Questions and Answers

Questions and Answers

Questions and Answers Dr. Petty: I would like to ask Dr. Miller to respond to the suggestion that was made, that at times one may do harm with an exer...

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Questions and Answers Dr. Petty: I would like to ask Dr. Miller to respond to the suggestion that was made, that at times one may do harm with an exercise rehabilitation program. This was a clear implication of Dr. Branscomb's remarks. Dr. Miller: It is true that harm can be done. We have learned that it is important to place realistic limitations on the activity of some patients in order to avoid the consequences of overenthusiasm in their new-found potential, in terms of physical capability. Discussions concerning the nature of their sexual activities are an absolutely essential part of the education of these patients. Some patients have not been sexually active for several years because of fear and impotence. With oxygen and the rehabilitation program, hypoxemic patients may find that the capability has returned and may be too enthusiastic. If there is any indication of coronary insufficiency or of exercise induced arrhythmia, emphasize the extreme necessity for utilizing supplemental oxygen during any form of severe stress. It does not suffice to make mere mention of this; it is essential to reassure the patient, but at the same time make it absolutely clear that without oxygen a serious added risk may be present. The patients and their families must be instructed specifically how they can utilize oxygen under all stressful circumstances, such as during bowel movements, bathing, showering, sexual intercourse as well as other forms of strenuous activity. Dr. Petty: I think in view of the hour and the size of the remaining crowd, we should call for general questions. Unidentified Questioner: We realize, all of us, that we are dealing with a progressive disease process. With this in mind, have any of the panelists or have any groups run controlled series with these series of patients that you are treating, to see if you truly have enhanced productability, enhanced and improved upon mortality and morbidity? It is just possible that patients might be improved by even less vigorous measures. We must also carefully consider the cost to the patient too. Therefore, what about controls?-Have there been enough changes and statistically significant improvements in these patients to warrant continuing such intensive programs? Dr. Petty: Dr. Branscomb, will you field that question and then I am going to ask for Dr. Kimbel also. Dr. Branscomb: Yes, I will make a couple of comments about it. Actually, the amount of time and effort required by me at the present time for

the program is not very great. I do not see these patients any longer, in fact as long, as most new patients that I work-up as consulting internist. Most of the work is being done by our technical people. The patients themselves are occupied almost all day with treatment. The second point is that the reduction in hospitalization is the only control compared to the patient's own previous year. But that is impressive, I think, and I know Tom's (Dr. Petty) data look very similar to ours on this. The reduction of hospitalization and the amount of a thousand dollars a year is impressive! I suspect that the reduction of hospitalization would also imply a reduction of morbidity of the disease. The other point I want to make is this. There were 85 patients, whom I had treated with what I called my rehabilitation program in my office before I started this program. From the 85 patients whom I followed for four months longer and on whom I had at least two months with three different studies with no change in pulmonary function, whom I then turned right around and admitted to the emphysema program in the new hospital when it opened. And in that group, the average improvement in MVV for example, was 38 percent when first seen in my office. And, at the time, I sent an inhalation therapist to the home and did all these things that we medical men or office practitioners do. They improved 38 percent initially; they improved an additional 28 percent when they got into the rehabilitation program. I think the program is worthwhile, but I would discourage anyone in the audience from feeling that you have got to have, for example, the treadmill. I could do the same things without a treadmill and even without the fancy devices for pulmonary function testing. Dr. Petty: Dr. Kimbel. Dr. Kimbel: I do not have a comparable group of control patients. Looking at the literature, however, we cannot find any difference in mortality and in progression that is measured by simple studies such as FEV 1. I think one must measure changes which occur as a result of a treatment program in two ways-the objective measurements that one can readily document, and subjective ones that are most difficult to document. We cannot take anyone of these modalities of care and relate it to a specific aspect of improvement such as longevity or decrease in rate of progression of disease. Any COPD patient who is receiving a good program of continuous medical care may be improved in some ways. We have very 285

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QUESTIONS AND ANSWERS limited means to manage patients with progressive pulmonary disease. However, most patients will do better objectively, subjectively, or both. The thing we do not know is which specific modalities will be most effective. As of now, I have no objective data which will substantiate that what we call rehabilitation, is any more helpful to the patient than good comprehensive office management from the standpoint of progression or mortality. Dr. Petty: Dr. Farrington, why do you not have any controls? Dr. Farrington: I cannot afford to have controls. The thing that goes through my mind is, yes, we are dealing in private practice with individual patients. We cannotset up a control group and treat half of them and .not treat the other half. Once you commit yourself into a program like this, you go all the way. The statistics that we do have, which I do not have with me though, are based on individual patients. One man having 27 days of hospitalization from first contact until he accepted the respiratory care program 60 days later; so, 27 days out of 60 were spent in the hospital. Since then he has spent 19 months out of the hospital. The man that we presented here is somewhat different because he did have acute respiratory complications, but that was his only hospitalization. It is our distinct feeling that it is not a simple modality that helps, it is a total approach to a patient; an approach that is tailored to the individual's needs. It is not a very scientific way of doing business, but it seems to work. Dr. Petty: I cannot help but comment that each of the forms of therapy that Dr. Miller described alone has been the subject of some critical analysis somewhere in the scientific published literature that withstood a critical editorial review. Each one of these modalities by some criteria has shown benefits that can be measured and none of these modalities of therapy has ever been shown to do any harm! Questioner: Tom, has anybody ever had a program like this and concluded that it was not doing any good? Dr. Petty: No, and I would like to ask Dr. Miller to comment upon that too. Has anyone ever abandoned a program such as we have described because of a conviction that it did not resolve some of the problems of disease? Dr. Miller: Not that I am aware of. Because of the time and effort involved I do not think most patients or doctors would pursue such therapy if they were not convinced that something was being accomplished. It has been demonstrated often in individual cases, where the patient serves as his own control, that very clearly patients are improved

with respect to morbidity, productivity and general improvement in the quality of life. The question of mortality is another issue that is far less predictable. However, this is not the major concern of most patients and indeed, is overemphasized by the antagonists to aggressive therapy. Questioner: My question concerns exercise. It seems to me that in the past ten years there has been a reversal of the approach to chronically ill patients. Now we have cardiac patients who are being exercised along with arthritis patients and pulmonary patients; and yet, when we get to the method type of exercise, one may be confused. Each one has his own individual method. I would like to ask the panel, is there any specific simple form of well-established exercise that would be more uniform and useful than the large number of exercises in various books on the subject? In addition, I would comment on whether rehabilitation really helps or not. I think that if someone gets out of the house and returns to work he is improved even if his pulmonary function remains the same. I would much rather have the person out of the house. Dr. Petty: Dr. Neff, would you comment on exercise-how elaborate need it be? and more specifics on exercise? Dr. NeD: I take the following approach to this. I think that if you are doing research one can get a treadmill, measure external work capacity, and see how this is improved, but my practical approach is based on a couple of observations that we made: 1. Exercise may be a little dangerous in a sick patient who has limited cardiac output and you try to overdo, and you may actually push him into some heart failure. I have had experiences with patients while on cardiac catheterization table with a catheter in the right ventricle while the patient is exercising and observed the development of heart failure. This may be very dangerous in the face of hypoxemia. Theoretically and idealistically, what we like to do is exercise the patient once in our laboratory at the beginning with and without oxygen, with a cardiac monitor, watching for arrhythmias and checking blood gases. This is very nice in research but the rule of thumb for my patients is that they need a systematic everyday program where they get exercise that is natural and physiologic, and I think walking is probably as simple as anything. I think a misconception that many physicians have perpetrated, that if you get short of breath-stop. I think they should walk through this until they get a bit tired, but not to the point of collapse. Each patient should push each day within reasonable limits.

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Dr. Burton ( Los Angeles) : Dr. Miller, you showed a picture of a patient working with a little breathing simulator strapped to her back. I agree with what you said, that none of these modalities has been shown to be harmful, but practicing physicians need to ask whether the work required to train all of the patients is worth the effort. As I recall, a study was done by Fred Eldridge and associates in Palo Alto, where they used a breathing simulator device. The patient listens to the recorded sounds of breathing and voluntarily follows this pattern. The results were very short lived because the patients forgot the breathing pattern shortly after the machine was discontinued. Have there been studies which show that people do retain this breathing instruction? Dr. Miller: This is a useful maneuver only if the patient learns to use it and is motivated sufficiently to keep using it. There is clearly no value if he does not continue to use it. The patients learn to use these techniques by continued training and practice, not only at rest but especially during stress where dyspnea and disordered breathing are likely to be a major problem. Over many years of experience, patients have repeatedly reported to me that learning to breathe properly was one of the most important benefits they have received from our program. I would like to make an additional comment about the specific indications for exercise rehabilitation. Exercise is for the individual who has been demonstrated by physiologic testing to need physical reconditioning and for whom it has been demonstrated to be physiologically safe. Moreover, the exercise program should be regulated to the patient's ability, yet sufficient to produce a training effect. There is no question that patients in a state of poor physiologic condition are relatively incompetent from the standpoint of work performance, When their state of physical condition is improved by whatever method of exercise, the patients perform better, not only by demonstrable increase in work capacity but also with lower heart rates, lower oxygen consumption and lessened oxygen debt for any given work load. There is nothing mysterious about this. It is a simple observed fact both for . patients with chronic heart or lung disease as well as normal subjects. Dr. Branscomb: Yes. That is right. It sometimes amazes me, Bill, that people do not know that. It is just not a debatable question. One time Giles Filley, when he was still at Saranac Lake, was using breathing retraining and sent out a questionnaire to all the people he treated a year earlier. The patients themselves replied saying that the thing they

thought that was best, was the breathing retraining. Now we find that if we sneak up behind our patients it is true that they are not breathing in a slow proper and low energy pattern as Reuben Cherniack demonstrated. They are not doing that when they are sitting around. When they exercise they become out of breath and it usually reminds them to do it. Now they resume the correct pattern of breathing, often with great relief. This is why I showed the slide of the young lady with the man on the stairs. What she is doing, is taking a patient who has been in our program two weeks, putting him on a stairway, and deliberately running him to the point where he is nearly out of breath, far beyond the desirable exercise level and then says, O.K., now get well. And you know, she is right, he will do this and discover by gosh he can! And this is one of the most liberating things they can learn. Dr. Kimbel: Our patients showed increased exercise tolerance in that they could do more at whatever tests we gave them, but we did not have any evidence of conditioning, that is, the oxygen consumption did not change; pulse rates and ventilation did not change. Perhaps they reaped nonspecific benefits or a sense of well-being and thus could be more physically active. I think the important thing about breathing retraining is that it represents something the patient can do for himself. The patient has to remember to do it; that is what you have to teach him; he needs to tum it on whenever he reaches a certain level of awareness of his dyspnea. Patients certainly do not do it when they sleep and very few can remember to do it continuously; it is like trying to remember to breathe-most people just do not think about breathing. The main benefit to the patient, in my opinion, is perhaps more in tenns of his getting the feeling he can control his respiratory symptoms, rather than from a short term physiologic change. Dr. Cohen (Los Angeles): I would like to ask a question of the distinguished panel. I wanted to get the feeling from them on the subject of breathing exercises. But first I want to respond to Dr. Burton's comment about Dr. Eldridge's studies. In Dr. Eldridge's case, the patients were allowed to listen to the recorded sound of breathing in the right pattern and their blood gases got better while following this pattern. But, they said, "tum that damn thing oft." They were not trained to want to breathe that way. In our respiratory program we have at Olive View, and I am sure in all of yours, the patients are trained to want to change their breathing pattern and they develop a habit. Just like getting out of a bad habit in a golf swing, you can get out of a bad habit of breathing when you are walking or holding

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your breath or breathing while tying your shoe, etc. My question is, most of the literature in doctors' offices on the subject of breathing retraining is actually on "breathing exercises" consisting of blow bottles, candles, tying towels around your chest and squeezing etc. Are there any comments on those modalities which most doctors think of when we talk about breathing exercises? Dr. Petty: Bill's just dying to talk about breathing exercises. Dr. Miller: As I have said many times before, I dislike the use of the word "exercise" because it implies the very things Dr. Cohen mentioned. I do not think there has ever been any evidence to indicate that such exertional or forced maneuvers accomplish anything except to attract the patient's attention. In the final analysis, all the maneuver does is force the patient to adopt a pattern of slow breathing, but if that point is not made, nothing of lasting benefit is accomplished. I want to add that there is a considerable amount of literature that documents the importance of slow, controlled breathing for patients with airway obstruction. Studies have been done by some of the most eminent physiologists in this country that demonstrate the physiologic benefit of controlled, slow breathing in these patients. There is no question about it! By any measure of distribution of ventilation or gas exchange you may choose, in patients with airway obstruction, a slow pattern of breathing improves functions. With that kind of evidence, I do not see why there should be any question about whether it offers something to a patient, or is a worthwhile procedure. On the other hand, nothing will be gained if the patient does not learn a relaxed, slow controlled breathing pattern. Dr. Petty: I have a question for Dr. Farrington. John, if you had it to do all over again, if you were setting up in private practice, how would you structure your team? The hidden part of the question is, who do you regard as the most important aid you have to your own professional efforts? Dr. Farrington: Well, the gray haired little lady you saw on the slide: She is a very good nurse who knew nothing about respiratory care when we started our program. We sent her to Dr. Petty's course in Denver. We have sent her to inservice training programs for nurses in the hospital. This woman has a delightful way with patients. She can sit down with them and chat with them and explain

things; when you are doing pulmonary function she can raise her voice louder than anyone I have ever heard! This is the one person I need. Dr. Petty: Do any of the panelists have any twosentence parting thoughts they'd like to put forward? Dr. Branscomb: Yes. I would say with all of our misservice to the team approach and multidisciplinary old words, the thing that is really important is having one person, like your gray-haired lady, who can do about 80 percent of all this allied health work. And I think we should all put the heat on the people who train the medical assistants and help train respiratory specialists to assist us. Dr. Farrington: This should be a person who is a good nurse and also a social worker who helps the visiting nurse and participates in everything else that comes down the pike. Dr. Neff: I will put a plug in for prophylaxis in this illness. I think that with focus today on a new stage disease that has gone on for 30 years, and I am not sure in my own mind over the last few years, that we have too many new ideas in this field. I think we are doing a good job, but we are not, you know, progressing; and I think we have to put our efforts and thoughts in a new direction towards the basic problem. I am not an evangelist and I do not think it is immoral to smoke, but I think we should best put some dollars into an antismoking program. Dr. Kimbel: I think one of the major needs for a rehabilitation program is enthusiasm; and getting the patient into a care program where he can receive the best we have available is important also. The problem is that we too often see patients who are near the end stage. We are doing something which makes many patients feel better, in my opinion. We have yet to document the value of many of the specific modalities that we use in a purely scientific fashion, in terms of their prolonged or continuous effect on the disease process which we are treating. Dr. Petty: I think a central theme has emerged from today's panel, which in spite of the need for realistic goals in therapy, that the development of a systematic, physiologically oriented care approach does great good! The amount of good that is done varies and is finally judged in the mind of the patient who is benefited. I would like to thank the panelists and the audience; we are adjourned.

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