Discussion Board Forum 2 Case Study MEDICAL HISTORY: DM is a 69-year-old white male who complains of shortness of breath on exertion and occasionally...

Discussion Board Forum 2 Case Study

MEDICAL HISTORY:

Mr. DM is a 69-year-old white male who complains of shortness of breath on exertion and occasionally at rest. The patient does not report any symptoms suggestive of myocardial ischemia. Additional findings from the medical history include treatment for hypertension and prostate cancer diagnosed within the past 5 yr. The patient quit smoking cigarettes approximately 3 yr ago and reports a 102 pack-year smoking history (average of two packs per day for 51 yr). The patient was admitted to a local hospital for an exacerbation of respiratory symptoms approximately 4 mo before enrolling in the exercise program.

The remainder of the medical history is unremarkable. The patient did not use supplemental oxygen at the time of entrance into the exercise program; oxygen saturation at rest by pulse oximetry is 95%. The patient's score on the dyspnea subscale of the Chronic Respiratory Disease Questionnaire, a measure of health-related quality of life, is 5 (on a 1-7 scale), corresponding to "some shortness of breath" during performance of activities of daily living. The patient also reports a sedentary lifestyle, rarely walking outside the home, and not participating in any sport or recreational activities.

Mr. DM reported the following scores for performance of selected activities of daily living and their relation to shortness of air: grooming (2.4), shopping (2.7), driving (1.0), light housework (3.1), and walking (2.8). The scale parameters are as follows:

1 = able to perform without shortness of air

2 = able to perform with slight to moderate shortness of air

3 = able to perform with severe shortness of air

4 = unable to do because of shortness of air

Results of the preexercise medical exam revealed the following:

• Height and weight of 70 in. (178 cm) and 222 lb (101 kg) (body mass index = 31.8)

• Resting heart rate of 85 and blood pressure of 144/98

• Enlarged anteroposterior chest diameter and decreased breath sounds, prolonged expiration, and wheezes

• Regular pulse with no murmurs, gallops, or bruits noted

• Normal hearing and vision, absence of edema in lower extremities, and good mobility On enrollment

into the exercise program, the patient reported the following medications:

• Atrovent inhaler, eight puffs twice a day (anticholinergic bronchodilator)

• Doxapram HCL, 50 mg three times a day (respiratory stimulant)

• Furosemide, 40 mg four times a day (diuretic)

• Hytrin, 2 mg four times a day (antihypertension drug 1-selective adrenoceptor-blocking agent)

• Prednisone, 5 mg four times a day (corticosteroid)

• Proventil, 0.5% twice a day ( b 2-adrenergic bronchodilator)

• Serevent inhaler, two puffs twice a day ( b 2-adrenergic bronchodilator)

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• Theo-Dur, 300 mg twice a day (methylxanthine derivative)

• Ventolin inhaler, two puffs twice a day (b 2-adrenergic bronchodilator) Pulmonary function testing revealed a forced vital capacity of 5.31 L (127% of predicted), an FEV 1 of 1.60 L (49% of predicted), an FEV 1 /FVC ratio of 30%, and a maximal voluntary ventilation of 77 L (60% of predicted). After administration of 200 mg of albuterol by metered dose inhaler, the FVC improved by 80 ml and the FEV 1 improved by 20 ml. Blood gas analysis was not performed.

DIAGNOSIS:

• Stage 2 (moderate) COPD with dyspnea on exertion

• Obesity

• Hypertension

• Physical deconditioning

EXERCISE TEST RESULTS:

The patient performed a graded exercise test on the treadmill with continuous 12-lead ECG monitoring and blood pressure assessments. Ratings of perceived dyspnea were assessed with the Borg scale (1 to 10); oxygen saturation was assessed by pulse oximetry; and respired gas analysis was performed with a metabolic cart. Resting data included heart rate of 88, blood pressure of 144/100, and oxygen saturation of 94%. The resting ECG was essentially normal. Mild nonspecific T-wave flattening was noted in the lateral chest leads. The patient was able to complete only the first stage of the graded exercise test using a modified Naughton protocol, walking for 2 min at 1.5 mph (2.4 kph) and 1.0% grade. Heart rate was 125 beats ・ min −1 (83% of age-predicted maximum), and blood pressure was 194/100 at maximal exercise. The patient reported a dyspnea rating of 5, corresponding to "strong shortness of breath" on the Borg scale. No ECG changes consistent with ischemia were noted, and the patient did not report

chest tightness, pain, or pressure. Rare premature ventricular contractions (PVCs) were observed during exercise. Oxygen saturation at maximal exercise decreased to 85%, and the peak oxygen consumption was 14.7 ml ・ kg −1 ・ min −1 . The test was terminated because of shortness of breath and oxygen desaturation. The patient also performed a 6 min walk for distance and a hands-over-head task for time before beginning the exercise program. The distance covered during the 6 min walking trial was 948 feet (289 m); oxygen saturation decreased to 85%, and the patient reported a shortness of breath rating on the Borg dyspnea scale of 7 (severe shortness of breath or very hard breathing). The hands-over-head task is designed to assess upper body strength and susceptibility to dyspnea when the patient uses the upper extremities. The task involves removing and replacing 10 lb (4.5 kg) weights along a row of six pegs

positioned at shoulder height. The patient completed this task in 57.4 s with a dyspnea rating of 3 (moderate shortness of breath) and an oxygen saturation of 86%. The average time for subjects in this particular rehabilitation program to complete this task is 50.3s.

EXERCISE PRESCRIPTION:

The primary consideration in prescribing exercise for this patient with COPD is his ability to maintain adequate oxygen saturation. The oxygen saturation values from the graded exercise test, the 6 min walk, and hands-overhead tasks indicate that the patient should be prescribed supplemental oxygen for use when exercising. In this case, the clinical exercise specialist can serve as patient advocate by providing the primary care physician or pulmonologist with documentation that supports the need for supplemental oxygen. During exercise, oxygen f low rate should be adjusted to maintain a minimum oxygen saturation of 90% or greater. The lack of ECG changes suggestive of myocardial ischemia during the treadmill test does not preclude the presence of coronary artery disease. Coronary artery disease is common in patients with COPD, and the diagnostic sensitivity of treadmill testing improves if the patient can attain a maximal or near-maximal level of exertion. In this case, the patient achieved a heart rate corresponding to approximately 83% of predicted. Signs and symptoms of myocardial ischemia should be carefully monitored during exercise training in this population. The exercise prescription for this patient includes the following components:

• Aerobic training through walking to improve functional capacity, perception of dyspnea, and ability to perform activities of daily living

• Upper body strength training exercises with dumbbells (biceps curl, triceps extension, shoulder flexion, shoulder abduction, and shoulder shrugs) to increase muscular strength and lean body mass

• Stretching exercises three times weekly, performed after walking to improve joint range of motion and mobility

• Frequency of three times weekly in a supervised setting to maximize training effects, minimize fatigue and risk of injury, and maximize compliance

• Intensity of aerobic training exercise at a dyspnea rating of 3 to 5 on Borg dyspnea scale and intensity of strength training at two sets of each exercise with a weight that allows 12 to 15 repetitions of the movement to maximize training effects, minimize risk of untoward cardiovascular or pulmonary events, and maximize compliance

• Duration of 30 min per session (interval training may be required, especially early in the training program) to maximize training effects, minimize fatigue and risk of injury, and maximize compliance

Question/Prompt: