By Kaye Prather
Imagine you’re unwell—it’s not hard to do. You’ve been through all kinds of tests, been poked and prodded and medicated. Everyone seems to be speaking Clinicalese, not English. You want to know what’s wrong and whether it can be fixed or if you have to learn to live with it. You have even Googled it, but that just brought up more questions. The main one: How does all of this apply to me? Someone says they’re going to educate you, and all you can think of is more big words and, OMG, a test—at least that’s the way you remember education in school.
As respiratory therapists—whether working in acute care, home health, outpatient pulmonary function, pulmonary rehab, research, or sleep studies—we all started our careers with a wealth of knowledge gained from years of education. Without realizing it, we started thinking and speaking the language of our profession. We use this language as a shorthand to communicate across a range of health-care providers, who understand, accept, and even expect us to talk this way. This language is part of our professionalism, and it also creates a second skin, protecting us from getting too close to our patients.
At the same time, we have a list of duties, practices, and procedures that make up our “scope of practice.” One of those duties is to educate our patients. The better educated our patients, the better their outcomes. We are expected to teach in a few minutes what it took us months or years to learn. That alone is difficult enough. But now add to that the fact that our patients are anxious and medicated. Their families—their best advocates for recovery—are also anxious and confused.
So, how do you educate your patients and their families without talking in clinical terms or in a patronizing way? You start by listening. Make some small talk. Ask them what they know and understand about their health to this point. This will give you an idea of what they know from their own perspective. This provides three benefits: 1. You learn what they already know, so you won’t waste your time or their time by going over information they already understand. 2. You’ll get a good idea of what they don’t know or understand. 3. In these few minutes spent in pleasant conversation, you can also assess their breathing (work of breathing, anxiety levels, etc.).
More often than not, our patients don’t understand how the clinical information given to them affects them. When they don’t understand, they don’t know what they can do to help themselves. In short, they don’t comply. So, instead of using the standard clinical information and terms, break things down for your patients. Elucidate. In other words, provide an explanation that makes things clear. Use terms they use daily. Use analogies to explain the function and effects of their disease, tests, procedures, and medications. Use everyday functions patients can relate to or have experienced as comparisons. This will help them understand the concepts and how they apply to their situation.
Through experience, I’ve found there are four basic things patients need to understand to improve their quality of life.
Patients have been told about diaphragmatic and pursed lip breathing—our classic standbys—by their doctors, nurses, and respiratory therapists, but they still do not understand it. Why? Because no one has actually explained to them what this type of breathing is and how it works. Therefore, they do not know why they need to learn and practice breathing. Let me break it down for you.
Diaphragmatic breathing: what this means in real life
The diaphragm is a large muscle whose main job is to breathe. When we came into this world, we used our diaphragm to breathe. But somewhere along the line, we started to use our chest and shoulder muscles to breathe. My theory is that males and females alike hit puberty and want big chests. Ask patients if they have watched a baby sleep. They will say yes. Ask them what goes up and down with each baby breath and most will say stomach. Some will say chest, but remind them that little babies really do not have chests per se and that will get them on the same page. Now you are both understanding and relating with each other. We can now explain that retraining their diaphragm will not be easy, but it will benefit them with increased oxygen and more energy.
Let’s talk about how to retrain our patients in their breathing. I came across the website of a voice coach, which offered a sensory method to feel diaphragmatic breathing. Here’s how they described it: as you breathe in it, feels like you’re pushing down, causing it to feel as though you have an inner tube filling up around your waist. Now add the clinical part: the diaphragm moves down, causing the stomach to push out. The body has muscle memory, which means the more you do something, such as using a muscle group, the more it will adapt and perform the behavior without thinking about it. There is no magic in it. Now, diaphragmatic breathing is no longer just a concept for your patient. He or she now has a method to check and practice breathing anywhere. The more the patient thinks about it and practices it, the more muscle memory will kick in and the less they will have to think about it
Now you are going to bring up COPD and hyperinflated patients, who do not have much play/room to move their diaphragms. True, they have less diaphragm movement. But if they use as much as they can, they will take some of the work off the accessory muscles. This decreases the work of breathing, thereby increasing oxygenation and making them less tired at the end of the day.
Pursed-lip breathing: why and how do we do it
Pursed-lip breathing is a method to get more air out of the lungs by stenting open the airways. Our patients do not relate to this and are unable to imagine airways—stented or otherwise. However, they do understand that when you put your thumb over the end of a garden hose with the water turned on, this blocks the flow of water and the hose swells up. If they turn the water off and move their thumb over a bit, the water will come out in a spurt and empty the hose because of the back pressure. Controlling their breath out, like the water in the hose, literally stents open the smaller airways, allowing more air out. Water and air have a similar flow, and since patients have experienced water flowing, they can relate to this illustration. But we also have to explain why we are worried about getting air out. Simple: to get air in. I tell patients a story a diving friend told me: one of the most common accidents in diving occurs when new divers forget to breathe out. When they get to the surface, they are out of air and start trying to take breaths, but their lungs are still full of air, so there is no room for more. I’ve never had anyone not understand this scenario.
I have to say at this point that I have a problem with the standard direction for pursed lip breathing: “smell the roses and blow out the candles.” I have had patients who don’t like doing this and say it doesn’t work. When I ask them to show me what they are doing, they show me breathing in through their noses (which is right), then blowing out fast and strong, trying to blow out those candles. They’re right that this won’t work. The principle of a controlled breath to maintain back pressure cannot be accomplished that way. Instead, I tell them to “put their lips together and blow.” Yes, everyone has heard that line before. A whistle uses the principle of a partially closed glottis (causing back pressure) to release air from the lungs slowly and more completely. This increases the exhalation phase, stents airways, creates a time constant to increase oxygenation, and slows the rate of breathing. If you don’t actually make a tune, that’s okay.
The Final Step: Patients are fearful and anxious while in the hospital. Getting home does not always bring peace of mind. Instead, it can bring on a whole new set of concerns. Listen to your patients. You will learn what they know and how anxious they are. You’ll also get a feel for the language they use. Answer their questions with analogies. Use common scenarios and illustrations they can relate to. You will find your own analogies based on your life experiences. Draw a picture, or, if you can’t draw, find one. Use humor. A person who laughs—whether at you or at themselves—lets go of fear for a moment and maybe even longer. Above all, be honest.
Kaye Prather RRT-NPS, AE-C started her healthcare career late in life. She went back to school at age 49, graduating an accelerated program as valedictorian. During her career, she has in worked acute care, rehab, home care, pulmonary rehab and as a contract trainer.