A detailed medical history is required to determine whether the patient should participate in the exercise sessions of a pulmonary rehabilitation program. Co-morbidities that may affect the patient’s ability to undertake exercise include cardiac, musculoskeletal and neurological conditions. A general medical assessment form is available to help assess patients referred for pulmonary rehabilitation.
As a result of the general medical assessment, some of the following information may require further follow-up:
- Nutritional status.
- Smoking history.
- Spirometry test results.
Body Mass Index (BMI) can provide valuable information regarding the patient’s nutritional status. Normal BMI values range from 20 to 25.
BMI = weight (kg) ÷ height2 (m)
Referral to a dietician may be required if:
- BMI < 20 = underweight.
Note: Poor nutritional status is implicated in higher mortality for patients with chronic obstructive pulmonary disease.
- BMI > 30 = obese.
- There is a recent history of weight loss of more than 10% in the last 6 months or 5% in the past month.
Assessing Mental Health
The high prevalence and negative impact of anxiety and depression amongst COPD patients are well-known.
Pulmonary rehabilitation provides a direct opportunity to address these problems.
Prior to pulmonary rehabilitation, it is recommended that patients are screened for the existence of clinically significant symptoms of anxiety and depression. Depending on local resources, this may be achieved in a number of ways.
Generic (e.g. SF36) and disease specific questionnaires (e.g. CRDQ, SGRQ) may capture some mental health symptoms but the results may not delineate the psychological components of common respiratory symptoms such as dyspnoea and fatigue. Consequently, specific mental health assessment is preferred.
Some programs will have access to the services of a mental health professional that may be available to assess the psychological status (including diagnosis) of prospective program participants via a structured or semi-structured interview.
Another means of screening for anxiety and depression problems involves case-finding via the use of mental health instruments (e.g. The Hospital and Anxiety Depression Scale and Depression, Anxiety and Stress Scale 21). These generic psychiatric screening tools typically assess symptom severity rather than providing definitive diagnoses. They are easy and quick to score and clear guidelines exist regarding the clinical significance of the results. Some screening tools such as The Hospital and Anxiety Depression Scale require a license for use. Therefore if a program decides to implement a licensed generic psychiatric screening tool, permissions will need to be arranged directly with the licensor on an individual basis. The DASS 21 screening tool is a publicly available, no-cost, self-administered tool with 21 questions and it has been normalised for Australian Populations. (http://www2.psy.unsw.edu.au/dass/)
Prospective program participants who meet the clinical criteria for significant scores (as defined by the screening tool) should be considered for further investigation and treatment of their mental health problems from a mental health clinician. Clinical pathways should be established between the PR program and mental health clinicians. A collaborative approach between local (internal or external to the program) mental health professionals and the pulmonary rehabilitation team is preferred.
If the patient is still smoking, refer the patient to a smoking cessation clinic or equivalent.
Spirometry testing is important to ascertain the degree of airflow limitation. Spirometry results are essential for diagnosing and describing the severity of chronic obstructive pulmonary disease (COPD). The stages of disease severity for patients with COPD are outlined in the table below [For further details, see: McKenzie, 2003].
|I – Mild COPD||FEV1 / FVC < 0.7 and FEV1 60% to 80% predicted|
|II – Moderate COPD||FEV1 / FVC < 0.7 and FEV1 40% to 59% predicted|
|III – Severe COPD||FEV1 / FVC < 0.7 and FEV1 below 40% predicted|
The BODE Index is a simple multi-dimensional grading system which scores the systemic components of COPD (Celli et al 2004). The BODE Index’s components are body mass index, respiratory function, dyspnoea, and exercise tolerance (for scoring details see Resources section). These components are graded into a simple 10 point scale, with the more severe the symptoms the higher the score. The BODE Index has been shown to be a better predictor of mortality than FEV1 alone (Celli et al 2004) and can be useful in predicting readmission to hospital (Ong et al 2005). The BODE index is sensitive to change following pulmonary rehabilitation, with a reduction of 1 point (or more) in the score indicating a ‘responder’ to the program (Cote et al 2005).