Running head: INTERVENTION

Marquis at Centennial Hills: Intervention Plan

Megan Lawrence
Touro University Nevada

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Occupational Profile
Client
Pam is a 67 year old woman who transferred to Marquis at Centennial Hills, a skilled
nursing facility (SNF), from acute care where she was admitted four days prior due to an
exacerbation of her Chronic Obstructive Pulmonary Disease (COPD). Pam was diagnosed with
COPD five years ago after smoking a half pack of cigarettes a day for the last 45 years. Pam
requires three liters of oxygen to maintain her blood oxygen saturation around 90% and still
occasionally smokes cigarettes. Pam suffers from dyspnea during activities of daily living (ADL)
and instrumental activities of daily living (IADL) secondary to her COPD. As a result, Pam has
high anxiety about independently completing her ADLs and IADLs within the SNF and at home.
Pams high levels of anxiety and decreased activity endurance have led to limitations within
occupational participation and overall quality of life. After her divorce from her husband two
years ago, Pam moved in with her daughter and her son-in-law. They live within a one story
house that has two steps to get into the front door. Pams bedroom has a small bathroom
connected to it, reducing the distance to travel when using the restroom at night. Pam enjoys
living with her daughter and her son-in-law and the company they provide, as she does not get
out of the house often. During the day, Pam enjoys watching her television shows and reading
the latest gossip magazines. Spending most of her time at home, Pam usually only brushes her
hair every couple of days due to increased fatigue. Pam occasionally tries to help her daughter in
meal preparation; however it often results in dyspnea and increased anxiety. Pam is able to
ambulate short distances before needing to sit down and rest. Prior to her COPD diagnosis, Pam
had worked as a clerk at a local grocery store. When standing at the check-out became too tiring,
Pam retired and is currently living on her retirement savings.

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Seeking Services and Concerns

Pam is seeking services to increase her endurance levels and decrease the anxiety
associated with her COPD. Due to Pams high anxiety levels and her decreased activity
tolerance, Pams daughter chooses to complete all the cooking and cleaning around the house.
When returning home Pam would like to assist her daughter within the household duties, as she
is starting to feel like a burden on her daughter.
After Pams diagnosis of COPD and the breathing difficulties and anxiety leading up to
the diagnosis, her grooming routines had gradually started to lessen. Restoring her grooming
routine to its prior level of involvement is an additional concern for Pam, and one that she wants
to increase her independence within. Pam is seeking services to increase her overall
independence in the aforementioned occupations through increasing her endurance and reducing
the resulting anxiety.
Successful and Problematic Areas of Occupation
Pam is successful within the occupation leisure, as she enjoys watching television and
reading magazines while in bed or seated on the couch. While occasionally becoming fatigued
during meals, overall Pam is independent within feeding and enjoys the time with her family. To
increase independence within ADLs and IADLs, Pam is open to modifying activities and
utilizing energy conservation strategies.
As Pams COPD progressed she gradually lessened many of her occupations including;
grooming, meal preparation, work, social participation, and community mobility. Due to
increased fatigue, a problematic area of occupation for Pam is grooming. On average, Pam may
participant within minimal grooming tasks such as brushing her hair or teeth, but does not have
energy to apply make-up or style her hair. An additional problematic area of occupation for Pam

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is meal preparation. Pams increased dyspnea during meal preparation increases her fatigue and
anxiety, resulting in her daughter deciding to taking over all meal preparation tasks. Overall, due
to the progressive nature and the anxiety associated with Pams COPD, her independence within
the majority of previously completed occupations has dramatically decreased.
Contexts and Environments
According to the American Occupational Therapy Association (AOTA) (2014), the
variety of interrelated conditions within and surrounding Pam influence her varying participation
and levels of support to her engagement within her desired occupations. Culturally, Pam comes
from a very family oriented background, making her transition and current living situation one
that Pam and her daughter are comfortable with. Although Pam previously worked part-time, it
was always her responsibility to complete many of the household tasks including the cooking
and cleaning. Currently, Pam becomes too easily fatigued to perform the majority of the
household chores she previously completed; resulting in Pam feeling as if she is a burden on her
daughter.
Personal contextual factors that inhibit Pams participation within desired occupations
include; being within a lower socioeconomic status and having limited education about living
with COPD. Having limited financial resources, Pam believes that she cannot afford additional
medical assistance with her COPD. As a result, Pam has not researched additional resources that
may be available to help mitigate the symptoms associated with chronic COPD. A personal
contextual factor that supports Pams participation within desired occupations is that she is
motivated to learn more about her COPD to help control the associated symptoms including
dyspnea and anxiety.

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Within Pams temporal context, Pam has been residing with her daughter for the past two
years. Currently, within the SNF Pam is expected to stay for three weeks if all goals are met. In
terms of virtual contexts, Pam talks with her daughter most days on the phone and occasionally
communicates through email with her sister who resides in Arizona. Talking with her family
always positively supports Pams mood and motivation to participate within therapy.
Pams physical environment offers both support and opposition in relation to
participating within meaningful occupations. While the SNF has all the medical equipment and
support Pam may need to participate within therapy safely, not being within her natural
environment limits Pams therapy process. Participating in meaningful occupations such as
cooking and grooming during therapy supports Pams goals of being independent within those
occupations when returning home. However, not being able to cook within her kitchen and
perform grooming within her bathroom at home increase the importance of Pams ability to
generalize learned strategies for completing desired occupations when returning home.
In terms of supports and limitations within Pams social environment, one main support
is Pams daughter. Pams daughter is able to assist Pam and provide company during the day, as
she stays at home while her husband works. One main limitation to Pams social environment is
her decreased interactions with people outside of her household. Mainly staying at home all day,
Pam has lost many of her previous social connections and has not tried to gain new ones (AOTA,
2014).
Occupational History
As Pams COPD progresses her participation within meaningful occupations is reduced.
When Pams daughter was younger, a major role in Pams life was being a mother and her
daughters primary caretaker. Pam enjoyed cooking and baking within the kitchen and had

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dinner ready each night when her husband returned home from work. Additionally, Pam was
responsible for maintaining the inside of her home and took great pride in having a clean house.
As aforementioned, Pam worked part-time as a clerk within a local store when her daughter was
in school. This allowed Pam the opportunity to gain social connections, which she had
maintained until a couple years ago. Currently, Pam spends most of her days lying in bed or
sitting on the couch watching television and reading magazines.
Clients Values and Interests
Pam highly values her family and the time she spends with them. Going through her
divorce two years prior further signified the importance of family for Pam, as her daughter was
there for her throughout the entire process. Pam is always interest in spending time with her
daughter; however increased fatigue often limits their activities together. In addition, Pam is also
very interested in baking and cooking, as it was one of her favorite occupations before the
progression of her COPD.
Clients Daily Life Roles and Patterns of Engagement
Residing with her daughter has decreased the roles Pam is responsible for. On a daily
basis, Pams roles include being a friend to her daughter, and occasionally completing small
loads of laundry and other tasks within the house that require minimal physical exertion. Pams
patterns of engagement have changed dramatically over the course of the years due to her COPD,
as discussed within her occupational history.
Clients Priorities and Desired Outcomes
Pams main priority and desired outcome of therapy is to increase her contribution to
tasks within the household when returning home from the SNF. Pam is very thankful to be living
with her daughter and son-in-law, and greatly appreciates all that they do. To show her

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appreciation and to increase her role competence within the household, Pam would like to
occasionally prepare meals for the family. To accomplish this outcome, Pam will need to learn to
utilize effective energy conservation strategies and apply learned techniques to reduce anxiety
when preparing a meal. An additional desired outcome within therapy for Pam is to increase her
feelings of health and wellness through independently completing all desired grooming tasks.
Having greatly reduced her prior level of grooming, Pam is eager to increase her grooming
routines. Pams motivation to increase her participation and independence within the household
is an extremely important factor, as the potential for caregiver fatigue is an important topic to
address for the overall quality of life for the whole family, and will be discussed within the
interventions.
Occupational Analysis
Context and Setting of Occupational Therapy Services
The context in which Pam received occupational therapy services was within a SNF.
Marquis at Centennial Hills is a very warm and welcoming facility that has a full kitchen and
laundry area within the rehabilitation gym. Within the rehabilitation gym there are often several
patients with different therapists, resulting in an occasional wait to use certain equipment.
Additionally, to complete many of Pams ADLs, her therapy occurs within her room. Pams
room within the SNF has a bathroom with a walk-in shower, a sink, and a toilet with grab bars
along the wall. The therapists within the SNF are all very encouraging and enjoy working with
Pam.
Activity Observed and Clients Performance
Arriving to the SNF from acute care, many of the activities observed were ones that
required limited endurance such as transfers to the toilet, feeding while seated, and small

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amounts of time spent on the arm bike. Throughout all the activities observed, the fatigue
throughout the activities was displayed through occasional dyspnea, oxygen saturation levels less
than 90%, and lack of motivation within the activity. Pam was unable to complete any of the
observed activities independently.
Key Observations
From observing Pam complete her ADLs it is clear that energy conservation strategies
are needed. Pam often displayed uncertainty in her abilities in completing an activity and the
anxiety associated with putting forth more effort. Pams movements were slowed and Pam easily
fatigued throughout the therapy session, resulting in decreased occupational performance.
Domains Impacting Success
Pam is an adult woman with COPD currently residing within a SNF. In terms of
occupational performance, there are several domains that are causing limitations to Pams ability
to be successfully engaged within her desired occupations. To begin with, under client factors
Pams limitations in respiratory system functions and structures impact her ability to be
successfully engaged in meaningful occupations. The reduction in endurance and increased
anxiety as a result of her limited respiratory system functions limits Pams overall occupational
performance. Within the performance skills domain; Pam has deficits within endures, paces, and
transports under motor skills. These limitations significantly impact Pams motor skills resulting
in reduced participation within meaningful occupations. Under the domain of performance
patterns; Pam displays deficits within her routines and roles, as she no longer can complete many
of her previous roles and routines (AOTA, 2014).

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Problem Statements
These problem statements were ordered in accordance to their importance to the client and
the overall impact they have on the clients life.
1. Client requires mod (A) in personal hygiene & grooming 2 endurance.
2. Client requires mod (A) in meal preparation 2 fatigue & anxiety.
3. Client requires min A in home maintenance 2
4. Client requires P in community mobility 2

endurance

anxiety.

endurance.

5. Client requires P in shopping 2 anxiety.

First Problem Statement
Client requires mod (A) in personal hygiene & grooming 2 endurance.
Long-term Goal
Client will complete 5/5 grooming tasks (I) while seated within three wks.
Short-term Goal
1. Client will utilize energy conservation techniques while gathering grooming supplies &
performing 3/3 grooming tasks with SPV within one wk.
Intervention
To accomplish Pams first short-term goal, she will be educated and skillfully instructed
on utilizing energy conservation techniques during grooming. The intervention will focus on
reducing Pams energy expenditure, decreasing the sensation of dyspnea, and increasing Pams
occupational performance during grooming. Velloso and Garden (2006) examined the functional
limitations clients with COPD are often subject to when performing ADLs and utilizing
appropriate energy conservation techniques to minimize symptoms. Clients with COPD use
significant amounts of energy to complete ADLs and often have increased sensations of dyspnea

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during the activity. To increase the clients occupational performance, utilizing energy
conservation techniques have been proven effective (Velloso & Garden, 2006).
To gain a better understanding of how Pam has attempted grooming prior to entry into
the SNF and what tasks within the occupation cause the greatest difficulties, an occupational
analysis on grooming will be conducted. Pam would like to first be able to comb her hair, brush
her teeth, and apply her make-up. Once the major difficulties within grooming have been
establish, the intervention will continue with skilled instruction and education into possible
energy conservation techniques to utilize during grooming. For example, Pam should complete
her grooming at times during the day when she has the most energy and be an active member of
planning the activity to increase the likelihood of goal attainment. To conserve energy, Pam will
be educated on adapting the environment and methods to use to fit her needs including; placing a
chair within the bathroom to sit on while grooming, arranging commonly used hair and make-up
products within the same easy to reach location, using a long-handled comb to reduce required
range of motion when combing, and breaking her grooming into smaller tasks to pace herself
throughout the occupation. Once education, Pam will then perform the occupation of grooming
utilizing the discussed energy conservation techniques (Velloso & Garden, 2006).
Intervention approach. The most appropriate intervention approach for the previously
explained intervention is the modify approach. By utilizing energy conservation strategies during
grooming, current activity demands will be adapted to ensure Pams success AOTA, 2014 .
Duration and frequency of intervention. Energy conservation techniques within this
intervention will be utilized over the duration of five times a week for one week. Even after her
first short-term goal and her long-term goal have been achieved, these learned strategies are
intended to be utilized and generalized to all of Pams occupations.

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Progress towards goals. Pams progress towards goals will monitored through the
amount of grooming tasks she can accomplish independently out of three total grooming tasks
each morning that she performs grooming.
Intervention outcome. The intended outcome of this intervention is increased
occupational performance within grooming. Improvement of the occupation of grooming is
required due to limitations in performance as a result of Pams COPD. The outcome of this
short-term goal will contribute to the success of Pams long-term goal through gaining additional
independence in grooming (AOTA, 2014).
Precautions/contraindications. During the intervention Pams oxygen levels will be
constantly measured for an oxygen saturation level below 90 %. Other precautions include being
observant to towards signs of dyspnea and other discomfort Pam may experience.
Framework. The Person-Environment-Occupation-Performance (PEOP) model will be
utilized in this intervention. This model will guide the intervention planning and implementation
by incorporating what the client finds important and the environmental influences that result in
the desired occupational performance. For example, Pam will make the appropriate adaptations
to the bathroom environment by placing a chair by the sink and mirror to reduce her energy
expenditure during grooming OBrien

Hussey, 2012 .

Client/caregiver training and education. Pam and her daughter will both be educated
about energy conservation techniques to utilize during grooming to increase the compliance
when returning home.
Short-term Goal
2. Client will (I) utilize pursed-lip breathing & dyspnea control postures while brushing her
hair & applying make-up within one wk.

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Intervention
During grooming Pam often experiences dyspnea, limiting her occupational performance
and overall participation within the desired occupation. To promotion Pams participation within
grooming, this intervention will focus on education, skillfully training, and implementing pursedlip breathing and dyspnea control postures during grooming activities. Pursed-lip breathing is
thought to prevent tightness in the airway and has been shown to decrease accessory muscle
recruitment while increasing the use of the diaphragm (Mathews, 2013). Integrating pursed-lip
breathing into Pams grooming will assist her in remaining in control of her breathing and in
limiting her dyspnea. In addition to pursed-lip breathing, Pam will also be educated on dyspnea
control postures. Dyspnea control postures are certain postures that can help reduce
breathlessness, especially when utilized during functional activities. When seated in front of the
mirror to complete grooming, Pam will be skillfully instructed to bend forward slightly at the
waist while her upper body is supported on the sink counter (Mathews, 2013).
Once educated, Pam will implement these newly learned techniques during grooming to
reduce her dyspnea and increase her participation within grooming. The therapist will provide
extrinsic feedback as needed, gradually lessening as Pams occupational performance increases.
Intervention approach. The intervention approach that will be utilized is restore. This
intervention aims to restore Pams grooming skills that have been limited due to her COPD
(AOTA, 2014).
Duration and frequency of intervention. Pursed-lip breathing and dyspnea control
postures will be utilized within this intervention and hopefully generalized into other
occupations. This intervention will have a frequency of 5 times a week for one week to allow
Pam to successfully utilize and implement the explained techniques.

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Progress towards goals. Pams progress towards goals will be monitored by her
independent utilization of pursed-lip breathing and dyspnea control postures during grooming
without needing verbal cueing. Additionally, Pams endurance during grooming including time
taken to complete and grooming tasks accomplished will be used to monitor her response to
intervention.
Intervention outcome. Through the intervention, the desired outcome is participation
within grooming. Throughout the years as Pams COPD progressed, her participation within
grooming reduced dramatically. This intervention focuses on utilizing learned techniques to
increase Pams participation within grooming (AOTA, 2014).
Precautions/contraindications. As within any intervention for Pam, her oxygen levels
and dyspnea resulting from her COPD will be closely monitored. The intervention will be placed
on hold if her oxygen saturation levels drop below 90%.
Framework. A compensatory frame of reference (FOR) will be used as the framework to
design and carry-out this intervention. Through utilizing the correct posture modifications, Pams
occupational performance within the occupation of grooming will have the opportunity to
improve.
Client/caregiver training and education. Client education is one of the main aspects of
this intervention. Additionally, Pams daughter will be educated on pursed-lip breathing and
dyspnea control postures to help her mother implement them at home.
Second Problem Statement
Client requires mod (A) in meal preparation 2 fatigue & anxiety.
Long-term Goal
Client will (I) complete a three step meal preparation within 40 min within three wks.

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Short-term Goal
1. Client will divert anxiety 75% of the time during meal preparation utilizing dyspnea selfmanagement strategies with SPV within one wk.
Intervention
The dyspnea associated with Pams COPD often leads to feelings of anxiety when
performing occupations, especially meal preparation. To help Pam reduce her dyspnea and
resulting anxiety during meal preparation, this intervention will focus on self-management
education that Pam can utilize during meal preparation and hopefully generalize to other desired
occupations. Norweg and Collins (2013) completed a systematic review on dyspnea selfmanagement associated with COPD. Self-management education focuses on education on the
problems identified by the patient, collaborative decision making, teaching problem-solving
skills, and increasing knowledge and self-efficacy to promote behavior change. Two of the five
studies reviewed found statistically significant results favoring the experimental groups receiving
self-management education. Utilizing self-management education within the intervention will
assist Pam in improving her dyspnea intensity, dyspnea distress, and dyspnea anxiety throughout
the occupation of meal preparation.
Once the self-management education has been discussed and the key elements within it
identified, Pam will perform a meal preparation activity of her choice within the facilities
kitchen. This will enable Pam to utilize her self-management skills just learned to reduce her
dyspnea and anxiety associated with meal preparation.
Intervention approach. A health and wellness approach will be utilized throughout this
intervention. Self-management education will give Pam additional resources to use for everyday
life including; increased health in terms of physical and mental well-being gained by

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accomplishing her goal of meal preparation and overall wellness achieved through Pam making
choices to use self-management strategies to increase her success (AOTA, 2014).
Duration and frequency of intervention. Effectively utilizing self-management
strategies will require many opportunities for Pam to practice. Therefore, the duration of the
intervention will be the three weeks Pam is within the SNF with a frequency of 5 times a week. It
is intended that Pam reach her short-term goal within one week, and then continue to utilize her
self-management strategies to accomplish her long-term goal within three weeks.
Progress towards goals. Pams progress towards goals will be monitored through
completion of meal preparation, how many steps meal preparation involved, and incidences of
anxiety during meal preparation.
Intervention outcome. The intended outcome of this intervention is increased
occupational performance. Receiving self-management education and practicing its utilization
during meal preparation will assist Pam in increasing her occupational performance within meal
preparation (AOTA, 2014).
Precautions/contraindications. Pams oxygen levels will constantly be measured
throughout this intervention, as meal-preparation requires greater amounts of endurance then
Pam is accustom to. Additionally, completing an intervention within a kitchen presents
precautions such working with sharp objects, being safe around hot surfaces, and not carrying
too much weight during functional ambulation within the kitchen.
Framework. A behavioral FOR will be utilized for the planning and implementation of
this intervention. The anxiety Pam experiences due to her dyspnea during activities greatly limits
her occupational performance, as well as her participation within desired occupations. By
identifying strategies to limit her anxiety within meal-preparation, Pam will be able to participate

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once again within occupations that are meaningful to her. During this intervention, the therapist
will provide positive reinforcement when self-management strategies are noted OBrien
Hussey, 2012).
Client/caregiver training and education. Both client and caregiver will be educated in
self-management strategies to increase their knowledge about COPD and potential problem
solving strategies.
Short-term Goal
2. Client will gather & perform meal preparation using energy conservation strategies with
SPV within one wk.
Intervention
As Pam progresses from her ADLs to IADLS within therapy, her ability to generalize
previously learned strategies to manage her COPD to other occupations and eventually new
environments is crucial. To promote Pams ability to utilize energy conservation techniques
within a different occupation, this intervention will focus on performing meal preparation. As
aforementioned, within one of Pams previous interventions, she was educated on and
implemented energy conservation strategies while performing her grooming routine. Within the
kitchen, ingredients are often further spread out and the need for functional ambulation while
carrying cooking items increases, therefore increasing the need for energy conservation
strategies.
Within a qualitative study examining perceptions of clients with COPD on their
experiences with occupational therapy, one of the main themes identified was a sense of taking
control of the disease and reengagement in activities (Chan, 2004). Occupational therapy
interventions accomplished this through education about COPD, breathing techniques, and

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energy conservation strategies. In addition, participants noted the effectiveness of using energy
conservation techniques not only within reengagement of activities, but as motivation to further
participate in other occupations due to their positive experiences (Chan, 2004). Energy
conservation techniques that Pam will be educated on during this intervention within the kitchen
include; placing commonly used ingredients in same area, having a chair in kitchen to sit when
stirring and during other tasks, sliding pans across the counters to reduce lifting, purchasing precut ingredients, and preparing meals during times of higher levels of energy. During reeducation, Pam will lead the discussion on energy conservation ideas that she could utilize to
asses her ability to generalize between occupations. Once re-education on energy conservation
techniques is completed, Pam will perform meal preparation for a meal of her choice.
Grading up and down. To grade this intervention up, limited external cueing will be
present during the intervention, and contextual interference will be increased through talking to
Pam during meal preparation and having other distractions such as a radio playing. Furthermore,
a time-limit could be set that Pam has to complete the meal within or the amount of rest breaks
taken decreased. To grade this intervention down, more external cueing could be present, set-up
could be completed by the therapist, and increased rest breaks could be allowed.
Intervention approach. The most appropriate intervention approach for this intervention
is restore. Before the progression of her COPD, Pam was the main cook within her household
and it was an occupation she really enjoyed participating within. Restoring Pams ability to
complete meal preparation is the selected strategy to accomplish her goal (AOTA, 2014).
Duration and frequency of intervention. Being an adapted continuation of a previous
intervention, this intervention will occur when completing meal preparation becomes within

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Pams just-right level. The expected duration of this intervention is for two weeks with a
frequency of three times a week.
Progress towards goals. Pams progress towards her goals will be monitored through
evaluating her ability to generalize energy conservation strategies, what level of assistance she
requires during meal preparation, and the length of time meal preparation takes.
Intervention outcome. The intended outcome of this intervention is increased
occupational performance. Receiving further energy conservation education and practicing its
utilization during meal preparation will assist Pam in increasing her occupational performance
within meal preparation (AOTA, 2014).
Precautions/contraindications. Completing this intervention within the kitchen,
precautions associated with it are the same as the previous intervention as aforementioned above.
Framework. The PEOP model will be utilized in this intervention. This model will guide
the intervention planning and implementation by incorporating what the client finds important
and the environmental influences that result in the desired occupational performance. Within
meal preparation, Pam will modify the environment to fit her needs to increase her success
OBrien

Hussey, 2012 .

Client/caregiver training and education. Pam will be further educated on additional

energy conservation strategies that she can utilize during meal preparation as the focus of this
intervention. Pams daughter will also be educated on additional energy conservation strategies
to help her mother in utilizing them in an effort to reduce the amount of assistance Pam requires.
Summary
The following interventions are designed to increase Pams independence within
occupations that are meaningful to her. Through the utilization of evidence-based practice, the

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intervention designs have the clinical utility to be effective for Pams needs with her symptoms
related to her COPD. Through a holistic and client-centered approach, the interventions will
encompass Pams needs and improve her levels of functioning within daily occupations. Pams
increasing independence within her ADLs and IADLs will reduce the amount of assistance she
requires from her daughter, and as a result decrease the potential for caregiver fatigue.

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References
American Occupational Therapy Association. (2014). Occupational therapy practice framework:
Domain and process (3rd ed.).
Chan, S. (2004). Chronic Obstructive Pulmonary Disease and engagement in occupation.
American Journal of Occupational Therapy, 58 (4), 408-415. doi: 10.5014/ajot.58.4.408
Matthews, M.M. (2013). Cardiac and pulmonary disease. In H, M. Pendleton & W. SchultzKrohn Eds. , Pedrettis occupational therapy. Practice skills for physical dysfunction.
(7th ed., pp. 1194-1211). St. Louis, MO: Elsevier Mosby.
Norweg, A., & Collins, E. (2013). Evidence for cognitive-behavioral strategies improving
dyspnea and related distress in COPD. International Journal of COPD, 8, 439-451.
doi:10.2147/COPD.S30145
O'Brien, J. C., & Hussey, S. M. (2012). Introduction to occupational therapy (4th ed., pp.135142). St. Louis, Mo.: Elsevier/Mosby.
Velloso, M., & Garden, J. (2006). Functionality of patients with Chronic Obstructive Pulmonary
Disease and obstructive techniques of energy conservation. Jornal Brasileiro de
Pneumologia, 32(6), 580-586. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/17435910