Chronic Obstructive Pulmonary Disease (COPD) Exacerbation in an Older Adult
A 72-year-old man with moderate COPD (GOLD 2) is admitted to the hospital with an acute exacerbation. He has a 50-year pack-year smoking history, continues to smoke, and uses home oxygen 2 L/min via nasal cannula. He reports increased dyspnea, productive cough with green sputum, and fatigue. Vital signs: HR 98, RR 24, SpO2 88% on 2 L/min, BP 138/86. Breath sounds: diminished with wheezes and crackles bilaterally. He is on prednisone 40 mg daily and azithromycin. He lives with his wife in a single-story home. The PT is consulted for mobilization and airway clearance.
1. What are the PT's priorities and precautions during this acute exacerbation?
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Priorities: 1) Airway clearance: Assist with huffing, coughing, and positioning to mobilize secretions. 2) Breathing retraining: Pursed-lip breathing and diaphragmatic breathing to reduce dyspnea. 3) Energy conservation: Teach pacing and activity modification. 4) Mobilization: Early mobilization to prevent deconditioning, but with close monitoring. Precautions: 1) Oxygen: Monitor SpO2; maintain between 88-92% for COPD patients to avoid hyperoxia-induced hypercapnia. 2) Infection control: Use PPE and hand hygiene due to green sputum (possible infection). 3) Medication effects: Prednisone may cause hyperglycemia and muscle weakness; monitor blood glucose. 4) Vitals: Stop activity if HR >120, RR >30, SpO2 <88%, or patient reports severe dyspnea or chest pain. 5) Fall risk: Assess due to fatigue and possible orthostasis. 6) Smoking cessation: Address in a non-judgmental manner, offer resources.
2. How would you structure an exercise session for this patient, and what outcomes would you measure?
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Structure: 1) Pre-session: Assess vitals, SpO2, and symptoms; ensure bronchodilator use if prescribed. 2) Warm-up: Gentle breathing exercises and range of motion. 3) Aerobic: Interval training with short bouts (1-2 min) of walking or seated marching, interspersed with rest and pursed-lip breathing. Monitor SpO2 continuously; use supplemental oxygen to maintain SpO2 ≥88%. 4) Strength: Low-intensity resistance exercises for major muscle groups, 1-2 sets of 8-10 reps. 5) Cool-down: Stretching and relaxation. 6) Education: Energy conservation, home exercise program, and smoking cessation. Outcomes: 1) Dyspnea: Borg CR10 scale before/after activity. 2) Functional capacity: 6-minute walk test (if stable) or 2-minute step test. 3) SpO2 and HR during activity. 4) Airway clearance: Sputum production and ease of expectoration. 5) Quality of life: CAT or SGRQ. 6) ADL independence: FIM or Barthel Index.