By: Khushali joganiThe Sarvajanik College Of

Physiotherapy,Rampura,Surat

PULMONARY REHABILITATION

IntroductionDefinitionsTeam membersSymptomsPathophysiologyAims or goals of Pulmonary RehabilitationSelection of patientAssessmentPulmonary rehabilitation componentsPhysical therapy careRecent advancesReferences

CONTENTS

Rehabilitation programs for patients with pulmonary disease have existed for more than 25 years.

The American Thoracic Society position paper and most of the research have shown the benefits of rehabilitation for patients with COPD.

The need for early detection and treatment of respiratory dysfunction is widely accepted.

Rehabilitation research is beginning to emphasize functional outcomes such as improvement in lung function, heart function, to improve maximal aerobic capacity and decrease mortality rate.

It is concerned with the issues of disability.

Pulmonary Rehabilitation as defined by National Institute of Health(1994) is “A multi-disciplinary continuum of services directed to persons with pulmonary disease and their families, usually by an interdisciplinary team of specialists, with the goal of achieving and maintaining the individual’s maximum level of independence and functioning in the community”

Physiotherapists play an integral part in management by giving the techniques aimed to reduce the work of breathing and improving disability.

It is an holistic approach to treatment of patients and their families with respiratory disease and requires number of health professionals such as:

The Advisory Board The Medical Director The Program Director The Respiratory Care Specialist The Exercise Specialist The nutritionist or Dietitian The Behavior Specialist

The main symptom is dyspnoea which is associated with anxiety and fear.

Limitations during daily life and reductions in exercise tolerance

Leg fatigue at lower work intensities compared to normals.

Symptoms

Peripheral muscle dysfunction

Atrophy of musclesAltered

metabolism

Reduction in type I &II

fibres

Corticosteroid

damage

Cachexia and cytokine production

Nutritional defects

Pathophysiology

Reduce dyspnoea Increase muscle endurance(peripheral and

respiratory) Improve muscle strength(peripheral and

respiratory)Ensure long term commitment to exerciseTo remove fear and anxiety Increase knowledge of lung condition and

promote self-management Improve nutritional status and health status

Aims and Goals of Pulmonary Rehabilitation

How to select patients for rehabilitation

Inclusion criteria

Exclusion criteria

Obstructive disease -emyhysema -bronchitis -bronchiectasis etcRestrictive disease -idiopathic pulmonary fibrosis -sarcoidosis etc

Inclusion criteria

Exposure to risks for COPD -cigarette smoking -occupational exposure -air pollution -infections of lungs -impaired immune defensesChest wall - chest wall surgeries - Intra-thoracic surgeriesAll patients with respiratory symptoms of

wheezing, coughing or dyspnoea require preventive care.

Patients with severe limitation in their chest mobility

Inability to learnPyschiatric instabilityDisruptive behaviourUnstable angina

Exclusion criteria

Assessment of patient should be done and than followed by problem list, goals should be made for proper pulmonary rehabilitation.

It includes: 1. history (history of presenting illness, previous

medical history, drug history, family history, social history)

2.subjective assessment

Assessment

-breathlessness (dyspnoea), cough,sputum and haemoptysis, wheeze, chest pain, incontinence and other symptoms like fever headache and peripheral oedema

-activity of daily living of patient by: London Chest Activity Of Daily Living Scale (Garrod et al

2000)

-activity of health related quality of life by:Chronic Respiratory Questionnaire(Guyatt et al 1987) and

St George’s Respiratory Questionnaire(Jones et al 1991)

-for dyspnoea by: Baseline and Transition Dyspnoea Index(BDI)(Mahier et

al 1984) and Medical Research Council Breathlessness Score(Fletcher et al 1960), Borg Scale Of Perceived Dyspnoea(Borg 1982)

3.Objective assessment - general observation like patient’s position, any

drips, drains, oxygen supply etc-observation of chest shape, breathing pattern, chest

movement-palpation of trachea position, chest expansion-percussion-auscultation(breath sounds, any abnormal sounds,

heart sounds)-exercise capacity of patient-examination of heart rate, blood pressure,

respiratory rate,spirometry4.Test results-ABG analysis, chest radiographs

General carePulmonary careExercise and functional trainingEducation Pyschosocial managementPhysical therapy management

Components of pulmonary rehabilitation

General care -As soon as patient comes, evaluation should be

done for medical and physical diagnosis-Prescription of medicine and oxygen support-Preventive care(smoking cessation, adequate

hydration, proper nutrition etc)

Pulmonary care -respiratory treatment techniques for clearing

accumulated pulmonary secretions include: -bronchial drainage-breathing techniques

-cough facilitation-postures to improve breathing-relaxation techniques-respiratory assistance devices to rest the

breathing muscles at night or during exercise

Exercise and functional testing-instructions for energy conservation, activity

pacing and use of adaptive equipment to optimize the patient ability for daily activities

Education-to provide knowledge and instruction to their

family members and patient regarding disease, its effect, treatment etc

Psychosocial management-its important as chronic disease places stress

on family members as well as for patient-so to provide them with coping strategies,

stress reduction, management techniques, behavioral strategies, and financial assistance as possible

Physical therapy management-physical therapy not only conduct exercise

sessions, they can also provide education regarding educational sessions, smoking cessation programs, weight control and stress management and relaxation techniques.

It depends whether exercises are to be prescribed for strength and endurance and than see the muscle response.

It is based on three components : 1)frequency of training 2)duration of training 3)Intensity of training 4)Mode of exercise

Exercise prescription

How often? Daily /*2 week/*3 week

How long? 4 weeks/8 weeks/12 weeks

Length of sessions 40-60 minutesTime of day

afternoons/morningsExercise? Resisted/unloaded

training/aerobic/walkingIntensity? Limited by

dyspnoea (borg scale)/by

VO2 peakRegimen?

Endurance/maximalAssessment? Physiological/

functional

Physiological response to training Improved mechanical efficiency

Improvement in mechanical efficiency can improve stride length and gait coordination.

Cardiovascular

Reduction in heart rate, minute ventilation ,lowering of onset of lactic acidosis, lowering maximum oxygen uptake.

Muscle changes

With endurance training , submaximal sustained effort result in transformation from type IIb to type IIa fibres, increasing their oxidative capacity.

With strength training, increase in size of muscle cells and number of myofibrils. So to improve oxygen uptake and ability to maintain aerobic muscle metabolism for prolonged period.

To measure exercise tolerance, laboratory test and field test can be used.

It is needed to set intensity ,assess the benefit of rehabilitation program, motivate the patient with exercise

Laboratory test measuring maximal oxygen consumption, heart rate, workload, arterial oxygenation, blood lactate levels

Field test like 12 min walking test and shuttle walking test are used.

Pulmonary careIndications:

1) removal of excessive secretions that lead to: -obstruction of airways -ventillatory defects -produce symptoms of cough -increase respiratory

infections -deterioration of lung function 2)when secretions are copious ,patients

are chronic

-following treatment can be given based on patients evaluation

Modified bronchial drainage position. foams or cushions can be used to assume trendelenburg position.

For percussion and vibration if adequate assistance is not there, palm cups, mechanical percussors, high frequency chest compression system

Series of deep breathing exercise, forced expirations(huffing), coughing, ACBT, autogenic drainage use of mask providing positive expiratory pressure.

Sustained exerciseDiaphragmatic breathing, pursed lip breathing

can be given to improve lung function.

To see whether patients can do it effectively and independently

Short term goalsLong term goals

Functional training Indications For this -environment modification -task modification -relief of dyspnoea

Physical conditioningGoals

According to patient condition,i.e -patients with mild lung disease -patients with moderate lung disease -patient with severe lung diseaseStrengtheningGoalsLower extremity strengtheningUpper extremity strengthening

FlexibilityDue to COPD, there is significant changes in

posture and reduced mobilityIndicationsExercisesPurpose

Respiratory muscle exercise Exercise for improving respiratory muscle

function are important component of pulmonary rehabilitation.

The increased work of breathing and chest wall changes with COPD make respiratory muscle fatigue

Two approaches for improving respiratory muscle fatigue:

Exercises

Progressive Resistance Exercise in Physical Therapy: A Summary of Systematic Reviews

Nicholas F Taylor, Karen J Dodd and Diane L Damiano

PHYS THER. 2005; 85:1208-1223Result showed that PRE was shown to

improve the ability to generate force, with moderate to large effect sizes that may carry over into an improved ability to perform daily activities

Impact of inspiratory muscle training in patients with COPD: what is the evidence?

(R. Gosselink, J. De Vos, S.P. van den Heuvel, J. Segers,M. Decramer,G. Kwakkel)

A meta-analysis including 32 randomised controlled trials on the effects of inspiratory muscle training (IMT) in chronic obstructive pulmonary disease (COPD) patients was performed.

IMT improves inspiratory muscle strength and endurance, functional exercise capacity,dyspnoea and quality of life. Inspiratory muscle endurance training was shown to be less

effective than respiratory muscle strength training. In patients with inspiratory muscle weakness the addition of IMT to a general exercise training program improved PI,max and tended to improve exercise performance.

H.Steven Sadowsky,Ellen A. Hillegass. Essentials of cardiopulmonary physical therapy.

Jennifer A Pryor,S Ammani Prasad.Physiotherapy for respiratory and cardiac problems(3rd edition)

Robert.L.Williams,James K. Stroller,Robert M.kacmarek. Fundamentals of respiratory care(9th edition)

Scot Irwin,Jan Stephen Tecklin.Cardiopulmonary physical therapy(2nd edition)

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REFERENCES

Susan B O’Sullivan,Thomas J Schmitz.Physical Rehabilitation(5th edition)

R. Gosselink,J. De Vos, S.P. van den Heuvel,J. Segers,M. Decramer and G. Kwakkel. Impact of inspiratory muscle training in patients with COPD: what is the evidence? Eur Respir J 2011; 37: 416–425

Nicholas F Taylor, Karen J Dodd and Diane L Damiano. Progressive Resistance Exercise in Physical Therapy: A Summary of Systematic Reviews. PHYS THER. 2005; 85:1208-1223