation as well as audible moisture when breathing & coughing. He was normally on home O2 @ 4L but was gradually put on increasing amounts as the days passed & eventually steadied at 35L O2 via high flow nasal prongs with humidification. In the time while I had been treating him he had had 2 MET calls (Medical Emergency Team) for increasing SOB at rest.



Task
From a physio point of view the main goals of treatment were to assist the patient with expectorating secretions, improve his SOB and improve his exercise tolerance. To assess the success of treatments I had to use auscultation and measures of exercise tolerance before & after treatment. Analysis of the patient’s sputum was also necessary.


Action
Subjective questioning was very difficult since the patients SpO2 regularly dropped from 97% to 90% just with talking, so clear concise questioning was a must. I asked questions about his previous levels of activity, what assistance he receives at home & who from, how his condition has progressed over time and what he has done at home in the past in terms of exercise & maintaining his health. Essentially to determine what his goals might be and if he is doing anything at home to prevent having more exacerbations.
Objectively I ausculatated and found that all areas of his lungs contained infiltrates (which was confirmed by CXR). Prior to the auscultation I asked the patient to cough which was strong, moist & productive of thick brown sputum (~1tspn). I then got the patient to walk which he could only manage for ~5m before his SpO2 dropped significantly and he became v. SOB+++. After the patient was allowed to recover for ~10mins I began to educate him on UL & LL ex’s which he responded to well and agreed to carry out when I wasn’t there seeing him. On the next occasion I carried out some percussions & vibrations after nebulisers had been administered but as time went by his tolerance for ambulation and percussion & vibes diminished as he was very anxious at how SOB he became with these interventions


Result
The percussion & vibes enabled the patient to expectorate some more sputum but since his lungs were very consolidated this did not show up in changes during auscultation. The patient reported that he had been completing the UL & LL ex’s in my absence but had suspicions about this fact since he could never accurately reproduce the exercises given to him.
The patient’s level of SOB and SpO2 were severely affected by my intervention which as mentioned made him very anxious and in numerous sessions refused to take part due to not feeling well or not being prepared to be involved. This was despite being explained what the benefits of physio treatment were.

Evaluation
The patient’s response to the treatments was very hard to tell as he was so negatively affected after each session yet expectorated large quantities of sputum. His anxiety contributed to me not being able to reassess what improvements had been made in this regard but I strongly suspected that no improvements had been made.
On one occasion a MET call was initiated which resulted in the Dr requesting more regular physio. It was explained to the patient by the Dr that he had to have physio. On reflection I should have been a bit more of a bully and pushed him in the earlier stages since a small bit of discomfort during physio could lead to big improvements later on.


Strategies
I think closer liaison with the medical team to explain the patient’s constant refusal for treatment may have alerted them to the fact that he was receiving little physio and action being taken sooner. As mentioned explaining even clearer & honestly to the patient the benefits of regular physio and that his state will deteriorate with constant refusal.