The PRAXIS Nexus The PRAXIS Nexus

A PRAXIS Case Study: Meg S.

Posted on March 13, 2018   |   
14 Comments   |   
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COPD case study

Meg S., age 62

Meg S. was referred to pulmonary rehabilitation following a visit with her primary care provider. Here is some of the information shared in the pulmonary rehab intake interview.

Past utilization: Meg has been seen in the ER x 3 over the last three months for extreme shortness of breath, rib pain and intractable cough, feeling as if she’s “choking on my phlegm.” On the second visit, she refused an overnight admission to acute care due to obligations at home. One week later, on her third visit, in addition to nebulizer treatments, low flow O2, and smoking cessation counseling, she was provided with an Acapella device for secretion mobilization.

Medical history: COPD, perforated spleen related to a colonoscopy. Her spleen was subsequently removed. FEV1 is 35% normal predicted. 75-pack-year cigarette history, still smoking. Negative for Alpha-1 Antitrypsin Deficiency. 2+ pitting edema in feet and ankles.

Family history: Father, age 84, living alone in another state, seemingly in good health. Mother deceased at age 38 after a prolonged illness, etiology unknown. (Throughout her teenage years, Meg was her mother’s primary caregiver.) Meg has two adult children, one 34-year-old son is on the autism spectrum with generalized anxiety disorder and lives at home. Her 30-year-old daughter in good health, lives in town.

CXR: Severe hyperinflation, no pneumonia.

Pulse oximetry: Room air 92%.

Height: 62” Weight: 89 lbs.

Medications: Spiriva q day, Albuterol MDI q4 hours and prn at noc, Acapella. Xanax. Mucinex prn.

Psych/Social: Meg appears much older than her stated age. She appears to be malnourished. Color after walking from the parking lot on room air is ashen. Worked as a realtor and interior designer, retired last year. Drinks two glasses of wine every evening. Lives with husband who is 82 years old. “He’s not as spry as he used to be and he’s becoming forgetful. My son from my second marriage works part time at a grocery store but still lives at home and requires a lot of help and support. I belong to a 'parents of autism' support group. Evan, my four-year-old grandson, is the light of my life and spends every Wednesday at my house. I know it makes for a busy day, but spending time with him is the highlight of my week and I don’t know what I’d do if I didn’t have him. I’m glad you don’t have rehab classes here on Wednesdays because I wouldn’t come. With taking care of my son and spending time with Evan, plus my book club, I don’t know if I have enough time for this rehab program as it is.”

Questions:

  • What are your impressions?
  • Would you expect Meg to complete her course of pulmonary rehab?
  • What additional consults would you recommend?
  • If you could accomplish only one thing in the course of Meg’s care in pulmonary rehab, what would that be?

14 Comments



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  • Still smoking is lane. She doesn't seem to care about her health.
    Reply
    • Could it be, at that time, that the addiction was stronger than Meg and her willingness to make a change?
      Reply
  • I wonder if Meg will be able to complete pulmonary rehab if she doesn't realize it needs to be a priority -- along with the other important parts of her life? How can her healthcare team best educate her on the importance of enrolling in and sticking to the program -- and on how it will improve her QOL all around, including her time with her grandson?
    Reply
  • It doesn't seem that Meg has a good idea of the benefits of Pulm Rehab - she seems to have the impression that it is just another thing to busy up her week. She may not think she needs help, but I'm not sure she realizes how much better she would feel after completing the program.
    I'm also a little concerned about the lower extremity edema and that she is quite a bit below her ideal body weight...
    Sounds like she could use some nutritional support...

    To me, it sounds like Meg is going to have to start seeing some benefits of the program right away, or she may not stick with it. The rehab team is going to have to focus in on what motivates her right away to keep her engaged.
    Reply
  • I agree, Kristen and Stephanie,

    Meg might not stick with rehab unless she sees a definite value in it. Luckily for her, this rehab did not require quitting smoking as a prerequisite to joining the program. It seems that all her life, and still at this point, Meg has taken care of everybody around her probably at the expense of her own health. Maybe if she feels some care is being given to her, by the PR staff and even classmates, she'll be able to accept it and soften up a bit.
    Reply
  • Meg is the perfect candidate for nasal high flow humidification therapy. Here’s why. She needs improved oxygenation and ventilation and hydrated secretions for airway clearance. She needs a therapy that will decrease her work of breathing and that will allow her to communicate & play with that cute grandson at the dinner table. She needs a therapy that she can use continuously or intermittently and that she can adjust as her inspiratory demand changes with ADL . It’s got to be comfortable or she won’t want to use it. If later she needs oxygen therapy,, that can be bled through the unit. The Acapella alone without hydrating the sticky secretions will be ineffective & consume energy which she needs to preserve. The Acapella with NHFHT, that makes more sense to hydrate the mucociliary clearance mechanisms allowing the cilia to move the mucus layer as it should, reducing the risk of infection due to retained secretions.
    Reply
    • Are you talking about a device like Airvo? I love it and have used it in SNFs to help support patients who need the kind of help you describe above. We just had to be careful not to fluid overload them if they had any signs of edema or CHF since it did such a good job of providing moisture :) .

      An additional question:
      Will insurance pay for Airvo devices in the home yet? I know for a long time they didn't but were working on it. I was just wondering about this a couple of days ago - hadn't had an update from any of my DME colleagues.
      Reply
  • Impression: Chronic Bronchitis secondary to chronic smoking. Malnourished , probably dehydrated. Probable CHF, probable pulmonary hypertension. Probable Bronchiectasis with chronic bacterial infection.

    Complete course of rehab? Highly unlikely given her psychological need to be everyone else's caregiver.

    Consults: Pulmonologist to manage/maximize home respiratory care regimen. Work-up for possible Lung Volume Reduction Surgery. Change home treatment to LABA/LAMA per nebulizer as I doubt she has sufficient inspiratory flow or capacity to allow MDI/DPI therapy to be effective.. Consider adding Sidinifil for probable Pul. HTN. Culture and Stain sputum for bacterial infection.
    Nutritionist to promote healthy diet and eating strategies. Possibly add a nutritionally dense supplement such as Pulmocare.
    Agree with HFNC for secretion hydration/mobilization. Consider High Frequency Chest Wall Oscillation per vest therapy for secretion mobilization.
    Continue to promote smoking cessation. Provide support for any quit attempt.

    One accomplishment for Pulmonary Rehab? That she accept permission to put herself and her health first in line for her caregiver activities.

    Reply
    • Great assessments n recommendations highly you covered it all
      Reply
    • I couldn't agree more. My first impression was the meds need to be adjusted, then I considered all possible diagnosis and finally thought about how Meg kept saying she would have no time. In order for PR to be successful the participant needs to want it and needs to be committed not only during the program but over a lifetime. PR is not a just a few weeks and all-done deal it is a lifestyle change that needs to become a part of her life.

      You state some real ideas and thoughts and the HFCWO would be yet another excellent idea. She could perform this twice daily and PRN. Appreciate the way you think.
      Reply
  • Slightly off topic but this raises the question, what do PR programs do to encourage patients to stay in the program and then to maintain their exercise routine? Are there specific strategies?
    Reply
  • Thank you, everyone, for your excellent insight into this case. Here is the original plan as well as the 8-week follow-up, telling us how Meg did in Pulmonary Rehab and beyond.

    Plan:
    1. Begin Pulmonary Rehabilitation sessions as soon as possible.
    2. Smoking cessation counseling.
    3. Nutrition consult for weight gain.
    4. Instruction and return demonstration for MDI’s and Acapella.

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    Eight weeks later

    Meg completed 13 out of 16 scheduled Pulmonary Rehab sessions, gaining endurance, strength and flexibility as well as knowledge on managing COPD and avoiding exacerbations and managing her overall health.

    She received one-on-one smoking cessation counseling from a certified counselor and also got support and suggestions from former smokers, peers, in her pulmonary rehab class. “I guess it was hard for them to quit, but they did it, so I figured maybe I could too. It's my new friends here who have helped the most.” She states that she has stopped smoking for good, although admits that staying quit is a “never-ending battle.”

    As a person who always kept meticulous written records, Meg actually enjoys using the My COPD Action Plan and has found it especially helpful in assessing ease vs. difficulty with daily tasks.

    Her daughter, Julie, joined Meg at a session with the dietician. Julie now picks up a “healthy meal (not just a burger and fries)” after work on Wednesdays and the family eats dinner together at Meg’s house. There are usually enough leftovers for Meg and her husband to have for lunch a few days later. Meg has gained six pounds since starting pulmonary rehab. She has not visited the ER since beginning the Pulmonary Rehab program.

    As a result of increased water intake and improved airway clearance and cough techniques, her frequent, non-productive cough has become more controlled.

    Meg's goal is to see Evan graduate from high school. She plans on continuing exercise in the Pulmonary Rehab maintenance class two times a week. She has gathered a list of her classmates’ names and their birthdays and sees herself as the “den mother” of the class.

    Reply

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