Pulmonary Rehabilitation Program in Saudi Arabia - Essay Example

?PR in Saudi Arabia Part One: Chronic Obstructive Pulmonary Disease, (COPD) is a common disease “characterized by persistence of air flow limitation that is progressive and associated with an enhanced chronic inflammatory response in the airways and lungs to noxious particles or gases” (Pauwels, Buist, Calverley, Jenkins, & Hurd, 2001). COPD is known globally as the fourth leading cause of death (Adams et al., 2007). It is a chronic illness and it targets the older people in the population, which limits their daily activities over time. Some developed countries around the world stand clear to fight against the attack of such a disease. They have started rehabilitation programs for the population that suffer from COPD or other chronic respiratory illnesses. These programs show a magnificent transition in the life of COPD population and improve their quality of life (Gershon, Wang, Wilton, Raut, & To, 2010). Despite the tremendous improvement in the COPD patients through the rehabilitation programs, the disease is still underreported and under-diagnosed in some countries such as in the Gulf Cooperation Council countries, especially Saudi Arabia (Al-Moamary et al., 2012). This paper focuses on such a disease in Saudi Arabia, and where the health services stand. Moreover, the paper will draw a path to implement a pulmonary rehabilitation (PR) program in a specific region of Saudi Arabia. Kingdom of Saudi Arabia is located in the Southwest of Asia and it is run by a traditional monarchy (Central Department of Statistics and Information, 2013). The population of Saudi Arabia is roughly 29,195,859 as of 2012 and 68 per cent of the population are citizens (Central Department of Statistics and Information, 2013). The country’s economy is based on the oil. The budget revenues of the country rely on the petroleum sector that accounts for approximately 75 per cent (Central Department of Statistics and Information, 2013). The government focuses on improving the education and health sectors to increase the employment opportunities for the Saudi population, and encourages private sector development to decrease the kingdom’s dependence on oil. Despite the great infrastructure of the health services and the expansion of medical schools and facilities, some diseases are still under-diagnosed. One of these diseases is COPD and its prevalence (Al-Amoudi, 2006). However, Al-Ghobain, Al-Hajjaj, and Wali (2011) conducted a study to screen the existence of COPD among smokers who attend primary health care clinics with the age of 40 years and above. Their study was the first one to estimate the prevalence of COPD in the country. Sixty primary health care clinics participated and 501 patients were included in the study in the three main cities of Saudi Arabia. The cities are Riyadh, Jeddah, and Dammam. Out of the 501 patients, 14.2 per cent had COPD that confirmed by a forced expiratory volume ratio in one second of less than 0.7. Therefore, the prevalence of COPD in Saudi Arabia is 14.2 per cent, and such prevalence is consistent with what other countries have published as their prevalence of the disease (Al-Ghobain et al., 2011). Nonetheless, PR program should be recognized in the country to improve the functional exercise capacity and the quality of life of patients with COPD. The first PR program was established in 2001 at King Abdulaziz Medical City (KAMC) in Riyadh, Saudi Arabia (Al-Moamary, 2010). Even though, the PR program in KAMC shows successful implantation and improvement in the quality of life of patients who attended the program, there are some teaching hospitals in Riyadh that lack PR programs and establishment of such programs should be considered in these facilities. The Prince Sultan Military Medical City (PSMMC) in Riyadh is an example of such a facility, where I used to work. Part Two: PSMMC has 1,192 beds including emergency room, delivery unit, and operating rooms. It also has 7,179 staff to ensure the quality of care that is provided to the patients (Prince Sultan Military Medical City, 2013). I used to work there as a respiratory therapist and my work area include, but are not limited to; intensive care unit, emergency room, neonatal and pediatric unit, and long term ventilation unit. The hospital refuses to give statistical information regarding the number of patients who have chronic pulmonary disease, and are admitted to the hospital. However, I dealt with numerous cases of chronic pulmonary illnesses such as COPD, asthma, interstitial lung diseases, and others. Those patients were between mild to severe stages of their disease progression, and they could have benefited from a PR course if the hospital had one. Unfortunately, the hospital has no such program. However, there are modifications for the hospital’s infrastructure today, where they can create a space for the PR program (Prince Sultan Military Medical City, 2013). All the health resources are available to establish the program, and in regard to the religious and cultural facts, the resources are enough for the program to accommodate both males and females separately. The physiotherapists perform their rehabilitation for the patients in the patient’s bed or exercise in the corridor due to the diminished space for physiotherapy exercise unit. Therefore, an exercise unit will not only benefit the patients with chronic pulmonary illnesses but also other patients who need physiotherapy rehabilitation. The PSMMC should take into consideration the outcome of the PR program that is established at KAMC, which is also located in the city of Riyadh. It is not enough to have one PR program in such a large city as Riyadh, with a population of 7,516,959.The KAMC is located in the far east of the city whereas the PSMMC is in the center of the city, making it difficult for patients to travel between the cities. Establishing a PR program requires a full plan to be drawn. It must include the patient assessment tools, model of the PR, content of education and exercise courses, and the clinical evaluation of the program. Also considered are the available resources and their ability to deliver the program correctly to the patients involved. The inclusion criteria for PR program should include a referral from a pulmonary physician or a family medical clinic (Al-Moamary, 2008). A pulmonary physician can confirm the existence of COPD in a patient by using a spirometry test (Pauwels et al., 2001). The American Thoracic Society (ATS) and the European Respiratory Society (ERS) have stated the use of spirometry as a diagnostic tool to confirm COPD (Celli, et al., 2004). A post bronchodilator is inhaled by the patient, and if the result of forced expiratory volume in one second /forced vital capacity (FEV1/FVC) ratio ? 0.7, it confirms the existence of air flow limitation that is not fully reversible. This eventually leads to the confirmation of COPD (Celli, et al., 2004). Any individual with a history of one or all of the following: exposure to smoking, environmental or occupational pollutions, frequent cough, sputum production, and/or dyspnea should obtain a spirometry test (Pauwels et al., 2001). Moreover, the assessment of exercise capacity of a patient is essential to help identify where he or she physically stands prior to the program (Pauwels et al., 2001). Examples of exercises are: a six-minute walking test (6MWT), treadmill, arm ergometer, and bicycle (Al-Moamary, 2008). The 6MWT will measure the functional capacity, whereas the others will measure the maximal capacity. Oxygen saturation at rest, and at the end of completing a functional exercise capacity as well as dyspnea score must be recorded (Australian Lung Foundation [ALF], 2009a). The evaluation of health status and the degree of breathlessness are also used besides the exercises as a baseline measure. The evaluation can be conducted by a specific questionnaire of health related quality of life (HRQoL) or interview with the patient. The health related quality of life questionnaires have been translated to Arabic language and validated (Al-Moamary et al., 2012). The symptoms that the patient has and the spirometry result will only be used as entry suitability to the program but are not as outcome measures. The exercises, HRQoL, and the degree of symptoms are important baseline and outcome measures (Pauwels et al., 2001). These, according to literature, are adequate for use when assessing a patient prior to enter the program. It is important to have the required resources in the patient assessment phase of the program. This phase will require a pulmonary physician to confirm the disease, trained physiotherapist or respiratory therapist to conduct the measurements and evaluate the parameters of the exercises that are used. The patient interview and questionnaire collection should be performed by a nurse but in case there is shortage in trained nurses for such a program, a physician, a physiotherapist, or a respiratory therapist can also perform them. Since there is lack of PR programs in Saudi Arabia, an institutional-based or hospital-based program should be implemented. Hospital-based program is known to show great benefits to COPD or chronic lung disease patients, and it is beneficial for both in-patients and outpatients (Frith, 2008). Community-based programs are helpful but the country is yet to start such programs. This is because there are fewer programs aimed at increasing awareness of chronic lung diseases and the risk factors. In terms of components of the program, the comprehensive program, which has exercise and education components, is preferable as it is the most reliable and improves the patient’s outcome. The literature shows that each component is beneficial but comprehensive programs are the most effective for better outcomes (Frith, 2008). The recommended length for a PR is from eight to twelve weeks and includes three sessions per week (Al-Moamary, 2010). The longer the program the better the behavioral changes outcome and it is recommended that at least two out of three sessions is supervised (Maltais et al., 1997; Sala et al., 1999). Keeping in consideration the local resources, a comprehensive program needs more of trained resources to meet the goals of the program. Physiotherapists and respiratory therapists are needed to supervise the exercise component of the program, and to set the goals for the patients. Nurse, dietician, psychologist, pharmacist, physiotherapist, respiratory therapist, and pulmonary physician are suitable to demonstrate the education component of the program. All these resources are available in PSMMC and they might be willing to participate in the program supervision. Education improves the patients’ knowledge on how to manage their symptoms, and the use of breathing techniques to control breathlessness. The education component seems to be more effective than standard medical care. It improves HRQoL, dyspnea, functional status, and to overcome psychological problems (Frith, 2008). Besides the patient, the family members or those caring for the patients should be involved in the education session to better understand the physical and behavioral changes that are associated with chronic lung diseases (ALF, 2009f). The content of an education sessions varies and depends on the availability of the local resources. Retaining information can be influenced by the group size and the mode of delivering the information to the participants. It is recommended to have six to twelve individuals maximum per class (Frith, 2008). The use of pictures, audios, videos, may help patients to retain information. For example, pictures showing a specific exercise technique and medication canisters showing an appropriate inhalation technique help patients retain such information. (ALF, 2009f). The facilitator should allow for active participation rather than using the passive methods. Patients with chronic lung diseases tend to have memory deficiency and encouraging them to participate in the session will help them to retain information as much as possible. (ALF, 2009f). The education topics may include, but are not limited to, medication, self-management, COPD management, home oxygen therapy, exercise and physical fitness, nutrition, stress and depression, and managing breathlessness (ALF, 2009b). A respiratory therapist or pharmacist can facilitate the medication topic, and a respiratory therapist or physician can facilitate COPD management and home oxygen. A psychologist, physiotherapist, social worker, or nurse can present the self-management and stress and depression topics. A dietician can present the nutrition and healthy eating topic to the patients. Last but not least, a respiratory therapist or physiotherapist can present the exercise, physical fitness, and breathlessness management topics. The session should not be longer than two hours once a week (Frith, 2008). Exercise component as discussed earlier is essential in PR program that has a great impact on the patient’s functional exercise capacity and quality of life (Lacasse et al., 1996). Each individual must undergo a comprehensive assessment to determine his/ her intensity, duration, frequency, type, and mode of a suitable exercise. The exercise component may include endurance, strength training for lower and upper limbs, flexibility and stretching, and balance exercises (ALF, 2009e). Endurance or aerobic training, which uses large muscle mass, is prescribed for lower limb. It includes walking or stationary cycling training. This exercise will allow the accessory muscle and respiratory muscle to work more efficiently (Frith, 2008). The prescription of the intensity should be based on the 6MWT result. The patient should first finish the 6MWT to calculate the initial intensity of the exercise. It is recommended that the intensity of walking training should be 80 per cent of the average 6MWT speed, and 60 per cent of peak cycle work rate for cycle training (Maltais et al., 1997). However, in regard to dyspnea, some patients may require certain intensities depend on their degree of dyspnea during training (ALF, 2009c). The duration for lower limb endurance training depends on the severity of the disease. The suggested duration for this exercise is 30 minutes per session and can be split between walking and cycling training of 15 minutes each. It is recommended to have three sessions per week, which include one unsupervised session. Also, patients are encouraged to do home exercise training one to two times per week so that exercise can be merged into home life (ALF, 2009c). The exercise can be administered in continuous or interval basis to meet the patients’ ability to exercise. Strengthening lower limbs is important as most of the COPD patients have skeletal muscle weakness (ALF, 2009g). These muscles are used on a daily basis and strengthening them is required. Moreover, there is a relationship between lower limb strength and work capacity (ALF, 2009g). It can be performed with or without weights. The number of repetition the patient can do defines the intensity of the exercise. The frequency is three times per week. It is suggested patients should have at least one day of rest between strengthening training sessions (O’Shea, Tylor, & Paratz, 2004). Examples of lower limb strength exercises are: knee extension in setting position, squats, and climbing stairs (ALF, 2009g). It is advisable to warm up by doing a lower limb aerobic training prior to strength training. Endurance and strength training of upper limbs are as important as training for lower limbs. This should start with or without weights depending on the degree of disability in the patient (ALF, 2009d, 2009h). The ability of a patient to repeat a set of exercise will determine its intensity. The goal is to do low weights with high repetitions (O’Shea et al., 2004). If the patient reached 15 repetitions for one set of exercise without fatigue, it is recommended to increase the exercise to three sets (ALF, 2009d). Each set of 15 repetitions should not take longer than one minute, and three sets with 15 repetitions for each should not take longer than five minutes with rest in between sets for at least 15 seconds (O’Shea et al., 2004). This exercise should be done three times per week with one unsupervised session. During exercise session the practitioner should keep watching the patients to avoid any dyspnea or attacks during exercises. Some exercises may tend to increase the oxygen consumption thus decrease the level oxygen saturation in the blood. All patients will have different stages of COPD or any other chronic lung diseases, and so their intensities should be carefully judged and adjusted. At the end of each PR program, the clinical outcomes of a patient should be measured. The outcome measures will help to clinically identify whether the patient benefited from the program or not. There are two ways to measure the outcomes of the program. First, to compare the baseline measures with the outcome measures. For example, the distance the patient walked in six minutes prior to enter the program compared to the distance he/she is able to walk at the end of the program. Such a comparison will determine if the functional exercise capacity increased. The dyspnea and oxygen saturation scores during 6MWT before and at the end of the program are also considered as outcome measures (ZuWallack, Haggerty, & Jones, 2004; ALF, 2009i). The other outcome measurement tool is the quality of life questionnaires (ALF, 2009i). The Chronic Respiratory Disease Questionnaire-Self-Administered with Standard (CRQ-SAS) questionnaire and COPD Assessment Test questionnaire are used nowadays to evaluate the patient’s condition and impact of the disease on his or her life (Frith, 2008). CRQ-SAS is a 20-item questionnaire and covers four domains: dyspnea, emotion, fatigue, and mastery (Schunemann et al., 2003; Jones et al., 2009). The CAT is used to quantify the impact of COPD on HRQoL during routine practice (Jones et al., 2009). The quality of life questionnaires have been translated into Arabic and they were found to be valid and reliable (Al-Moamary et al., 2012). The patient should be encouraged to keep exercising at home after the PR program for at least three times per week. In conclusion, the previous studies that have been done in Saudi Arabia have defined the need of PR programs in the country. There is only one PR program in Riyadh, Saudi Arabia, which is located in the far east of the city. The program has been contacted on many occasions to request their assistance, which would help in writing this paper to no avail. However, implementing a PR program in PSMMC is a challenging but possible task. The literature shows the importance of PR for COPD and chronic lung disease patients and its positive impact on their life. Moreover, the PR program will meet the religious believes and cultural needs of the country of Saudi Arabia. In terms of patients, male and females will interchange in attending the program. This means that during the off days of males, females will attend, and vice versa. The educational sessions will be provided for each group separately, and male or female practitioner can present the education topics. During exercise sessions, only female practitioner will attend the female sessions, and the male practitioner will attend the male sessions. Read More