COPD Intervention. Components:

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1 COPD Intervention 1. Primary disease education Member will have an increased understanding of chronic obstructive pulmonary disease, the causes, risks and complications. Explain COPD Explain how COPD is diagnosed Explain impact on individual, stages of COPD, and spirometric classification of severity Describe difference between asthma and COPD Provide risk factors of COPD (i.e., cigarette smoking, genes) 2. Signs and symptoms /seeking medical attention Member will have increased understanding of warning signs/ symptoms of COPD, when to contact their health care provider, and/or when to seek emergency treatment. Provide education about signs and symptoms of COPD: o Persistent, frequent cough o Sputum production o Dyspnea on exertion o Wheezing o Fatigue o Lung infections, such as bronchitis more than once a year o Weight loss and anorexia in late stages Provide education about when to seek medical assistance: o Change in baseline dyspnea, cough and/or sputum beyond normal day to day variations Recommend member to talk with their doctor about when to call/seek treatment 3. Role of medications Member will have increased understanding of role medications play in the treatment of COPD. Review medications used to prevent and control symptoms, reduce the frequency and severity of exacerbations, improve health status and improve exercise tolerance Teach importance of taking maintenance medicines every day to help control symptoms Teach how to recognize worsening symptoms and when to take their rescue medications Teach if using rescue medicines everyday, they need to see their HCP Review potential side effects from their meds and what symptoms they need to report to their doctor Assess and teach proper use of and care of MDIs, DPIs, and nebulizers Teach to keep a written list of their medicines and take to each doctor's appointment

2 Teach to mark their calendar to note when medications will need to be reordered Teach antibiotics may be needed for a respiratory infection Review oxygen administration and safety as indicated The classes of medications commonly used in treating COPD are listed below. The choice within each class depends on the availability of medication and the patient's response. Beta 2-agonist Short-acting bronchodilator Beta 2-agonist Long-acting bronchodilator o Resting tachycardia o Exaggerated somatic tremor Anticholinergics Short-acting muscle relaxant Anticholinergics Long-acting muscle relaxant o Dryness of mouth o Bitter, metallic taste with Atrovent Combination short-acting B2-agonists plus anticholinergic in one inhaler Methylxanthines bronchodilator and stimulates diaphragm and breathing o Headache o Insomnia o Nausea and heartburn o Atrial and ventricular arrhythmias o Grand mal convulsions o Significant interactions with commonly used medications ie. Digitalis and Coumadin Inhaled corticosteroids anti-inflammatory o May increase incidence of bruising o Side effects are dependent on dose and type of corticosteroid o Thrush o Hoarse voice Combination long-acting B2-agonists plus corticosteroids in one inhaler Systemic corticosteroids anti-inflammatory o Long-term treatment can lead to steroid myopathy o Muscle weakness o Decreased functionality o Respiratory failure in advanced COPD o Osteoporosis

3 Pharmacologic Therapy by Disease Severity Mild: Short acting bronchodilator as needed Moderate: Short acting bronchodilator prn + one or more long-acting bronchodilators (when needed) Severe: Short acting bronchodilator prn + one or more long-acting bronchodilators. Add inhaled glucocorticosteroids if repeated exacerbations Very severe: Short acting bronchodilator as needed, one or more long-acting bronchodilators, inhaled glucocorticosteroids, oral prednisone and long-term oxygen if chronic respiratory failure 4. Physical activity Member will gain knowledge of the benefits of the principal goals of pulmonary rehabilitation. Reduce symptoms Improve quality of life Increase physical and emotional participation in everyday activities Check with physician before beginning any exercise program, especially if not currently active Carry appropriate ID at all times Walk 20 minutes per day if a formal respiratory rehab program is not available Use resistance training (weights) for upper limb exercises Participate in physical or occupational therapy if formal program not available 5. Healthy nutrition To increase member knowledge of healthy eating and assist them in adopting strategies to meet the increased energy needs. (People with COPD use up to 10 times more energy to breathe than persons without it.) Assess any recent dietician education and/or recommended diet Eat a healthy diet; it could help by: o Providing energy to be more active o Improving the way the lungs work o Helping fight infections o Improving overall feeling of wellness Promote limitation of salt/sodium and caffeine Promote the avoidance of overeating and gas-producing foods such as: carbonated drinks, fried or spicy food, beans/legumes, cabbage Promote fluid intake to help thin secretions/mucus and keep airways open. Should check with health care provider re: amount of fluid they should drink

4 6. Self-care Member will increase understanding importance of monitoring symptoms and how to manage exacerbations to maintain optimal breathing. Follow COPD action plan Keep a symptoms journal to review with your doctor at each visit Teach purse lip breathing when dyspnea worsens Teach cough techniques to help keep airway clear Avoid irritants and allergens Call your doctor immediately or go to nearest ED if you have any of the following: o Shortness of breath that is not relieved by controlled breathing exercises or by your fast acting medication o Increase mucous, yellow, green, bloody, or smelly mucous o Fever or chills o Tightness in your chest that does not go away with normal medications o Irregular heartbeat o Swollen ankles o Trouble doing your usual activities Keep the air in home clean and stay indoors when air pollution indexes are high Do things slowly, while sitting down if possible Put items you use frequently in easy-to-reach places, so that you don't have to bend or reach overhead very often Find simple ways to cook, clean, and do other chores Wear lose clothing that is easy to put on and take off Exercise on most days of the week to build stamina See your doctor at least twice a year 7. Preventive care and maintenance Member will have increased understanding of the benefits of preventive care and regular maintenance of all body systems. Offer smoking cessation options and help member select best option to help them stop smoking Reinforce smoking cessation is a must to help their COPD from progressing Carry quick relief inhaler at all times Wash hands often and use hand sanitizers while away from home Avoid spending time around people with respiratory infections. Talk to HCP about influenza and pneumococcal vaccines Get annual mammogram. The American Cancer Society recommends an annual mammogram for women age 40 and older. Get an annual PSA test. The American Cancer Society recommends an annual PSA test for men age 50 and older.

5 8. Weight management To increase understanding of the impact of weight on COPD and appropriate weight reduction (or weight gain) methods and learn importance of achieving/maintaining recommended BMI. Explain how excess weight makes heart and lungs work harder Encourage member to ask health care provider and/or dietician what appropriate weight for them is Explain how being underweight can cause decrease in energy, fatigue and increase likelihood of infections Educate member on tips for healthy eating o Eat frequent, small meals instead of 3 big meals o Eat while sitting up o Eat slowly and chew foods well o Use pursed-lip breathing while eating o Drink liquids at end of meal o Control salt/sodium intake o Use liquid supplements if needed o Consider increasing foods with Omega-3 oils o Calcium and Vitamin D supplements if osteopenia or osteoporosis is a concern Promote ways to improve appetite: o Avoid non-nutritious drinks-black coffee, tea, soda o Increase intake of protein such as chicken and fish o Eat fewer simple sugars o Eat small meals and consume healthy snacks often o Walk or do light physical activity prior to meals o Keep food within easy reach 9. Safety Member will increase knowledge of safety precautions of COPD with the use of oxygen therapy. Proper care, use of equipment, and transportation of oxygen per DME provider Medication guidelines and precautions Medical alert/medication list Importance of a support person knowing what to do in an emergency 10. Long-term lifestyle modifications Members will be encouraged to continue with lifestyle modifications.

6 Identify barriers that challenge required behavior changes Develop strategies to respond to these barriers Avoid situations that make it hard to change Encourage and support (small steps) 11. Psychosocial Member will increase understanding/recognition of signs and symptoms of depression that may be associated with COPD and learn strategies to deal with depression and treatment options. Discuss normal feelings of denial, anger, and sadness associated with COPD Assess for symptoms of depression and encourage talking to their doctor Assess for gross noncompliance with medical treatment plan or depression with possibility of self-harm Assist member to identify support persons as resource and emergency back up Explore treatment options including pulmonary rehab program that can focus on ways to decrease social isolation and improve altered mood states Offer resources available for long-term psychosocial support such as support groups and counseling FEP members may call or visit to inquire about mental health benefits and treatment options 11. Working with healthcare team Member will understand the importance of setting goals and interacting effectively with their healthcare providers to achieve/maintain compliance with their treatment plan. Assist member to list and identify the roles within their health care team Reinforce member's position as the most important person on their health care team Discuss ways to achieve the most from health care visits by taking the daily COPD log and writing down questions prior to visit Encourage member to ask questions and participate in the development of their treatment plan Explain the importance of ongoing discussions with health care provider concerning medications, activity, nutrition, prevention and symptoms to report 12. Travel Member will learn importance of careful travel planning to ensure effective management of COPD when traveling.

7 Discuss travel plans with your doctor o Ask about if you may need different medicines for your trip o Ask for help arranging for oxygen while traveling Bring a health history from your doctor that includes: o List of your medicines o List of allergies o Travel or activity limitations Make sure you have plenty of your inhalers and medicines Ask for non-smoking rooms in hotels and rental cars Resources: See list on resources page. February 2009 Revised: April 2011 Revised March 2012 Dr. Myron Leinwetter, MD April 30, 2012 Date

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