Supporting respiratory health in a goal orientated world

People with physical disabilities and families will rarely come to a health professional with a goal like “to maintain my respiratory health.”

Respiratory problems are common for people with cerebral palsy, especially those with more severe impairments (GMFCS IV and V), swallowing difficulties and those who are underweight.

Goals health professionals support people with physical disabilities with should always be directed to participation and activity in the home and community. The strategies to achieve these goals need to include health support. Good health and wellbeing are a vital first step in being able to participate.

Health professionals are encouraged to discuss respiratory health as a strategy when supporting anyone with risk factors for respiratory ill health. Being sick is not normal for anyone. Having a disability does not equal ill health. Often respiratory problems have become normalised. It is up to health professionals to educate and encourage a proactive approach to respiratory management across the lifespan. Prevention is the key. Integrating recommendations into the person’s life will always work better and be sustainable.

There are many interventions that health professionals provide regularly that can assist respiratory management for people with physical disabilities. The emphasis is however often more related to musculoskeletal management. It is possible to support both respiratory and musculoskeletal needs with similar strategies.

Recommendations:

• CP-Checklist: encourage use of this checklist. While created for children and young adults with cerebral palsy to guide risk level for respiratory problems, it is useful for people of all ages and diagnosis. www.abilitycentre.com.au/resources/cp-checklist
• Team approach: team includes consumer, their family / network, GP, nurse, physiotherapist, speech pathologist, dietitian, occupational therapist and support workers
  • Discuss management of co-morbidities such as reflux, overnight tube feeding or sleep apnoea
• Refer to GP: implement plans with regular reviews e.g. asthma, medication. Refer to respiratory specialists anyone experiencing ongoing chest infections, regular antibiotics prescription and other respiratory risk factors
• Refer to dietitian: those at risk or are underweight and at risk of chest infections and have swallowing difficulties
• Refer to speech pathologist: those with dysphagia risk or problems
• Refer to physiotherapy: those at risk of or have respiratory problems.
  • Assessments should routinely include respiratory health and the spine / trunk
  • Education:
    • Explain why respiratory health assessment is necessary and the importance of respiratory health
    • Explain the need to be provided with opportunities to take deep breaths or to move and experience different positions to enable the lungs to work optimally
    • Provide examples about the effect of position and movement on lung health and function
• Refer to physiotherapy and occupational therapy: those who cannot move and position themselves for independently for support with:
  • Day positions:
    • Seating and mobility devices:
      • Postural support to consider musculoskeletal and respiratory needs
      • Tilt and recline functions to achieve optimal chest expansion
      • Spirit levels useful to indicate optimal ranges for rest and mealtimes
      • Alternative seating useful to provide different positions each day
      • Day rest in bed
      • Standing frame / tilt table options
      • Floor time
  • Night time positioning:
    • Consider the best position based on both respiratory needs and musculoskeletal needs
    • Supine:
      • Often best for musculoskeletal needs, provides best symmetrical positioning
      • Often not ideal for those with respiratory problems
      • Often not appropriate for anyone who suffers from reflux
    • Left sidely:
      • Often best for those with aspiration issues (right lung generally more affected)
      • Recommended to be used in combination with other positions to prevent asymmetry
      • Right sidely:
      • Use as part of a program of positions for chest infections to prevent asymmetry
      • Modified supine with head raised:
      • Often best when supine is required for postural needs when respiratory problems exist
      • 30 degree head raise often suitable for those with reflux
    • Modified sidely:
      • Often best when respiratory problems exist in combination with contracture or pain or discomfort or any other reason that full sidely position is not achievable
      • Recommended to be used in combination with other positions to prevent asymmetry
    • Exercises and Mobility
      • Anything to experience movement through different positions, increase cardiovascular fitness and promote chest expansion should be considered
      • Active if possible e.g. water based therapy, dancing, bike - static or dynamic, motomed (active through to passive)
      • Active assisted e.g. water based therapy, motomed, hands on facilitation / support
      • Passive e.g. upper limb facilitation, passive movements, motomed

Supporting respiratory health in a goal orientated world

An example of an approach:

24/7 Model of Support

• Considers the needs of all stakeholders i.e consumers, all members of the family / all members of the household.
• Considers the routines of the individual and family / household and support worker shifts and availability to support consumer.
• Works for everyone regardless of age or disability.
• Is always individualised allowing all aspects of the individual’s supports to be integrated.
• Considering the weekly routine helps people to incorporate the plan into their lives and increases the likelihood of long term respiratory health management.
• Leaves the consumer with a 24 hour positioning and mobility plan.

Process recommended:

• Ensure all plans are in place and being followed.
• Determine what positions, mobility devices & activities are most suited to the individual e.g.
  • Manual wheelchair for home and community
  • Alternative seating for home e.g. lounge or recliner
  • Standing frame use three times per week
  • Water based therapy once per week +/- intermittent land therapy sessions.
• Discuss with the consumer / family / group home re routines every day and across the week. The aim is to incorporate everything into the routine rather than setting time aside. For example:
  • Manual wheelchair has two spirit level positions, one for mealtimes and for upper limb tasks; the other for rest times. Seating is providing optimal positions for chest expansion.
  • Standing frame could be used after day activities one day a week and before lunch on the two days home.
  • Water based therapy once per week in the class setting.
  • Land based therapy sessions scheduled to limit disruption of routine. Complete some activities after shower each day, during rest times on days home and as a formal program while at day activities.
• Write up the plan as discussed, noting clearly that everything is fluid, households can and should adjust the activities to suit their needs.
• For people in respite or supported accommodation, it is recommended that a more prescriptive approach is implemented to assist the support staff to support the person with a physical disability. For example:
  • Over night:
    • Right sidely, supine, left sidely – 1/3 each.
  • Day:
    • Manual wheelchair with customised seating throughout day.
    • Fall out chair with supports for afternoons upon return from day activities.
    • Passive upper limb and neck exercises daily, hourly during waking hours except busy times.
    • Tilt table Tuesday, Saturday and Sunday (days home from day activities)
    • Rest on bed 30minutes each side Tuesday, Saturday and Sunday and if health in decline.
• Review at least yearly and if anything changes.