Episode 59: Patience and Pacing

The goal is to learn , inspire and bring Cardiopulm to the forefront of conversation . Thanks for joining me today and let's get after it . Hello , hello and welcome to today's episode of Talking All Things Cardiopulm . I am your host , Dr . Rachele Burriesci .

So today's episode is titled Patience and Pacing , and we're going to talk a lot about patience and , obviously , pacing in the pulmonary population , but just a couple of things that I've been working on in my personal life . That is sort of hobby and fun kind of follows these same rules , and so I feel like

having patience in certain aspects is very difficult . I think in today's world , where we have such immediate gratification for so many different things , having patience is now maybe a skill , a learned behavior , and I think it's an important thing to be teaching right , whether you have kids or adult children .

I should you know , I'm not a parent , but this is something that is very difficult to teach to your clients and your patience , patience you see the fun word there , so I recently started taking up pizza making . I don't know if I told the story last week , so I'll tell it today . My family is Italian .

We do a lot of things in the world of cooking from scratch , so I make my own sauce for the year . It's this whole project , it's a day experience where you make jars and jars of sauce for the entire year .

We make cookies for Christmas You've heard me talk about these things and there is a part of my culture , heritage , family that I feel when I keep on these traditions . Plus , there's like an expectation . Right , there is nothing like your own sauce . I have tried jar sauce . Not into it .

I'd much rather take canned tomatoes , canned puree and then work it as much as I can . Yes , I've had to do that when we've lived in apartments , when we've run out of jar sauce for the year , when we weren't making jar sauce yet . It's just not the same . So there's like an expectation to it .

And so during COVID apparently , my parents were making pizza and I was like how come ? I don't know how to do this ? They're like well , you know , dad worked in a pizzeria when he was a kid . Of course he knows how to do this . I'm like okay , everyone pause . We know how to make pizza and I don't have this skill in my back pocket .

I'm a New Yorker that lives in the Midwest . When people say , do you want to go get pizza ? My immediate response is usually not really , because it's just never what I want . It's my expectation , just typically isn't met . So my wife likes to tell me that it's not bad , it's different , and so this is something that I now live by .

But when I go home , getting pizza is like a top priority because it just it feels like home and I yes , I take it back with me . I usually travel with a duffel bag filled with

pizza and bagels and it makes it through security . I've got a whole technique down and it holds me over , usually close enough to my next visit . I asked my parents . I was like you need to teach me how to make the dough , and it looked good too Like when they made it . It didn't .

It didn't look like brick oven pizza , it looked like New York style pizza and I was like , oh my God , I need to know how to do this . Long story short , they haven't taught me yet . I probably need to pester a little bit more , do some more FaceTiming for it , but it just hasn't happened . So I decided to learn , look up some recipes .

There's this guy on Instagram that does New York style pizza and it's just like , fired me up a little bit . So patience is a big part of pizza making . You don't just get the dough and make it and have a pizza in 10 minutes . That is not the name of the game .

Like most things that are worth waiting for , this is worth waiting for and of course , there's a time component . So you make the dough , you have to let it rise for an hour or two on the counter . Once it hits a certain level or certain time , then it goes in the fridge

for 24 hours . Then you have to take it out at 24 hours , knead it some more , do a whole bunch of stuff , separate it , put it into two separate pans , put it back in the fridge for another 24 hours . So now we're at 48 hours before you can even think about cooking this pizza , and some people even recommend 72 hours .

So there's just this level of patience . It's not going to be immediate . It is a slow process . Gardening you know , you've heard me talk about gardening . This is my season . The rain season has been on delay and we have literally been in some sort of major storm warning for the last three to four weeks .

We really have lucked out overall and I'm just very grateful for that . But we've gotten a lot of rain and heavy rain with heavy wind , and there's no way you can put a little baby seedling that's just getting some strength in the ground in the garden box in a pot right now . It's just it can't , they won't make it .

So patience , patience on waiting , patience on waiting for the last frost , patience on waiting for the seedlings to be strong enough to put in the ground Everything just takes time and I think sometimes we forget that patience is difficult to do in lots of different scenarios . Right , we just want it done .

And this really had me thinking about my pulmonary patients . So I'm currently re-recording my lectures for my NPTE prep course . So if you are studying for the NPTE and you have that coming up , be on the lookout because that prep course is going to be re-coming out soon .

I have re-recorded and so I'm just digging back into some of these diagnoses and thinking about my patients at the hospital , into some of these diagnoses and thinking about my patients at the hospital ,

and patience is something that I'm constantly teaching , constantly educating on , constantly coaching , because it is not an easy thing to do so with the pulmonary populations , with patients who are in an exacerbation state , patients who are dysmycon exertion patients , who are maybe end stage . Slowing them down is sometimes their best choice to doing more .

And it's so counterintuitive because when you are short of breath , your goal is to get it over with . Get there , get there as fast as I can so I can sit and recover , versus slowing down , being patient , pacing through the activity to then get there .

It takes a lot of time , it takes a lot of control and it's not an easy thing to teach your patients because they're short of breath . They just want to get the task over with . On top of which , we don't have time to take 10 minutes to maybe walk across the room .

We don't have time to take three hours to cook a meal or whatever the task is that they're trying to accomplish . But I promise you this is going to make them more efficient , more capable , increase their function . It's just a really hard sell . I feel like I say that a lot . I'm like this is a hard sell but it works .

So , especially in the pulmonary population , even heart failure . I put them kind of in this piece too , because dyspnea on exertion tends to be their primary symptom .

And when patients are dyspneic , there is fear that they're going to run out of air , and that is a common statement that is said I feel like I'm going to run out of air , I feel like I'm not going to make it there . So what do they do ? They do it fast , and what happens when you do something fast , you are utilizing or needing to utilize more oxygen .

We are trying to have our tissues exchange that oxygen at the tissue level and they are running out , maybe literally . A lot of these patients are typically on oxygen . They're just not efficient . They've had the slow decline in functionality and they've been doing less and less .

So anytime they try to do something , they might tank , and if they're not tanking on their SpO2 , they're feeling dysmic in general . Either one fits this education piece right . You might have the patient who just like tanks , and then you might have the patient whose oxygen stays stable , but they are significantly short of breath .

Stable , but they are significantly short of breath , slowing them down . Talking about pacing with each level of activity and I usually clump in pairing in the same context and I've talked about this with other patients before other podcast episodes .

If you can slow down the task and coordinate the breath with the movement , you tend to get more out of your movement , your function . But it's a hard sell

and it takes time to learn how to coordinate the breathing . And I don't use the same technique for everyone . I almost feel like pacing is the hardest thing to teach a patient because it depends on a number of things . It depends on their breath control .

It depends on their strength , their underlying level of endurance , their underlying level of mobility , endurance , their underlying level of mobility . So sometimes the patients who move well and tank quick are the hardest ones to teach because you have to slow them down .

Slow them down , control their breath , incorporate in through the nose long exhale out with their activity , whether it's every step , every four steps , just a nice coordinated movement .

It has to match up with their abilities , which I think is why it's hard to teach this to both other clinicians and to the patient right , because if you have them over-breathe then that can also cause panic and less efficiency and then less function and then we have a full decline in the wrong direction . If you can coordinate rest breaks , seated or standing .

Coordinate basically per slip , breathing with the activity so that their breath is paced or controlled with the level of movement that they're performing and then regroup so that they don't get into a pant . And once they get into the pant , that is their cue to stop , rest , rescue , breathe , whatever the recovery period looks like for that person .

But you really want to have this rhythmic coordination with your breath control . It is the hardest thing to do because you are thinking about breathing with your activity for a prolonged period of time and we know we're not made to do that because it is an automatic process and it's automatic for a reason .

Right , think about how many things you have to think about in your day . If I had to pay attention to breathing as well , we all know we would not be very good at it .

So taking that voluntary control over your breath with activity is key , and a lot of it has to do with just building patience with pacing , slowing them down enough that their pulse ox is maybe staying in range or just going at a pace that does not make them short of breath . I've had a number of patients tell me this , so I'll share it with you .

I have one guy I'm thinking of from the VA and he's like I just want to keep up with my wife . She always has to stop for me and he felt very embarrassed by that . And that is another component to dyspnea is that there's an embarrassing feeling to it .

You can't keep up with your peers , you can't keep up with your wife , you panic in a grocery store , you panic in wherever you are and you can't make it Right and then ever haven't been able to catch your breath and you feel like you're going to suffocate . It just perpetuates that breathlessness .

So I had this one guy and he would go walking with his wife . It was part of their routine . And he's like I just want to keep up with my wife , I have to go faster . And I kept slowing him down , I kept forcing him to do interval training .

And interval training is such a game of patience for both the clinician and the patient because it's going to take a lot more time . But you become more efficient and eventually can go further and further without stops . Right , if you don't have to stop constantly Because you're panting , you're stopping at a comfortable distance pace .

They will do better because you're not recovering each time . So when I was slowing him down .

He told me this makes me feel embarrassed because I can't keep up with my wife , I can't keep up with my friend group , I can't keep up on the golf course , and we had to have , you know , this conversation and we talked about , well , if you can walk slower and that does force your wife to potentially walk slower with you .

So there is , you know , a piece of this that has to be discussed .

You will be able to go further , longer , at this pace with your wife without having to stop and panic and find a bench out in the park or wherever you are , and you're not going to have that feeling then of breathlessness , panic and potentially embarrassment because you can't get to a safe spot .

If we can slow you down to allow you to go further , longer , even if it's slower , wouldn't that help that overall piece and this was a hard sell , this was a lot of conversation , this was a lot of practice this is also that ability to not only be patient but also to self-reflect on how you're currently feeling in this state , like knowing that stop point

before you get to panic , knowing to stop , rest , rest your breathe in a standing position , so then you could go longer , further .

It takes time , it takes patience from a learning perspective , it takes patience from an education perspective and it physically takes patience in the actual performance of the task because it's going to potentially take longer . The goal , then , is for that rest us to stop and rest before we get to panic and be able to do more and more .

Hopefully , that starts to outweigh each other .

So this is going to be a short one today , but it was a thought that I was having while learning how to make pizza , being patient with the process while being patient with the garden and , of course , treating patients who are short of breath , who have a really hard time slowing down to go further , and so sometimes you really do have to take one step back

to take five steps ahead . It's a hard sell , it's not an easy sell , and it takes time for the clinician to teach it , as well as the patient to not only get on board but to learn that process . So think rhythmical breathing in through the nose , out through the lips .

You could pace with the number of steps , you can pace with time , you can pace with simply comfort . So once that breathing starts to come out of that normal maybe two to four ratio , and you start to see the change in breath control . That's your cue to stop before you get into pant . So it's different for every patient , which makes it hard to teach .

But if you slow your patient down , you essentially create intervals to stop and rest potentially in standing versus sitting if needed or if they're able to , and then continue before they hit panic . It will build their overall tolerance and ability and potential function . Tolerance and ability and potential function .

Same can be true for prepping meals , performing laundry , cleaning the home , where you know that you can tolerate X number of minutes , x number of time in standing , this amount of activity with paced breathing , and take a forced rest break . It's going to take longer , it's going to take patience .

Patients want to rush and get it done and you have to do everything in your power to prevent that feeling of rushing just getting it over with , because they will not benefit long-term from that consistent cycle of shorter breath , panic recover .

Shorter breath , panic , recover . You want them to slow down , pace , rest continue . Slow down , pace , rest , continue and hopefully the function increases , the endurance increases and hopefully the function increases , the endurance increases versus panic recover . Desat that picture right . Slow it down , go further , take more breaks . It's a hard sell .

It takes patience , and when I tell you from a clinical side of things , where there might be a time crunch for seeing patients , this takes more time . It takes patience on your side to not get frustrated . It takes patience to get cueing correct because , I'm telling you , every single patient learns it differently .

Every single patient adjusts differently and it's not just like learning a paired breathing You're going to breathe on the way up and on exhale on the way down . It's not that simple because it's not that easy to instruct . It takes discipline from the patient perspective . It takes trying different verbiage , instructions , timing , with the clinical side of things too .

One other tip I will give in this regard sometimes is just utilizing a pinwheel , and so I do this a lot with either treadmill , walking or new step or arm ergometer . I just place the pinwheel in a spot that they can maintain breathing and I have them pace their breath with pursed lip breathing so that the pinwheel spins on exhale .

And the reason why I do that is because it tells me when the patient switches to open mouth breathing versus controlled pursed lips , once that pinwheel stops spinning , that's their cue to rest . Or you can utilize SpO2 as well , or you can utilize a dyspnea scale and have them stop when they're at a 2 out of 10 or a two out of four on the breathing scale .

You can do this a number of different ways , but at the end of the day , what you're trying to do is get more time , more function , while slowing down and learning how to pace so that you can eventually go further . So we want to take them out of that panic , recover , deset , do it again . We want to slow down , pace , rest , continue , okay .

So I want you to try this out . I want you to let me know how it goes . Tell me what you struggle with in teaching this . Tell me what you've seen your patients struggle with .

This is the part where it takes trial and error and I promise you every single patient has a different cue that just clicks and sometimes , from your perspective , it takes patience to get there because not everyone is going to follow the same rules , not everyone's going to get the same cue , and sometimes it just takes trying different techniques , trying different

pacing on different devices . Like I said before , like treadmill versus new step versus level ground walking If you think I haven't held a pinwheel in front of someone's mouth while they're level ground walking .

You know for a fact that I have done this and it works because it allows you to have a visual feedback as well as the patient , and that's the cue right . The cue is for them to learn to stop before they have to . It takes in the whole concept of interval training .

You have to be patient , you have to pace and you have to slow it down sometimes to get further and hopefully over time that can build so that eventually that they do become more functional , increase their endurance , so on and so forth .

So patience and pacing is a huge piece of teaching patients with pulmonary disease and even heart failure to do more for longer . But sometimes they have to slow down and be patient . So hopefully that was helpful for you . Let me know how that was . Let me know if that was something that you can use in practice .

Let me know if you have problems with cueing or difficulty with getting your patients to pace , and that can also help me steer different instructions . But I promise it does take different words with each patient . Trial and error . Try the pinwheel , try using time , try using steps .

You can do it with stairs , you can do it with anything that takes a rhythmic movement and you just have to coordinate that breath to the movement in a nice controlled way and once they start to hit change in pattern or panic , you're stopping before you hit that point . All right , let me know if that works . Let me know if that was helpful .

Thank you for being here . Thank you for listening . If you found this helpful , share it with a friend , drop some stars , write a great review . It is all appreciated . I hope you all have a wonderful day and , whatever you have to do , a good afternoon .