Assessment and Treatment Approaches for the Patient With COPD As more adults reach their later years, chronic obstructive pulmonary disorder (COPD) becomes a highly complicating factor with regards to overall health. For the purpose of this article, “COPD” is used as an umbrella term that includes emphysema, bronchitis, and, at times, asthma. It is progressive in nature. The main ... Article
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Article  |   December 2009
Assessment and Treatment Approaches for the Patient With COPD
Author Affiliations & Notes
  • Jocelyn E. Alexander
    Therapy Partners of Ohio, Middleburg Heights, OH
  • © 2009 American Speech-Language-Hearing Association
Article Information
Speech, Voice & Prosodic Disorders / Voice Disorders / Swallowing, Dysphagia & Feeding Disorders / Older Adults & Aging / Speech, Voice & Prosody
Article   |   December 2009
Assessment and Treatment Approaches for the Patient With COPD
SIG 15 Perspectives on Gerontology, December 2009, Vol. 14, 33-36. doi:10.1044/gero14.2.33
SIG 15 Perspectives on Gerontology, December 2009, Vol. 14, 33-36. doi:10.1044/gero14.2.33

As more adults reach their later years, chronic obstructive pulmonary disorder (COPD) becomes a highly complicating factor with regards to overall health. For the purpose of this article, “COPD” is used as an umbrella term that includes emphysema, bronchitis, and, at times, asthma. It is progressive in nature. The main symptoms of COPD are usually readily apparent to the skilled observer: shortness of breath, decreased capacity for physical activity, presence of a chronic obstructive cough, loss of appetite with possible weight loss, and increased fatigue (Connell & Richman, 2009). Not surprisingly, this short list of symptoms alone can create havoc for the speech-language pathologist, because COPD can cause a multitude of problems, including voice, communication, and swallowing disorders.

As more adults reach their later years, chronic obstructive pulmonary disorder (COPD) becomes a highly complicating factor with regards to overall health. For the purpose of this article, “COPD” is used as an umbrella term that includes emphysema, bronchitis, and, at times, asthma. It is progressive in nature. The main symptoms of COPD are usually readily apparent to the skilled observer: shortness of breath, decreased capacity for physical activity, presence of a chronic obstructive cough, loss of appetite with possible weight loss, and increased fatigue (Connell & Richman, 2009). Not surprisingly, this short list of symptoms alone can create havoc for the speech-language pathologist, because COPD can cause a multitude of problems, including voice, communication, and swallowing disorders. The pervasive nature of this condition affects so many parts of the speech-language pathologist’s scope of practice, even so far as to say that “the presence of COPD was shown to be the most significant risk factor for aspiration pneumonia in nursing home patients” (Gross, Atwood, Ross, Olszewski, & Eichorn, 2009, p. 559). Studies have shown that pulmonary rehabilitation programs are effective in the management of COPD symptoms and also increase the quality of life for patients (Norweg, Whiteson, Malgady, Mola, & Rey, 2005; Stallard, 2007). Thus, it is imperative for speech-language pathologists to learn more about effective and measurable methods of evaluation and treatment for the patient with respiratory compromise. The purpose of this article is to provide the medical speech-language pathologist with a basic foundation in order to serve this growing population.
First, there are some basic techniques with which clinicians should be familiar. The speech-language pathologist should be proficient with taking vital signs (heart rate, blood pressure, respiratory rate) and should know adult baselines, because these can be important in documenting the patient’s baseline and response to treatment. For example, it could be helpful to include vital information such as blood pressure readings before, during, and after a treatment that includes breathing exercises. For instance, lowered blood pressure during and after the treatment could show decreased anxiety (which is a complicating factor when combating dyspnea). In addition, the clinician should be practiced in thoracic auscultation, because this can be a vital part of both assessing and treating the patient with COPD. There is an abundance of information available regarding specific technique; however, Kisner and Colby (2007) suggest that documentation should include breath sounds with the appropriate lobe. Possible breath sound descriptions include normal; decreased; absent, rales (fine, medium, or coarse); and rhonchi or wheeze. For example, “wheezing, left upper lobe” might be documented. For those speech-language pathologists who need more experience in determining the differences between lung sounds, a helpful auscultation assistant guide can be found at www.med.ucla.edu/wilkes/index.htm.
Due to the wide-ranging effect of COPD on a variety of other co-morbidities, several clinical considerations should be taken prior to completing an assessment or developing a plan of care. Connell and Richman (2009) offer the following as helpful tips. First, ensure proper positioning of the patient, because individuals with COPD often cannot lie flat without dyspneic symptoms. This is widely assumed to be due to increased pressure on the diaphragm from the abdomen and organs, as well as the possibility of increased pulmonary edema and decreased cardiac output. Avoidance of Valsalva-type maneuvers is also recommended due to possible strain and cardiac implications. A speech-language pathologist should learn the typical signs of respiratory muscle fatigue, which include rapid and shallow respirations, uncoordinated chest wall movement, increased accessory muscle movement, and dyspnea. Dyspneic patients often will brace themselves with their arms in order to free the accessory muscles (normally used for trunk stabilization and upright sitting) for the task of breathing. Last, the clinician should recognize the psychological implications of the presence of COPD. Often, the individual’s inability to breathe effectively will “trump” any other concern and, many times, increase the likelihood of therapy refusal.
In completing an effective assessment, the clinician should first review the etiology of the illness, including the length or duration of the symptoms, the past medical history, and any possible co-morbid diagnoses. Connell and Richman (2009) also suggest a review of both past and current courses of treatment, including medical management of COPD. This may provide the clinician with information regarding use of supplemental oxygen, inhalers or nebulizers, and current medications. They also suggest a review of previous therapies and their results. In addition, the DynaMed Editorial Team (2009) suggests a review of diagnostic tests, such as arterial blood gas (ABG), complete blood count (CBC), chest x-ray, ventilation perfusion scan, EKG, and pulmonary function tests (PFT). Noting supplemental oxygen usage is particularly important during the assessment, because during the course of therapy it may be possible for the patient to wean to a lower rate of oxygen, which can be used as measurable documentation. Cigna (2005) states that pulse oximetry is an effective tool to measure oxygen levels in the blood. Care should be taken that levels do not drop below 90-93%.
Once the review of the above is completed, the speech-language pathologist may generally proceed with standard evaluation procedures, taking into special account maximum phonation time, phrase length during connected speech or conversation, vocal quality, coordination of respiration and swallowing, and meal endurance. In addition, it is prudent to thoroughly assess cognitive status, because this can be a limiting factor for learning new strategies and techniques. Observation of physical appearance also can give the clinician clues, including cyanosis, chest shape and size, hypertrophy and overuse of accessory muscles, clubbing of fingers, edema of lower extremities, and abnormal posture such as kyphosis (Connell & Richman, 2009). It also can be helpful to consult with an occupational therapist to discuss whether there are any functional limitations with activities of daily living (ADLs) and current use of adaptive equipment.
Now that the assessment has been completed, the clinician will need to develop a concise and measurable plan of care. Therefore, it is necessary to determine the target outcome measures. Examples of outcomes may include improvement of breathing function; improvement of cough strength to clear airways independently (Connell & Richman, 2009); restoration of adequate vocal quality, maximum phonation time, and phrase length for communication; and improvement of vocal hygiene. In addition, it is possible to increase endurance levels by increasing the amount of oxygen being respired (inhaled and exhaled) and infused into the bloodstream (Cigna, 2005).
Once the speech-language pathologist has developed a plan of action, treatment methods become the focus. Some of the most widely used—and most effective—strategies are breathing exercises, including pursed lip breathing, diaphragmatic breathing, and assisted cough (Spahije, de Marche, & Grassino, 2005).
Pursed lip breathing can help the patient control his or her breathing rate as well as hold the airways open during exhalation. This can help reduce carbon dioxide retention, a common problem in patients with COPD. Direct the patient to inhale through the nose for a count of two, then exhale gently through pursed lips for a count of 3 to 4—preferably without using the abdominal muscles. More active forms of this exercise may include activities such as blowing bubbles (ideal for the visual learner) or blowing cotton balls from the palm of one’s hand into a basket. A common verbal cue to give the patient is “Smell the roses, blow out the candle.”
Diaphragmatic breathing is most easily taught by initially placing the patient in a reclined (semi-Fowler’s) position, due to the patient’s frequent inability to lie flat. In the early stages, clinician-facilitated diaphragmatic breathing is recommended. This consists of placing one hand over the patient’s stomach while instructing the patient to breathe in through the nose into the clinician’s hand. This technique gives verbal, visual (watching the stomach expand out), and tactile cueing for multimodal learning. The patient should then be instructed to exhale normally. When the patient is able to complete facilitated exercises, more challenging, independent diaphragmatic breathing exercises can be more initiated. In this technique, it has been found to be effective to have the patient place one hand on the chest and the other on the stomach. The goal is for the patient to focus on movement of the diaphragm (lower hand) and to ensure there is very little movement in the accessory muscles (upper hand). Once a patient is able to effectively perform diaphragmatic breathing, introducing strengthening activities so as to challenge the inspiratory muscles can be instrumental in improving overall respiratory efficiency (Sykes & Hang, 2005). This can be done via use of an incentive spirometer (found in various medical supply catalogs) as well as other breathing devices available on the market. Incentive spirometers are particularly popular because of their lower per-unit cost. Other available devices include The Breather (AliMed) and The PowerLung Breather (Sammons Preston). Another simple option is to use ankle weights, because they are readily available in nearly all rehabilitation departments. A light weight (4 pounds or less) may be placed over the epigastric region during diaphragmatic breathing in order to make the exercises progressively resistive.
Assisted cough techniques, which can also be referred to as lung clearance techniques, are useful for both the patient with dysphagia and voice deficits. The clinician may opt for either controlled coughing or a manual cough assist. These techniques are very effective for those patients who have difficulty in adequately protecting the airway during swallowing and also can be used for patients who have a greater amount of secretions that affect voicing and, ultimately, communication. For the controlled cough, the speech-language pathologist cues the patient to take a deep breath through the nose, then cough twice on the same breath. The force of the first cough should loosen any sputum trapped in the airway, while the second, more forceful, cough should mobilize secretions up towards the throat and mouth. Use of the manual cough assist is for patients who have a weaker cough than those who could perform the controlled cough. To perform a manual cough assist, the clinician positions his or her hands on the patient’s abdominals, just under the ribcage. The patient is then cued to take a breath and cough while the clinician provides physical assistance (moving up and in with the hands) to help stimulate muscle contraction for the cough. Both of the above exercises can be completed in a reclined or sitting position.
It should be noted that rehabilitating the patient with COPD can be an excellent opportunity for interdisciplinary consultation and cooperation. By working closely with physical and occupational therapies, the speech-language pathologist can assist by improving carryover and generalization of strategies, such as pacing, energy conservation, and relaxation techniques (which rely on diaphragmatic/deep breathing) and coordinating phases of respiration with specific exercises (referred to in many physical therapy manuals as exhalation-exertion). In addition, there are many techniques in which physical and occupational therapists receive training that would be beneficial for the speech-language pathologist to learn when appropriate (such as postural drainage), and according to state practice acts and best practice patterns. When a team works well and efficiently together, it not only boosts the patient’s performance and progress, but also promotes a feeling of camaraderie and mutual respect.
The above list of interventions and exercises is not exhaustive, but is meant to stimulate interest in this growing patient population. New research is being completed at an astounding rate. More and more patients are in need of services due to this condition; hence, effective assessment and treatment of COPD has become imperative in a speech-language pathologist’s repertoire.
References
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