Home Management of COPD with BiPAP Support: A Fictional Patient Case Study
A detailed clinical documentation of how structured home healthcare, pulmonary rehabilitation, and BiPAP therapy supported recovery after a severe COPD exacerbation with Type II respiratory failure.
Patient Background
Ramesh Chawla, a 69-year-old retired textile mill supervisor, lived in Panipat, Haryana, with his wife Sunita Chawla, aged 65. His son, a mechanical engineer based in Delhi NCR, provided secondary support during medical emergencies and follow-up visits. Ramesh had spent over three decades working in a textile mill environment before retirement, an occupational setting associated with prolonged exposure to cotton dust and particulate matter.
He had been living with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) for nearly 12 years. Throughout this period, his breathing had gradually worsened despite regular use of prescribed inhalers. His smoking history was significant. He had accumulated 40 pack-years of exposure before quitting during his recent hospitalization. A pack-year history of this magnitude represents a major, well-documented risk factor for COPD progression and respiratory failure.
Beyond his respiratory condition, Ramesh carried several associated medical diagnoses. He had been managing hypertension for approximately 10 years. He also had Gastroesophageal Reflux Disease (GERD), which is commonly seen alongside COPD and can worsen respiratory symptoms when stomach acid irritates the airway. Additionally, he had been diagnosed with mild pulmonary hypertension, a condition where the blood pressure in the arteries of the lungs rises above normal, adding strain to the right side of the heart.
The combination of long-standing COPD, a heavy smoking history, occupational dust exposure, and associated conditions like GERD and pulmonary hypertension placed Ramesh in a high-risk category for acute exacerbations. Patients with this profile are particularly vulnerable during winter months when cold air, indoor pollution, and seasonal infections converge. This is a pattern frequently observed in cities across the Delhi NCR region, including Panipat. Understanding how industrial dust affects retired workers’ lung health is essential for planning appropriate long-term care.
Prior to this admission, Ramesh was managing his daily activities with increasing difficulty. He could walk independently indoors but required rest after short distances. Climbing stairs had become a significant challenge. His wife Sunita managed most household responsibilities and served as the primary caregiver, though she had no formal medical training. This is a common situation in Indian households where family members assume caregiving roles without structured guidance.
During winter, his symptoms worsened considerably. He developed severe breathlessness, a persistent cough producing thick sputum, and his oxygen levels dropped to concerning levels. These are classic signs of a COPD exacerbation, which is defined as a sudden worsening of COPD symptoms beyond normal day-to-day variation. When his condition did not improve with his usual medications at home, his family sought emergency hospital care.
Clinical Diagnosis
Upon hospital admission, Ramesh was diagnosed with an acute exacerbation of COPD leading to Type II (hypercapnic) respiratory failure. Type II respiratory failure is a serious condition where the lungs fail to remove enough carbon dioxide from the blood, causing CO2 levels to rise. This is different from Type I respiratory failure, where the primary problem is low oxygen without high CO2. In COPD patients, Type II failure typically occurs when the breathing muscles become too fatigued to maintain adequate ventilation.
Respiratory Assessment Findings
The clinical respiratory assessment revealed several important findings. Bilateral reduced air entry was noted on auscultation, meaning that air movement was diminished in both lungs. Expiratory wheeze was present, indicating narrowed airways during breathing out. There was mild use of accessory respiratory muscles, which means Ramesh was using the muscles in his neck and chest to help breathe, a sign of increased breathing effort. He had a productive cough with small amounts of sputum. He was able to speak in complete sentences while resting, which suggested his respiratory distress, while significant, had not yet reached a critical point where speech was limited to single words.
Disease-Specific Severity Markers
| Assessment Parameter | Finding | Clinical Significance |
|---|---|---|
| Six-Minute Walk Test (6MWT) | 165 meters | Well below the predicted range for his age group, indicating severe exercise limitation |
| mMRC Dyspnea Grade | Grade 3 | Walks slower than people of the same age on level ground, or has to stop for breath after walking about 100 meters |
| BiPAP Dependency | Required during sleep | Indicates that his respiratory muscles could not maintain adequate ventilation independently at night |
| Sputum Production | Productive, small amounts | Suggests ongoing airway inflammation and possible chronic bronchitis component |
This diagnosis required immediate intervention with Non-Invasive Ventilation (BiPAP) in the ICU. Without this support, rising carbon dioxide levels can lead to drowsiness, confusion, and potentially life-threatening respiratory arrest. The decision to initiate BiPAP was medically critical and time-sensitive.
Vital Signs at Initial Home Assessment
| Parameter | Value | Reference Range |
|---|---|---|
| Blood Pressure | 134/82 mmHg | Slightly elevated, consistent with his hypertension history |
| Heart Rate | 90 bpm | Upper normal range, possibly reflecting respiratory effort |
| Respiratory Rate | 22/min | Elevated (normal 12-20), indicating increased breathing demand |
| Temperature | 98.5 degrees F | Normal, no active fever at assessment |
| Oxygen Saturation (Room Air) | 94% | Borderline low for a COPD patient; target typically 88-92% |
| Oxygen Saturation (With Support) | 97% | Improved with prescribed oxygen, confirming ongoing need |
Hospital Treatment
Ramesh was admitted to the hospital for a total of 13 days. The first four days were spent in the Intensive Care Unit, where his respiratory failure was actively managed. The ICU stay was necessary because Type II respiratory failure requires close monitoring of blood gases, conscious level, and ventilatory support settings that cannot be safely provided on a general ward.
ICU Interventions (Days 1 to 4)
Non-Invasive Ventilation using a BiPAP machine was the cornerstone of his ICU treatment. BiPAP delivers two levels of pressure: a higher pressure during inhalation (IPAP) to help push air into the lungs, and a lower pressure during exhalation (EPAP) to keep the airways open. This reduces the work of breathing and helps clear carbon dioxide. Understanding the role of BiPAP machines in home ICU settings is important for families whose loved ones require this support after discharge.
Alongside BiPAP, he received oxygen therapy titrated to maintain safe saturation levels. In COPD patients, excessive oxygen can actually suppress the breathing drive and worsen carbon dioxide retention, so careful titration is essential. Intravenous antibiotics were administered to treat the underlying infection that likely triggered the exacerbation. Nebulization was performed every 4 to 6 hours to deliver bronchodilator medications directly to the airways. Corticosteroid therapy was given to reduce airway inflammation. Chest physiotherapy was initiated to help clear secretions from the lungs.
The treating team chose Non-Invasive Ventilation (BiPAP) rather than intubation and mechanical ventilation. This decision was clinically appropriate because Ramesh was conscious, able to cooperate with the mask interface, and did not have absolute contraindications like facial trauma or inability to protect his airway. BiPAP avoids the complications of invasive ventilation, such as ventilator-associated pneumonia, and allows the patient to communicate and participate in care. For patients who continue to need this support at home, BiPAP and CPAP care at home for seniors requires proper setup and monitoring.
Ward Care and Rehabilitation (Days 5 to 13)
After his respiratory status stabilized and he was transferred out of the ICU, the focus shifted to pulmonary rehabilitation and preparation for discharge. Smoking cessation counselling was provided, which led to Ramesh quitting smoking after 40 pack-years of exposure. This is arguably the single most important intervention for slowing COPD progression, and the fact that he quit during this admission was a significant positive step.
Pulmonary rehabilitation exercises were introduced gradually in the hospital setting. These included breathing techniques, supervised mobilization, and education about energy conservation. The rehabilitation team also assessed his home environment and family support system to determine whether home-based care would be safe and appropriate after discharge.
Discharge Status
At the time of discharge, Ramesh had improved compared to his admission. However, he remained significantly limited. He was still dependent on night-time BiPAP. His exercise tolerance was poor. He became breathless with minimal activity. The pulmonology team recognized that sending him home without structured support would carry a high risk of readmission. This is a well-documented concern in COPD care. Studies show that the period immediately after hospital discharge is one of the most vulnerable times for COPD patients, with readmission rates within 30 days being substantial.
The transition from hospital to home is a critical period for elderly patients with chronic conditions. Medical guidelines for safe recovery at home after hospital discharge emphasize the need for structured monitoring during the first weeks. Patients can appear stable at discharge but deteriorate rapidly once the safety net of hospital monitoring is removed.
Why Home Healthcare Was Needed
The decision to recommend comprehensive home healthcare was not arbitrary. It was based on specific clinical needs that Ramesh had at the time of discharge. Each need corresponded to a clear medical rationale.
Continued BiPAP Monitoring
Ramesh needed BiPAP every night to maintain adequate ventilation during sleep. Without proper mask fitting, correct pressure settings, and regular compliance monitoring, the therapy could fail silently. His wife Sunita, though dedicated, had no training in managing BiPAP equipment. A poorly fitted mask causes air leaks, skin breakdown, and patient discomfort, all of which lead to non-compliance. When a COPD patient does not use BiPAP as prescribed overnight, carbon dioxide levels can rise to dangerous levels by morning. This is one of the key nighttime dangers for elderly patients that home nursing helps address.
Oxygen Therapy Management
He required prescribed oxygen support to maintain his saturation within the target range. As noted earlier, COPD patients require carefully controlled oxygen levels. Too much oxygen suppresses the hypoxic drive to breathe, while too little causes tissue hypoxia. Managing oxygen therapy at home in a clinical setting requires regular saturation checks, flow rate adjustments based on activity level, and awareness of when to increase or decrease support.
Pulmonary Rehabilitation Continuity
The rehabilitation started in the hospital needed to continue at home. Stopping pulmonary rehabilitation after discharge leads to rapid deconditioning. The muscles that support breathing weaken further, exercise tolerance declines, and the patient often ends up in a worse state than at discharge. Home-based pulmonary rehabilitation for COPD patients has been shown in clinical studies to improve exercise capacity, reduce breathlessness, and enhance quality of life when delivered consistently.
Medication Adherence and Nebulization
Ramesh had multiple respiratory medications including inhalers and nebulized medications. Correct inhaler technique is frequently inadequate in COPD patients, even after hospital education. Nebulizer therapy at home requires proper equipment cleaning, correct medication preparation, and timing around meals and activities. Missing doses or using incorrect technique directly affects symptom control and increases exacerbation risk.
Early Detection of Deterioration
One of the most important reasons for home nursing is the early detection of warning signs. COPD exacerbations can escalate quickly. A slight increase in sputum volume, a change in sputum color, a small drop in oxygen saturation, or increasing breathlessness at rest can signal the start of an exacerbation hours before it becomes obvious to an untrained family member. Recognizing early warning signs in elderly patients at home allows timely medical intervention, potentially preventing another ICU admission.
Caregiver Support and Education
Sunita, at 65 years old, was managing her husband’s care alone for most of the day. Caregiver burden in chronic respiratory disease is well documented. Without training and support, caregivers experience stress, anxiety, and fatigue, which can affect the quality of care they provide. The difference between professional home nursing and basic patient care becomes critical in complex cases like this one, where the patient depends on multiple medical devices and medications.
In summary, home healthcare was needed because Ramesh was discharged with active medical devices (BiPAP, oxygen concentrator), required multiple daily treatments (nebulization, breathing exercises, medications), had significant functional limitations, and carried a high risk of readmission. His wife, despite her dedication, needed professional support to manage this complexity safely. A home ICU setup at home with trained nursing provided the safety net that the hospital discharge team had identified as necessary.
Home Care Plan by AtHomeCare
The home care plan was structured around Ramesh’s specific clinical needs. Each component was chosen based on the assessment findings and the pulmonologist’s recommendations. The plan was not generic. It was tailored to his diagnosis, his functional level, his home environment, and his family situation in Panipat.
Home Nursing
A trained home nurse was assigned to provide daily care. The nurse’s responsibilities were clearly defined and went beyond basic assistance. Every morning, the nurse performed a respiratory assessment that included checking Ramesh’s breathing pattern, listening to his chest with a stethoscope, assessing his sputum (color, volume, consistency), and measuring his oxygen saturation using a pulse oximeter. These daily assessments created a record that helped track trends over time, making it easier to detect subtle deterioration before it became obvious.
Oxygen saturation monitoring was performed multiple times a day, not just once. Saturation was checked at rest, during activity, and after nebulization. This multiple-check approach is important because a patient might maintain acceptable saturation at rest but drop significantly during even minor exertion. The nurse also monitored BiPAP compliance by checking the machine’s usage data each morning, noting how many hours Ramesh had used the device and whether there were any air leak alerts.
Medication administration was another key responsibility. The nurse ensured that inhalers were taken at the correct times, with proper technique, and using a spacer if prescribed. Medication monitoring and management at home is particularly important for elderly patients with multiple prescriptions, as the risk of errors increases with the number of medications. Blood pressure was monitored daily because of his hypertension history and because blood pressure can fluctuate with respiratory status. Infection surveillance was ongoing, with the nurse watching for fever, increased sputum purulence, or worsening cough.
The nurse also provided patient education on breathing techniques, including pursed-lip breathing and diaphragmatic breathing. These techniques help reduce the feeling of breathlessness by slowing the breathing rate and keeping airways open longer during exhalation. Teaching these techniques requires more than simply demonstrating them once. The nurse reinforced them daily and corrected any errors in technique.
Patient Attendant
In addition to the nurse, a patient care attendant was assigned to provide support during the hours when the nurse was not present. The attendant’s role was focused on safety and daily functioning rather than clinical tasks. This included providing assistance during episodes of breathlessness, which could be frightening for both Ramesh and Sunita. Having a trained person present who knew how to position the patient, calm him down, and determine whether the episode required medical escalation provided significant reassurance.
The attendant supported equipment cleaning, which is essential for preventing infections. BiPAP masks, tubing, and humidifier chambers need regular cleaning according to manufacturer instructions. The attendant also supervised Ramesh during walking, which was important for fall prevention given his breathlessness and the mild ankle swelling noted in his assessment. Meal preparation assistance ensured that he received small, frequent, nutritious meals that were easier to eat without triggering breathlessness. Energy conservation techniques, such as pacing activities and sitting during tasks like grooming, were reinforced throughout the day.
Physiotherapy
A physiotherapist visited regularly to deliver a structured pulmonary rehabilitation program. The goals were specific and measurable: improve breathing efficiency, clear secretions from the airways, increase exercise tolerance, strengthen respiratory muscles, improve posture (which affects breathing mechanics), and reduce breathlessness during daily activities.
The rehabilitation program included breathing exercises such as diaphragmatic breathing, pursed-lip breathing, and segmental breathing to improve ventilation in different parts of the lungs. Chest physiotherapy techniques, including postural drainage and percussion, were used to help mobilize and clear secretions. An incentive spirometer was provided as part of the medical equipment setup to encourage deep breathing and prevent atelectasis (collapse of small air sacs in the lungs).
Exercise training was introduced gradually and progressed based on Ramesh’s tolerance. This included walking exercises, lower limb strengthening, and upper limb exercises. The key principle was to push Ramesh enough to improve his fitness without pushing him to the point of severe breathlessness or exhaustion. Indoor physical activity and breathing exercises for elderly patients must be carefully calibrated, especially during the initial weeks after a hospitalization.
Doctor Home Visit
A pulmonologist conducted home reviews every two weeks. These visits served multiple purposes. The doctor assessed Ramesh’s respiratory status through physical examination and review of the daily nursing notes. BiPAP settings were reviewed and adjusted if needed based on comfort, compliance data, and clinical response. Inhaler medications were reviewed and adjusted. Oxygen therapy requirements were re-evaluated. Perhaps most importantly, the doctor actively worked to prevent future exacerbations by identifying and addressing risk factors early.
Having a specialist visit the home rather than requiring Ramesh to travel to a clinic was a significant advantage. Travel, especially in winter, can trigger breathlessness and expose him to cold air and infections. COPD winter care strategies emphasize minimizing unnecessary exposure to triggers, and home visits directly support this goal.
Medical Equipment at Home
The following equipment was set up in Ramesh’s home as part of the care plan. Each piece served a specific clinical purpose:
| Equipment | Purpose | Monitoring Responsibility |
|---|---|---|
| BiPAP Machine | Provides non-invasive ventilatory support during sleep to maintain adequate ventilation and reduce CO2 retention | Nurse checks compliance daily; doctor reviews settings biweekly |
| Oxygen Concentrator | Delivers supplemental oxygen during waking hours to maintain saturation within prescribed target | Nurse monitors saturation and adjusts flow as needed |
| Nebulizer | Converts liquid bronchodilator medication into fine mist for direct airway delivery | Nurse administers and documents response; attendant cleans equipment |
| Pulse Oximeter | Non-invasive measurement of oxygen saturation and heart rate | Nurse records readings multiple times daily |
| Blood Pressure Monitor | Daily blood pressure tracking given hypertension history | Nurse records morning readings; reports deviations |
| Fowler Hospital Bed | Allows adjustable positioning for optimal breathing comfort and reduced reflux | Attendant adjusts position; nurse assesses comfort |
| Incentive Spirometer | Encourages sustained deep breathing to improve lung expansion | Physiotherapist guides use; nurse monitors compliance |
A regular flat bed makes breathing harder for COPD patients, especially those with GERD. The Fowler bed allows Ramesh to sleep with his upper body elevated, which reduces the work of breathing by allowing the diaphragm to move more freely. It also helps prevent acid reflux, which can trigger coughing and bronchospasm. Premium hospital beds enhance patient comfort in ways that directly affect clinical outcomes, not just convenience.
Structured Daily Care Plan
The day was organized around Ramesh’s respiratory needs, energy levels, and treatment schedule. A structured routine reduces unpredictability, which in turn reduces anxiety, a known trigger for breathlessness in COPD patients.
| Time Block | Activities | Responsible |
|---|---|---|
| Morning | Oxygen saturation check, morning inhalers, nebulization, deep breathing exercises, high-protein breakfast, short supervised walk | Nurse, Attendant |
| Afternoon | Pulmonary rehabilitation exercises, hydration, lunch, rest period, controlled breathing practice | Physiotherapist, Attendant |
| Evening | Walking session, chest expansion exercises, nebulization if prescribed, medication review, family interaction | Nurse, Physiotherapist, Family |
| Night | Light dinner, BiPAP setup and mask fitting, sleep with respiratory support, overnight comfort monitoring | Nurse/Attendant |
COPD patients often experience reduced appetite and unintended weight loss. Eating large meals can cause breathlessness because a full stomach presses against the diaphragm. The care plan addressed this by encouraging small, frequent, high-protein meals. Nutrition and hydration management for elderly patients is a component that is sometimes overlooked but directly affects respiratory muscle strength and immune function.
Risks Being Monitored
Throughout the home care period, the clinical team maintained active surveillance for several specific risks. Each risk was monitored with defined parameters, so that any deviation would trigger a predefined response.
Recovery Timeline
The recovery was not linear. There were good days and difficult days. The timeline below documents the key milestones and clinical observations throughout the 10-week home care period.
The home care team arrived at Ramesh’s residence in Panipat. Initial assessment confirmed the discharge findings: oxygen saturation 94% on room air, respiratory rate 22/min, noticeable use of accessory muscles during speech, and visible anxiety about being home after the ICU experience. BiPAP machine, oxygen concentrator, and other equipment were set up and tested. Sunita was visibly relieved to have professional support but also anxious about whether she could manage the equipment.
Nursing intervention: Complete baseline assessment, equipment setup and demonstration, first BiPAP trial at home with mask fitting adjustment. Patient response: Ramesh was cooperative but tired. He expressed fear about another hospitalization. Family observation: Sunita said she had not slept well for days worrying about managing the BiPAP machine alone.
The daily care plan began to take shape. Morning nebulization and breathing exercises were introduced. Ramesh managed a short walk of approximately 30 meters within the home with supervision. BiPAP compliance for the first two nights was around 4 hours per night, below the target of at least 6 hours. Mask discomfort and air leaks were identified as the primary barriers.
Nursing intervention: Mask refitting, adjustment of strap tension, application of barrier cream to prevent skin breakdown. Patient response: Reported better sleep quality on the second night after mask adjustment. Doctor review: None at this stage; care managed per discharge plan.
By the end of the first week, Ramesh had adapted to the home routine. BiPAP compliance improved to approximately 5.5 hours per night. He could walk 40 to 50 meters with one rest stop. Sputum production remained stable with no change in color or volume, which was a reassuring sign that no new infection was developing. His appetite remained poor, and he had not gained weight.
Nursing intervention: Continued education on energy conservation during daily activities. Introduced small, frequent meals with emphasis on protein intake. Physiotherapy: Initial assessment completed; gentle breathing exercises started; walking distance set as a baseline for tracking. Family observation: Sunita reported feeling more confident with the equipment and said she could now clean the BiPAP mask independently.
The pulmonologist conducted the first home visit. Respiratory examination showed bilateral wheeze was less prominent than at discharge. BiPAP data showed compliance averaging 6 hours per night, which was an improvement. Oxygen saturation was stable at 95% with prescribed oxygen during the day. Blood pressure was 130/80 mmHg, which was within an acceptable range given his hypertension. Walking distance had increased to approximately 70 meters.
Doctor’s actions: BiPAP settings were reviewed and found to be appropriate. Inhaler regimen was confirmed. The doctor counseled Ramesh on the importance of continuing smoking cessation and avoiding exposure to winter pollution. The next review was scheduled for two weeks later.
By the fourth week, the improvements became more noticeable. Ramesh could walk approximately 120 meters before needing to stop, more than double his initial distance. BiPAP compliance had reached 7 to 8 hours per night. His breathing exercises had become more natural, and he was using pursed-lip breathing during activities without being reminded. His appetite had improved, and he was eating regular small meals. Sputum had reduced in volume.
Nursing intervention: Increased walking distance targets. Continued reinforcement of breathing techniques during functional activities like bathing and dressing. Physiotherapy: Added lower limb strengthening exercises. Introduced chest expansion exercises with the incentive spirometer. Family observation: Ramesh’s son visited from Delhi NCR and noted visible improvement in his father’s energy levels and mood.
At the eight-week mark, Ramesh was walking 200 to 250 meters with one or two brief rest stops. His mMRC dyspnea grade had improved from Grade 3 to Grade 2, meaning he now became breathless only after walking about 200 meters on level ground, a meaningful functional improvement. BiPAP compliance exceeded 90%. He had gained approximately 1 kg of body weight. No respiratory infections or exacerbations had occurred during the entire period.
Doctor’s actions: The pulmonologist reviewed progress and noted that the home rehabilitation program was delivering results consistent with hospital-based pulmonary rehabilitation. Oxygen flow rate was reviewed and maintained at the current prescribed level. The doctor discussed weaning possibilities but decided to continue the current plan for the remaining weeks before considering any changes.
The 10-week mark brought a comprehensive reassessment. Walking distance had reached nearly 300 meters. The Six-Minute Walk Test improved from 165 meters at baseline to 340 meters, more than double the initial distance. BiPAP compliance exceeded 95%. Breathlessness during daily activities had reduced significantly. Oxygen saturation remained stable within the prescribed range. He had gained a total of 1.8 kg. No hospital readmissions had occurred during the entire rehabilitation period.
Doctor’s final assessment: The pulmonologist documented the improvement and recommended continuing home-based pulmonary rehabilitation at a reduced frequency. BiPAP was continued as the patient remained dependent on night-time support. A follow-up schedule was established for ongoing monitoring. The family was educated on long-term management principles.
Clinical Evidence
The following tables present the clinical measurements documented during the 10-week home care period. All values are drawn directly from the documented assessments. No values have been estimated or inferred.
Functional Improvement Over Time
| Parameter | At Discharge (Baseline) | Week 4 | Week 10 |
|---|---|---|---|
| Walking Distance Before Rest | 50 meters | 120 meters | Nearly 300 meters |
| Six-Minute Walk Test | 165 meters | Not retested | 340 meters |
| mMRC Dyspnea Grade | Grade 3 | Grade 2 to 3 | Grade 2 |
| BiPAP Night Compliance | Not yet established at home | 7 to 8 hours | Exceeded 95% |
| Body Weight Change | Baseline (not documented) | Approximately +1 kg | +1.8 kg total |
Stability Indicators Maintained Throughout
| Parameter | Status Over 10 Weeks |
|---|---|
| Oxygen Saturation | Remained stable within prescribed range |
| COPD Exacerbations | None occurred |
| Respiratory Infections | None occurred |
| Hospital Readmissions | None during the rehabilitation period |
| Blood Pressure | Stable around 130-134/80-82 mmHg range |
| Sputum Character | Remained stable, reduced in volume over time |
Functional Independence Status
| Activity Category | Required Assistance | Independent |
|---|---|---|
| Eating | Yes | |
| Bathing | Yes | |
| Grooming | Yes | |
| Medication Understanding | Yes | |
| Communication | Yes | |
| Personal Decision-Making | Yes | |
| Indoor Walking | Yes | |
| Transfers (bed to chair) | Yes | |
| Outdoor Walking | Supision required | |
| Shopping | Assistance required | |
| Heavy Household Work | Assistance required | |
| Climbing Multiple Flights of Stairs | Assistance required | |
| Equipment Maintenance | Assistance required | |
| Transportation for Follow-up | Assistance required |
Medical Authority
