Physicians Roundtable

Exercises for Patients with Cardiopulmonary Compromise

Putting patients on the proper course of treatment is a highly individualized process.

Cardiopulmonary compromise is an umbrella term for an impairment of the body's ability to deliver oxygen properly. The treatment and rehabilitation processes, however, rely heavily upon the specific symptoms presented by individual patients and on effective communication between patients and their physicians and respiratory therapists.

To discuss this topic in greater depth and detail, ADVANCE recently had the opportunity to speak with Hassan Bencheqroun, MD, FCCP, Interventional Pulmonary and Critical Care, assistant clinical professor - University of California Riverside School of Medicine.

ADVANCE: To begin, can you provide an overview of cardiopulmonary compromise? (What is it, what are its signs and symptoms and which patient populations are most at risk of it?)
Bencheqroun: Cardiopulmonary compromise refers to the inability to meet the body's demands for oxygen delivery either through the respiratory system with impairment of gas exchange and work of breathing, or through the cardiac system through impairment of circulation and tissue oxygen delivery, or a combination of both.

ADVANCE: As a critical care physician and pulmonologist, what are some ways you measure a patient with cardiopulmonary compromise to see which exercises they're able to perform and how intensely they're able to work at them?
Patients with cardiopulmonary compromise symptoms need to keep an open dialogue with their physicians.Bencheqroun: First, I ask the patient how much are they able to do at home. One must focus on how many flights of stairs can they do unloaded or loaded (e.g. carrying a laundry basket or two gallons of milk or groceries, etc.). Further, upon initial physician examination, one starts to get an idea of the patient's ability to undergo exertion and to what level. The primary assessment should focus on assessing what is the irreversible state of the body (e.g. heart failure, emphysema, pulmonary fibrosis, etc.), and what are the imposed elements that could be reversible (e.g. pleural effusion, bronchospasm, pulmonary edema, pneumonia, etc.). Reviewing the patient's history plays an incredibly important role in completing that information (e.g. echocardiogram, PFT, oxygen dependence, medication list, etc.).

ADVANCE: It seems as though this sort of rehabilitation for cardiopulmonary compromise is another instance of interdisciplinary healthcare professionals working side-by-side. Can you speak to the importance of respiratory therapists, physical therapists, exercise science professionals (and any other physiology professionals I'm leaving out) in helping patients with cardiopulmonary compromise achieve ideal outcomes?
Bencheqroun: While each health professional has spent years specializing and perfecting their craft within their specialty, in order to achieve optimal recovery from cardiopulmonary compromise, it stands to reason that there should be a cooperation and communication between the different disciplines participating in rehabilitating patient's body to health. A physical therapist cannot walk with the patient without a respiratory therapist assisting with the oxygen supplementation, and nebulized medications. Similarly, a respiratory therapist cannot assess the proper patients' needs for oxygen or inhaled medications without the challenge of physical exertion imposed by the physical therapist. Both professionals above cannot function independently of the nurse who would deliver the medications to optimize the cardiac function including blood pressure, fluid status and potential infection that could be compromising the patient's health. Moreover, a nutrition specialist participates in assessing the patient's caloric needs for muscle contribution to their rehabilitation, and how to meet them within the constraints of the patient's inability to eat and swallow. A speech and swallow therapist complements the team by making recommendations about swallowing techniques, aspiration precautions, and texture of nutrition. A pharmacist is necessary on the team to evaluate the interaction of a variety of medications that could be treating one aspect of the patient's health, and may have side effects on another. Different physicians are necessary to orchestrate the overall care, within the context of variety of comorbidities. One should not forget the role of the spiritual counselor in keeping the patients motivated within their own spiritual values in reaching their optimal health goal. A social worker may assist in bringing together the family support to reach that goal, and the discharge planner contributes greatly in crafting a future plan once the patient leaves the medical institution to the home setting, in order to continue on the path of recovery. The interdisciplinary team is incredibly important for the optimal goal of restoring the patient to health from their cardiopulmonary compromise.

SEE ALSO: COPD Patients After Discharge

Patients with cardiopulmonary compromise should consider yoga as a part of their rehab.ADVANCE: Does the duration of treatment and rehab vary with each patient? And how frequently are they reassessed? Which markers are you looking for in order to deem a patient successfully and sufficiently rehabbed and back to health?
Bencheqroun: Much like any other aspects of our life, our recovery is individualized. Some of us heal quickly. Some need more time. As such, the duration of treatment varies per patient. The patient needs to be reassessed twice a week or at least once a week to determine if their progress meets the expectations. One looks at a variety of components: vital signs are important. Heart rate during exertion is disproportionately high initially as the patient is deconditioned. As the days go by, we observe more regularization and tolerance of the cardiac response to exercise. Oxygen levels are also important. In addition, the patient's perception of dyspnea is essential to evaluate. Subjective feeling of improvement is motivating and also may provide early insight that may not manifest in vital signs until a day or two later. Labs at least once a week would ensure the blood components are continuing on the right path, whether it is WBC count or inflammatory markers, or electrolytes necessary for the function of cells in the body. The distance to walk before dyspnea or exertion is to be noted and hopefully increase with every day.

ADVANCE: In your experience, what percentage of patients with this condition struggle with it ongoing for an indefinite period of time? And do patients with this compromise who go through rehabilitation require it again at some point down the road?
Bencheqroun: There are no studies that have determined the percentage of patients that struggle with cardiopulmonary compromise indefinitely, simply because it is a term that encompasses a variety of diagnoses, each with its own set of statistics and recommendations of rehabilitation. But roughly, one considers that about 15-30% of patients would be oscillating in their recovery. They represent the bulk of patients that are readmitted to the hospital shortly after discharge. In that case, a re-evaluation of their rehabilitation plan is conducted, and perhaps the goals would be less ambitious. Further workup may reveals unknown causes such as an ongoing autoimmune disease, a cancer diagnosis, a recurrent aspiration or a severe infection such as C Difficile colitis. They may have experienced a silent myocardial infarction or a venous thromboembolic event. This highlights again that each rehabilitation plan is not only unique to the individual, but within the individual's health plan, it may be unique to that point in time in which it is devised, and should be revised frequently depending on patient's progress. In rehab. it's crucial to be aware of limitations and take the process step-by-step.

ADVANCE: Are there any recommendations you would make to physicians and respiratory therapists treating patients with cardiopulmonary compromise? Perhaps lessons you've learned from past patients with this condition that you've treated?
Bencheqroun: I cannot emphasize enough the power of communication between the team members, and respect for each one's role as delineated above. Any member of the team that is marginalized either by the team, or by themselves thinking they are not contributing as the other, puts the patient's goal of recovery at risk of not being achieved in a timely manner.

Tamer Abouras is on staff at ADVANCE. Contact: tabouras@advanceweb.com.

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