With the increasing complexity of the delivery of medical care, there are many opportunities for respiratory therapists to be involved in the delivery of care for outpatients with chronic lung and sleep disorders. Opportunities for RTs in the office setting include early detection, testing, treatment, and overall disease management. Such opportunities abound within the primary care and specialty office practices.
Uncovering an underlying lung or sleep disorder is of upmost importance in the care management of every patient. For patients who are current or former smokers; are older than 35 years of age; and have symptoms of cough, shortness of breath, or sputum production (based on the NLHEP recommendations), performance of simple spirometry should be the first step.1 In addition, the use of various types of questionnaires can help determine which patients might be at risk for obstructive lung disease.2,3
A similar strategy for determining patients who might be at risk for obstructive sleep apnea also can be implemented. A patient who has daytime sleepiness or fatigue, snores, is overweight, or has a large neck collar size should be considered as potentially having sleep-disordered breathing. There are various types of questionnaires (eg, the STOP-BANG questionnaire) that can be helpful in this early detection process.4 Respiratory therapists can assist in developing early detection programs, not only in specialty office settings but, more important, in primary care office settings. Working with members of those offices to develop such programs will help to uncover patients who have either of these illnesses.
Confirming a diagnosis is also important. In the case of COPD, this can be performed easily in the office setting by using spirometry. The respiratory therapist can play a key role in spirometry testing. If RTs are not working directly in the primary care office setting, they can help to train members of such offices’ staff to perform spirometry correctly. In some areas, an RT comes to a primary care office setting once or twice monthly to perform spirometry on those patients who the primary care clinicians believe have underlying lung disease. Several programs exist, such as the AARC’s spirometry driver’s license5 and the NBRC’s certification examination, that help to guarantee that the RT has achieved the proper credentialing to ensure adequate performance of this type of testing.
There are various other types of testing that an RT can perform in the office setting, whether it be a primary care or specialty office practice. In some practices, complete pulmonary function testing is being performed, and an RT is particularly well suited for doing such testing. Measurement of flow rates (pre- and post-bronchodilator), lung volumes, and diffusing capacity can be performed in those settings, and the RT can play a lead role in such testing.
Probably the most important type of testing that can be performed in the office setting is exercise testing (eg, timed walk testing or expired gas analysis testing). Timed walk testing (such as 6-minute walk testing and shuttle-walk testing) is becoming commonly used as a measure of functional capacity in both clinical and research settings for a variety of disease processes, ranging from chronic lung disease to congestive heart failure to pulmonary hypertension. Correct performance of these types of tests is necessary to ensure the accuracy of the information obtained to help guide appropriate therapy. In some settings, measurement of expired gas and oxygen consumption can be performed, although due to the expense of the equipment, this type of testing is often not done in the office-practice setting. Assessing a patient for the use of supplemental oxygen therapy also can be performed during this testing. Respiratory therapists are particularly well positioned to conduct such types of testing.
For patients who are suspected to have a sleep disorder, appropriate evaluation and diagnosis should be performed. The RT can help to direct the patient to have the appropriate testing, whether it be a complete polysomnography or a portable sleep test. Coordination of the results of this testing can help direct a treatment plan.
Pulmonary rehabilitation is an important component in the management of a patient with chronic lung disease. It improves exercise tolerance, reduces dyspnea, improves quality of life, and reduces health care-resource utilization and should be included as part of the management of any patient who has chronic lung disease and who is symptomatic.6 In most areas of this country, pulmonary rehabilitation is performed in the outpatient setting, and in some areas, it is performed within a physician’s office. Respiratory therapists can play a vital role in the development and performance of rehabilitation in such a setting. In office settings in which rehabilitation is not performed, the RT can educate the patient about the benefits of rehabilitation and help the clinician refer that patient to a nearby program.
Respiratory therapists also can play a role in educating patients with chronic lung disease who are seen in the office setting. Most clinicians can spend very little time with patients describing their illnesses in detail. Instruction on the type of illness, treatment options, and potential complications/comorbidities associated with that illness can help patients understand what they have and how that will affect their lifestyles. Differentiating between the various types of obstructive lung diseases, such as asthma, COPD, and bronchiectasis, can be very helpful for patients.
Most patients are confused about their medication regimens, particularly their use of the various types of inhaled medications. An RT can help answer questions about the medications and assist in educating each patient about the correct inhaler-use technique. Repeated education will help to improve patient adherence to the medication regimen. This also should help to reduce symptoms as well as overall health care-resource utilization.
Respiratory therapists also can help manage patients who are receiving long-term oxygen therapy. Ensuring that the patient fully understands the reasons that oxygen therapy was prescribed and how such therapy will benefit the patient should help to improve compliance with therapy. Making certain that the patient understands the various types of delivery systems and that the best type of therapy for that particular patient is being used is a key component in this educational and management process, thus ensuring that the patient is receiving sufficient oxygen for adequate oxyhemoglobin saturation levels.
Chronic Lung Disease Management Programs
Respiratory therapists can play a vital role in the development of many disease management programs. With an increasing number of resources being dedicated to the care of patients with chronic lung disease, particularly COPD, emphasis will be placed on “accountable care.” Making certain that the care transitions from inpatient to outpatient settings are as smooth and effective as possible will be a cornerstone of accountable care programs. Coordinating care when a patient is discharged from the hospital either to a home care team or back to the primary care clinician’s office setting is one role the therapist can play. In some instances, the RT (as part of the outpatient management team) might actually visit the patient in the home setting to help manage the ongoing care. Helping to reduce the 30-day readmission rates for patients who are discharged from the hospital will ultimately aid the patients as well as decrease overall health care expenditures. Using currently recommended outcome measures will help the RT effectively manage each patient and each program.
Respiratory therapists also can assist in developing similar programs for other chronic lung diseases. Managing patients with asthma can involve particular challenges, but effective management programs have been shown to improve patient health and well-being and to reduce health care costs. Respiratory therapists should become actively involved in these types of endeavors. Various guidelines exist for the management of patients with chronic lung disease and should be incorporated by the RT in the management of each individual.7-9 An excellent review of the role of the RT in the collaborative care model for managing patients with chronic lung disease was presented at the AARC International Congress meeting in December 2008.10
In many areas, chronic management programs for sleep disorders are being developed. The RT can play a key role in the management of patients in these types of office settings. Helping to coordinate the overall treatment of each patient is important and involves not only making certain the patient is receiving the appropriate therapy, such as positive airway pressure therapy for obstructive sleep apnea, based on the results of the diagnostic testing, but also helping to ensure that the patient is actually using the therapy that has been prescribed. Assessing compliance with the use of PAP therapy as well as trouble-shooting the use of the nasal/oral mask interfaces can be done by the RT and help to improve overall therapy compliance.
There are many ways that RTs can help in the management of patients with chronic lung and sleep disorders in office settings. Developing early detection programs followed by making the appropriate diagnoses is the cornerstone of detecting patients with a lung or sleep disorder. Helping to perform the various tests also can be easily done by RTs. Aiding in the management of patients with chronic lung or sleep disorders is yet another way the RT can be actively involved in their care. All of these aspects of the provision of care will ultimately help to better treat and manage patients with chronic lung or sleep disorders from an outpatient perspective.
Brian W. Carlin, MD, FAARC, is assistant professor of medicine, Drexel University School of Medicine, Allegheny General Hospital, Pittsburgh. For further information, contact [email protected]
- Ferguson GT, Enright PL, Buist AS, Higgins MW. Office spirometry for lung health assessment in adults.Chest. 2000;117:1146-61.
- Yawn BP, Mapel DW, Mannino DM, et al. Development of the Lung Function Questionnaire (LFQ) to identify airflow obstruction. Int J Chron Obstruct Pulmon Dis. 2010;5:1-10.
- Martinez FJ, Raczek AE, Seifer FJ, et al. Development and initial validation of a self-scored COPD population screener questionnaire (COPD-PS). COPD. 2008;5:85-95.
- Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008;108:812-21.
- Nelson S, Enright PL. Spirometry “Driver’s License.” Presented at: 55th Annual Respiratory Congress; December 2009; San Antonio.
- Casaburi R, ZuWallack R. Pulmonary rehabilitation for management of chronic obstructive pulmonary disease. N Engl J Med. 2009;360:1329-35.
- Global Initiative for Obstructive Lung Disease (GOLD) guidelines. Available at: www.goldcopd.org/Guidelines/guidelines-resources.html. Accessed August 18, 2011.
- Qaseem A, Wilt TJ, Weinberger SE, et al. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med. 2011;155:179-91.
- Nelson HS. The National Asthma Education and Prevention Program 2007 Revision of the Asthma Treatment Guidelines. NIH Publication No. 07-4051. Available at: www.jhasim.com/files/articlefiles/pdf/Nelson-Article2.pdf. Accessed August 18, 2011.
- Christopher KL. Engaging patients through a collaborative care model. Proceedings from a special symposium on Improving Symptom Control in Patients with Chronic Respiratory Disease. Presented at: 54th International Respiratory Congress; December 2008; Anaheim, Calif.