1. PULMONARY REHABILITATION CLINIC PROTOCOL
Objectives :
1.To improve exercise capacity
2. To reduce perceived intensity of breathlessness
3. To improve health-related quality of life
3. To reduce number of hospitalizations and durations of hospitalizations.
4. To reduce anxiety and depression associated with COPD
5. To improve arms function by strength and endurance training of upper limbs
6. To improve survival
7. To enable respiratory muscle training for optimal utilization
Participants : SKN Medical College, Narhe, Pune
1.Department of Respiratory Diseases
2.Department of Psychiatry
3.Department of Physiotherapy
4.Department of Nutrition & Dietetics
The Components:
1. The S G Respiratory Questionnaire
2. History & Clinical examination
3. Laboratory investigation
4. Six minute walk test
5. Spirometry
6. Radiological investigation
7. Morbidity assessment
8. Medical management
9. Psychiatry guidance for smoking cessation
10.Physiotherapy
11.Nutritional guidance
The S G Respiratory Questionnaire
It is in two parts. Part I produces the Symptoms score, and Part 2 the Activity and
Impacts scores. A Total score is also produced.
Part 1 (Questions 1-7 to assess the patient’s perception of his/her recent respiratory
problems.
Part 2 (Questions 8-14) addresses the patient’s current state (i.e. how they are
these days). The Activity score measures disturbances to daily physical activity.
The Impacts score covers a range of disturbances of psycho-social function.
Administration of Questionnaire

2. he questionnaire should be completed in a quiet area, free from distraction and the
patient should ideally be sitting at a desk or table.
Explain to the patient why they are completing it, and how important it is for
clinicians and researchers to understand how their illness affects them and their
daily life.
Ask him or her to complete the questionnaire as honestly as they can and stress
that there are no right or wrong answers, simply the answer that they feel best
applies to them.
Explain that they must answer every question and that someone will be close at
hand to answer any queries about how to complete the questionnaire.
It is designed for supervised self-administration. This means that the patients
should complete the questionnaire themselves so family, friends or members of
staff should not influence the patient’s responses.
Once the patient has finished, it is very important that you check the questionnaire
to make sure a response has been given to every question, before he/she leaves.
If a patient gives an answer you disagree with it is not appropriate to challenge
their response . It is their view of their condition we are interested in – no matter
how strange the response!
The following are notes that may help you explain to patients what is required
1. In Part 1 of the questionnaire, emphasise to patients that you are interested in
how much chest trouble they have recently. The exact period is not important.
We are looking for an impression or perception of health.
2. An attack of chest trouble (Part 1, Question 5) is any episode of worse
symptoms that constitutes an attack in the patient’s own judgement. Not just severe
attacks as judged by medical staff.
3. COPD can vary day-to-day. Part 2 is concerned with the patient’s current state
(i.e. on average over ‘these days’), not necessarily just today.
4. For Part 1 Question 6, emphasise that you are interested in the number of good
days that they have had.
5. In Part 2, Questions 8 and 14 require a single response, but Questions 9 to 13
require a response to every question. It may be worth emphasising this to the
patient.
6. Many patients do not engage in physical activity. It is important to determine
whether this is because they do not wish to (in which case the answer would be
‘False’) or cannot engage in these activities because of their chest trouble (in
which case the answer would be ‘True’).
7. Responses to Questions 12 and 13 concern limitations due to breathing
difficulties and not any other problems. If the patient does not engage in an activity
for another reason, they should tick ‘False’.
ST GEORGE’S RESPIRATORY QUESTIONNAIRE FOR
COPD PATIENTS

3. PART 1 (exact duration/period is not important )
Question 1: You have cough on:
a. Most days
b. Several days
c. With chest infections
d. Not at all
Question 2: You bring up phlegm (sputum) on:
a. Most days
b. Several days
c. With chest infections
d. Not at all
Question 3: You have shortness of breath on:
a. Most days
b. Several days
c. Not at all
Question 4: You have attacks of wheezing on:
a. Most days
b. Several days
c. A few days
d. With chest infection
e. Not at all
Question 5: How many attacks ( in the patient’s own perception, not as judged by
any medical personnel )of chest trouble have you had?
a. 3 or more
b. 1 or 2 attacks
c. None
Question 6: How often ( number ) do you have good days (with little chest
trouble)?
a. None
b. A few
c. Most are good
d. Every day
Question 7: If you have a wheeze, is it worse in the morning?
a. No
b. Yes
PART 2 ( overall current condition, not necessarily today )
Question 8: How would you describe your chest condition? ( a single response is to
be selected )
a. The most important problem I have
b. Causes me a few problems
c. Causes no problem
Question 9: Questions about what activities usually make you feel breathless.
( response necessary to every question )

4. a. Getting washed or dressed
b. Walking around the home
c. Walking outside on the level
d. Walking up a flight of stairs
e. Walking up hills
Question 10: More questions about your cough and breathlessness. .( response
necessary to every question )
a. My cough hurts
b. My cough makes me tired
c. I get breathless when I talk
d. I get breathless when I bend over
e. My cough or breathing disturbs my sleep
f. I get exhausted easily
Question 11: Questions about other effects your chest trouble may have on you. .
( response necessary to every question )
a. My cough or breathing is embarrassing in public
b. My chest trouble is a nuisance to my family, friends or neighbors
c. I get afraid or I panic when I cannot get my breath
d. I feel that I am not in control of my chest problem
e. I have become frail or an invalid because of my chest
f. Exercise is not safe for me
g. Everything seems too much of an effort
Question 12: Questions about how activities may be affected by your breathing. .
( response necessary to every question ; If patient is unable to do the activity due to
any other reason than breathing difficulties , the response should be ‘false’ )
a. I take a long time to get washed or dressed
b. I cannot take a bath, or I take a long time
c. I walk more slowly than other people, or I stop for rests
d. Jobs such as housework take a long time, or I have to stop for rests
e. If I walk up one flight of stairs, I have to go slowly or stop
f. If I hurry or walk fast, I have to stop or slow down
g. My breathing makes it difficult to do things such as walk up hills, carry things
up stairs, light gardening such as weeding,etc.
h. My breathing makes it difficult to do things such as carry heavy loads, dig the
garden, jog or walk at 5 miles per hour, etc.
Question 13: We would like to know how your chest trouble usually affects your
daily life. .( response necessary to every question ;If patient is unable to do the
activity due to any other reason than breathing difficulties , the response should be
‘false’ )
a. I cannot play sports or games
b. I cannot go out for entertainment or recreation
c. I cannot go out of the house to do the shopping
d. I cannot do housework
e. I cannot move far from my bed or chair

5. Question 14: Tick the statement which you think best describes how your chest
affects you.( single response is to be selected )
a. It does not stop me doing anything I would like to do
b. It stops me doing one or two things I would like to do
c. It stops me doing most of the things I would like to do
d. It stops me doing everything I would like to do
The entire questionnaire has been translated into Marathi by the department of
Respiratory Diseases and then validated by the department of Community
Medicine.
Item weights :Each questionnaire response has a unique empirically derived
'weight'
(Note: the wording is abbreviated from that used in the questionnaire.)
PART 1
Question 1: I cough:
Most days 80.6
Several days 46.3
With chest infections 28.1
Not at all 0.0
Question 2: I bring up phlegm (sputum):
Most days 76.8
Several days 47.0
With chest infections 30.2
Not at all 0.0
Question 3: I have shortness of breath:
Most days 87.2
Several days 50.3
Not at all 0.0
Question 4: I have attacks of wheezing:
Most days 86.2
Several days 71.0
A few days 45.6
With chest infection 36.4
Not at all 0.0
Question 5:How many attacks of chest trouble have you had
3 or more 80.1
1 or 2 attacks 52.3
None 0.0
Question 6: How often do you have good days (with little chest trouble)?
None 93.3
A few 76.6
Most are good 38.5
Every day 0.0

6. Question 7: If you have a wheeze, is it worse in the morning?
No 0.0
Yes 62.0
PART 2
Question 8: How would you describe your chest condition?
The most important problem I have 82.9
Causes me a few problems 34.6
Causes no problem 0.0
Question 9: Questions about what activities usually make you feel breathless.
Getting washed or dressed 82.8
Walking around the home 80.2
Walking outside on the level 81.4
Walking up a flight of stairs 76.1
Walking up hills 75.1
Question 10: More questions about your cough and breathlessness.
My cough hurts 81.1
My cough makes me tired 79.1
I get breathless when I talk 84.5
I get breathless when I bend over 76.8
My cough or breathing disturbs my sleep 87.9
I get exhausted easily 84.0
Question 11: Questions about other effects your chest trouble may have on you.
My cough or breathing is embarrassing in public 74.1
My chest trouble is a nuisance to my family, friends or neighbours 79.1
I get afraid or panic when I cannot get my breath 87.7
I feel that I am not in control of my chest problem 90.1
I have become frail or an invalid because of my chest 89.9
Exercise is not safe for me 75.7
Everything seems too much of an effort 84.5
Question 12: Questions about how activities may be affected by your breathing.
I take a long time to get washed or dressed 74.2
I cannot take a bath or shower, or I take a long time 81.0
I walk more slowly than other people, or I stop for rests 71.7
Jobs such as housework take a long time, or I have to stop for rests 70.6
If I walk up one flight of stairs, I have to go slowly or stop 71.6
If I hurry or walk fast, I have to stop or slow down 72.3
My breathing makes it difficult to do things such as walk up hills, carry things up
stairs, light gardening such as weeding, 74.5
My breathing makes it difficult to do things such as carry heavy loads, dig the
garden, jog or walk at 5 miles per hour, 71.4
Question 13: We would like to know how your chest trouble usually affects your
daily life.
I cannot play sports or games 64.8

7. I cannot go out for entertainment or recreation 79.8
I cannot go out of the house to do the shopping 81.0
I cannot do housework 79.1
I cannot move far from my bed or chair 94.0
Question 14: Tick the statement which you think best describes how your chest
affects you.
It does not stop me doing anything I would like to do 0.0
It stops me doing one or two things I would like to do 42.0
It stops me doing most of the things I would like to do 84.2
It stops me doing everything I would like to do 96.7
Scoring Algorithm :A Total and three component scores are calculated: Symptoms;
Activity; Impacts.
Each component of the questionnaire is scored separately.
Sum the weights for all items with a positive response.
Symptoms component:
This consists of all the questions in Part 1. The weights for Questions 1-7 are
summed. A single response is required to each item. If multiple responses are
given to an item, the weights for the multiple positive responses should be
averaged then added to the sum. This is a better approach than losing the data set
and this
technique was for calculating scores used in the original validation studies for
patients who gave multiple responses. (Clearly a better approach is to prevent such
multiple responses occurring).
Activity component :This is calculated from the summed weights for the positive
responses to items Questions 9 and 12 in Part 2 of the questionnaire.
Impacts component :
This is calculated from Questions 8, 10, 11, 13, 14 in Part 2 of the questionnaire.
The weights for all positive responses to items in Questions 10, 11, 13 are summed
together with the responses to the single item that should have been checked
(ticked) in Questions 8 and 14. In the case of multiple responses to either of these
items, the average weight for the item should be calculated.
Total score :The Total score is calculated by summing the weights to all the
positive responses in each component.
Calculate the score
The score for each component is calculated separately by dividing the summed
weights by the maximum possible weight for that component and expressing the
result as a percentage:
Score = 100 x ( Summed weights from all positive items in that component ÷ Sum
of weights for all items in that component)
The Total score is calculated in similar way:
Score = 100 x (Summed weights from all positive items in the questionnaire ÷ Sum
of weights for all items in the questionnaire)

8. Sum of maximum possible weights for each component and Total:
Symptoms 566.2
Activity 982.9
Impacts 1652.8
Total (sum of maximum for all three components) 3201.9
(Note: these are the maximum possible weights that could be obtained for the
worst possible state of the patient).
CLINICALLY SIGNIFICANT DIFFERENCE IN SGRQ SCORE
The threshold for a clinically significant difference between groups of patients and
for changes within groups of patients is four units. Note this is an indicative value
(the threshold is not 4.0). As with all measurements there is biological variation,
sampling error and measurement error. Four units is an average value obtained in
different groups of patients.
The following is the Protocol form for patient record –Evaluation as well as
Management.

9. Patient Record
OPD No. : Study Sr No.
Name :
Age : years
Sex : Male Female
Address :
Contact no. :
Occupation :
Occupation type : Sedentary □ Moderate □ Heavy □
Social History : No. of family members :
No. of earning members :
Monthly income of entire family :
Chief Complaints Duration in days
1.
2.
3.
4.
5.
CHEST SYMPTOMS :
COUGH
Onset : Sudden / Gradual
Duration : Days / Month / year
Progression (change in severity of cough since onset ) : increased /
decreased/ constant/ fluctuating
Nature : Hacking / Barking /Whooping / Bubbling
Pattern : Occasional / Regular / paroxysmal

10. Related to : - Time of day : Morning / Night /throughout the day
- Weather : Winter / Summer / Rainy / Change of seasons
- Exertion :
- Activities : Talking/ Laughing/Deep breathing
- Eating: Post Meal
- Specific food Items
Severity: Not causing any distress/Tiring / interfering with day-to-
day activities
Sleep disturbed
Causing Chest pain
Postural relation : (increases in which posture) :
Associated Symptoms: Dyspnoea/ Chest Pain / Headache/ Choking /
Vomiting/ Syncope
SPUTUM
Onset:
Duration: Days /Month / year
Diurnal variation ( more at what time of day) : Mornings/ Evenings/ night/
throughout the day
Consistency: Viscous/Watery/ Salivary
Amount: Teaspoon/ Table Spoon / Cup / katori
Postural relation : (increases in which posture) : Sitting/ supine/prone/
Rt lateral decubitus/ Lt lateral decubitus
Appearance: Mucoid / Mucoprulent/ Purulent / Greenish / Black / Rusty
Presence of Thick Plugs & Threads : yes / no
Presence of foul odor : Yes/ No
WHEEZE:
Onset: sudden /insidious

11. Duration: in days/Month / year
Timings( heard when ): Inhaling / Exhaling/ Continuous)
Frequency: Throughout the day / Intermittent / Morning/ Night
Aggravating factors : With Exercise/ Food / Emotional upsets
BREATHLESSNESS
Onset: Sudden / insidious
Duration: in days/Month / year
Progression:(change in severity of breathlessness since onset ) : increased /
decreased/constant/ fluctuating
Posture(increases in which): Sitting/ supine/prone/ Rt lateral decubitus/ Lt
lateral
decubitus
Severity of breathlessness: Grade (according to the Medical
Research Council Scale)

12. CHEST PAIN
Onset : sudden/insidious
Duration: in days/ Month / year
Nature : Pleuritic / Muscular/ Nonspecific)
Location: Localized / Diffuse; presence of radiation
Aggravating factors: With Exercise/ Food / Emotional upsets
Relieving factors:
HAEMOPTYSIS
Onset ( first episode )
Duration : in Days/ Month / year
Appearance of blood : Fully Bloody / blood-streaked / Bright red / brown
Amount in ml.(Approx): each episode / over 24 hours
No. of episodes over last 1 week :
Associated symptoms:
Vomiting
Cough
FEVER
Onset:
Duration: in days / Month / year
Nature : Continuous/ Intermittent/ Remittent)
Grade: Low /Mod. /High

13. Associated with : chills/ rigors
Obstructive Sleep Apnoea/ Sleep Hypoventilation :
Onset
Duration: in days / Month / year
Snoring / Daytime somnolence. / Choking in Sleep / Sleep Deprived Behaviour)
Allied Respiratory Symptoms
NOSE: Sneezing/Watery running nose/ Thick secretion / Nose block/ Itching
SINUSES: Headache/Post nasal drip/ Facial pain/ Heaviness
THROAT: Itching/ Burning/Swallowing difficulty / Dryness / Change of
Voice
EYES: Itching/ Burning / Swelling / Watering eyes
SKIN: Itching/ Burning/ Diffuse swelling / Eczema/ Urticaria
EARS:Itching / Block / Discharge
Past History: IF YES ( Duration in Years) 2. NO
1. Diabetes
2. Hypertension
3. GERD
4. Alcoholic liver disease
5. Pulmonary Tuberculosis
6. Renal disease
7. Connective tissue disease
8. Malignancy
9. Hypothyroidism
10. IHD

14. 11. OSA/HS
12. Surgery (if yes, which)
13. Drug reactions
14. Allergies
Family History: 1.YES 2.NO If yes, Maternal / Paternal
1. Diabetes
2. Hypertension
3. Asthma / Allergic rhinitis
4. Tuberculosis
5. Malignancy
6. Connective tissue disease
Personal History: 1.YES ; Duration in years. 2.NO
Smoking:
Alcohol:
Tobacco chewing:
Other addictions:
History of drug intake including current treatment:
Drug Dosage Duration
1.
2.
3.
4.
5.

15. 6.
`Physical Examination:
Build (Frame) : Small □ Medium □ Large
□
Height (cms): Ideal body weight
Weight (Kgs):
Weight loss(Kgs): In what duration
Waist (cms) Hip (cms)
BMI : Waist-hip ratio
Mid-Arm Circumference (cms) Skin fold thickness (mm)
Temperature: Pulse:
R.R: Blood Pressure:
SpO2: PEFR (L/min) :
AP diameter (cms) Transverse diameter(cms):
AP:Transverse ratio : Chest expansion (cms)
Icterus Clubbing
Cyanosis Pedal edema
Skin Spine
JVP Lymphadenopathy
Systemic examination:
Respiratory System: yes/no
Accessory muscles working :
Intercostal bulging and ribs horizontals:
Widening of subcostal angle
Length of extra-thoracic trachea
Type of breathing
Rhythm/pattern
Auscultation :
Cardiovascular System:

16. Abdomen:
Central Nervous System:
Laboratory Investigations:
Complete Haemogram:
Hb (gm %)
TLC (cu.mm)
DLC P (%)
L (%)
E (%)
M (%)
ESR (mm/hr)
Platelets (cu.mm)
RBS (mg/dl):
Serum Calcium
Serum proteins
Serum albumin
Renal function test :
B.Urea (mg/dl)
S. Creatinine (mg/dl)

17. Serum C-Reactive proteins
Lipid Profile:
Sr cholesterol
Sr triglycerides
Sr LDL
Sr HDL
Sr VLDL
Chest X Ray PA view:
Hyperinflation:
Collapse: Bulla : Localized air-
trapping :
Other
SPIROMETRY (PRE AND POST BRONCHODILATOR):
Pre % pred. Post %pred. %change
FVC
FEV1
FEV1/FVC
PEFR
REVERSIBILTY
6 MINUTE WALK TEST
DISTANCE (metres)
BORG SCALE
Borg Scale for perceived dyspnoea after exertion :
0 nothing at all
0.5 very very slight
1 very slight
2 slight
3 moderate
4 somewhat severe
5 severe
6

18. 7 very severe
8
9 very very severe ( almost maximal )
10 maximal
PRE POST AT HALT
PULSE
BP
RR
SpO2
ABG:
PH
PO2
PCO2
HCO3
ECG:
2D ECHO:
Other Investigations :
SpO2
Morbidity Grade :
1. Patient symptomatology
2. Spirometric abnormalities
3. Presence of complications
The BODE index,
1. FEV1
2. Six-Minute Walk Test
3. MRC Dyspnea Index

19. 4. Body Mass Index (BMI)
Total score :
Medical Management now advised
i. Inhaled medications
ii. Oral medications
iii. Vaccines to prevent infective exacerbations
iv. Anabolic steroids
v. Anti-oxidants
vi. Domiciliary Oxygen
vii. NIV support
vi. Others

20. Psychiatry Guidance for Smoking Cessation
Fagerstrom’s Test for Nicotine dependence
1. How soon after you wake up do you smoke your first cigarette ?
After 60 minutes (0)
31-60 minutes (1)
6-30 minutes (2)
Within 5 minutes (3)
2. Do you find it difficult to refrain from smoking in places where it is
forbidden ?
No (0) Yes (1)
3. Which cigarette would you hate most to give up ?
The first in the morning (1)
Any other (0)
4. How many cigarettes per day do you smoke ?
10 or less (0)
11-20 (1)
21-30 (2)
31 or more (3)
5. Do you smoke more frequently during the first hours after awakening than
during the rest of the day ?
No (0) Yes (1)
6. Do you smoke even if you are so ill that you are in bed most of the day ?
No (0) Yes (1)

21. Nutritional Guidance
Diet History
Appetite
Constipation diarrhea vomiting
Current intake
Food item amount
Morning :Tea/coffee/milk Milk C/B
Breakfast:
Lunch:
Snacks:
Dinner
Nonveg : Chicken
Egg
Mutton
Fish
Oil -Saturated
Unsaturated
Coconut
Groundnut
ENERGY : Carbohydrates :
PROTEINS : Fats :
Recommended food Plan
ENERGY : Carbohydrates :

22. PROTEINS : Fats :
Fooditem Amount
Morning :Tea/coffee/milk Milk C/B
Breakfast:
Lunch:
Snacks:
Dinner
Nonveg : Chicken
Egg
Mutton
Fish
Oil -Saturated
Unsaturated
Coconut
Groundnut

23. INTERPRETATION GUIDELINES :
Spirometry
Obstruction is defined as e/o increase in FEV1 by >200 ml as well as 12% above
pre-bronchodilator levels.
Staging is on the basis of post-bronchodilator values
Stage 1 : Mild : FEV1/FVC % < 70
FEV1 > 80% predicted
Stage 2 : Moderate : FEV1/FVC % < 70
50% < FEV1 < 80% predicted
Stage 3 : Severe : FEV1/FVC % < 70
30% < FEV1 < 50% predicted
Stage 4 : Very Severe : FEV1/FVC % < 70
FEV1 < 30% predicted or
FEV1 < 50% pred. with chronic
respiratory failure
Normal FEV1/FVC is always above 70 %.
Six Minute Walk Test
Standardisation of the six-minute walk test (6MWT) is very important.
At the commencement of pulmonary rehabilitation, the 6MWT must be performed
on two occasions to account for a learning effect. Please note that:
• The best distance walked in metres is recorded.
• If the two tests are performed on the same day, at least 30 minutes rest should
be allowed between tests. Debilitated individuals may require tests to be
performed on separate days, preferably less than one week apart.
• The walking track should be the same layout for all tests for a patient:
o The track may be a continuous track (oval or rectangular) or a point-to-point
(stop, turn around, go) track.
o The track should be flat, with minimal blind turns or obstacles.
o The minimum recommended length for a centre-based walking track is 25m
and could be marked in metre increments.
Note: If you do not have access to a 25m track, make sure you use the same
track for all tests and be aware that the distance walked may be less due to
the patient having to slow down and turn more often in the six minutes.
Before the 6MWT

24. • Ensure that you have already obtained a medical history for the patient and
have taken into account any precautions or contraindications to exercise testing.
• Instruct the patient to dress comfortably, wear appropriate footwear and to
avoid eating for at least two hours before the test (where possible or
appropriate).
• Any prescribed inhaled bronchodilator medication should be taken within one
hour of testing or when the patient arrives for testing.
• The patient should rest for at least 15 minutes before beginning the 6MWT.
• Record:
o Blood pressure.
o Heart rate.
o Oxygen saturation.
o Dyspnoea score.*
o
* Note: Show the patient the dyspnoea scale (i.e. Borg scale) and give
standardised instructions on how to obtain a score.
Instructions for the 6MWT
Instructions and encouragement must be standardised.
Tip: Put the instructions on a laminated card and read them out to each
patient.
Before the Test
Describe the walking track to the patient and then give the patient the following
instructions:
"You are now going to do a six-minute walking test. The object of this test is to
walk as quickly as you can for six minutes (around the track; up and down the
corridor etc… depending on your track set up) so that you cover as much ground as
possible.
You may slow down if necessary. If you stop, I want you to continue to walk
again as soon as possible. You will be regularly informed of the time and you will

25. be encouraged to do your best. Your goal is to walk as far as possible in six
minutes.
Please do not talk during the test unless you have a problem or I ask you a
question. You must let me know if you have any chest pain or dizziness.
When the six minutes is up I will ask you to stop where you are. Do you have any
questions?"
Begin the test by instructing the patient to:
“Start walking now.”
During the Test
Monitor the patient for untoward signs and symptoms.
At the End of the 6MWT
• Put a marker on the distance walked.
• Seat the patient or, if the patient prefers, allow to the patient to stand.
Note: The measurements taken before and after the test should be taken with
the patient in the same position.
• Immediately record oxygen saturation (SpO2)%, heart rate and dyspnoea rating
on the 6MWT recording sheet.
• Measure the excess distance with a tape measure and tally up the total distance.
The patient should remain in a clinical area for at least 15 minutes following an
uncomplicated test.
Normally the clinician does not walk with the patient during the test to avoid the
problem of setting the walking pace. The pulse oximeter should be applied
immediately if the patient chooses to rest, and at completion of the six-minute
walking period. Any delay may result in readings being recorded that are not
representative of maximum exercise response.
If the Patient Stops During the Six Minutes
• Allow the patient to sit in a chair if they wish.

26. • Measure the SpO2% and heart rate.
• Ask patient why they stopped.
• Record the time the patient stopped (but keep the stop watch running).
• Give the following encouragement (repeat this encouragement every 15
seconds if necessary):
“Begin walking as soon as you feel able.”
• Monitor the patient for untoward signs and symptoms.
Stop the Test in the Event of Any of the Following
• Chest pain suspicious for angina.
• Evolving mental confusion or lack of coordination.
• Evolving light-headedness.
• Intolerable dyspnoea.
• Leg cramps or extreme leg muscle fatigue.
• Persistent SpO2 < 85%.
• Any other clinically warranted reason.
Predicted Normal Values for the 6MWT
• Predictive equation for males: 6MWD(m) = 867 – (5.71 age, yrs) + (1.03
height, cm)
• Predictive equation for females: 6MWD(m) = 525 – (2.86 age, yrs) + (2.71
height, cm) – (6.22 BMI).
6MWT as an Outcome Measure
The change in the distance walked in the 6MWT can be used to evaluate the
efficacy of an exercise training program or to trace the natural history of change in
exercise capacity over time.
The minimum important difference (i.e. improvement) in the distance walked in a
6MWT has traditionally been estimated as 54 metres (
Smaller improvements in 6MWT distance may occur in patients who walk a very
short distance (eg less than 200 metres) in their 6MWT before pulmonary
rehabilitation. For these patients, it may be more reasonable to evaluate efficacy
based on the percent change rather than a change in a set number of metres. A
change of 10% has been suggested as clinically important in COPD.

27. Laboratory Parameters
Haematocrit : <35% bad survival prognosis
35-55% Moderate survival prognosis
>55% good survival prognosis
SpO2
Arterial Blood Gases : ( by Definition, PaO2 < 60mm Hg with or without PaCO2 >
50mm Hg when breathing room air is respiratory failure )
Serum Erythropoietin levels
Grading of morbidity :
1. Patient symptomatology
2. Spirometric abnormalities
3. Laboratory & Radiological Parameters
4. Presence of complications
5. Presence of Co-morbidities
The BODE index, a simple multidimensional grading system, is better than the
FEV1 at predicting the risk of death from any cause and from respiratory causes
among patients with COPD( a good prognostic indicator ).
Scoring: Add each of 4 criteria scores for total from 0-10 points
1. FEV1
1. Points 0: FEV1 >64%
2. Points 1: FEV1 50-64%
3. Points 2: FEV1 36-49%
4. Points 3: FEV1 <36%
2.Six-Minute Walk Test
5. Points 0: Walks >349 meters
6. Points 1: Walks 250-349 meters
7. Points 2: Walks 150-249 meters
8. Points 3: Walks <150 meters
3.MRC Dyspnea Index
9. Points 0: Dyspnea Index 0-1
10. Points 1: Dyspnea Index 2
11. Points 2: Dyspnea Index 3
12. Points 3: Dyspnea Index 4-5

28. 4.Body Mass Index (BMI)
13.Points 0: BMI >21
14.Points 1: BMI 21 or less
Interpretation
Higher BODE scores correlate with an increasing risk of death
Interpretation of BMI :
BMI Classification Results
<16 Severe
16-17 Moderate
17-18.5 Mild
18.5-20 Marginal
20-25 Normal
25-29.9 Grade 1 obesity
30-40 Grade 2 obesity
>40 Grade 3 obesity
Interpretation of Waist-Hip ratio :
Normal Male 1 Female 0.85
Interpretation of Triceps skin-fold thickness
14. Psychiatric guidance for Smoking
Cessation
Fagerstrom’s Test for Nicotine Dependence
Interpretation of the scores
0.2 very low dependence

29. 3.4 low dependence
5 medium dependence
6-7 high dependence
8-10 very high dependence