PULMONARY REHABILITATION BASICS

1. PULMONARY REHABILITATION
MUSKAN RASTOGI
222139001

2. CONTENTS
DEFINITION
GOAL
SCOPE AND BENEFITS
GUIDELINES
PULMONARY REHABILITATION TEAM
INDICATIONS
CONTRAINDICATIONS
OUTCOME MEASURES
ASSESSMENT
COMPONENTS OF P.R. PROGRAM
NEW APPROACHES

3. DEFINITION
“Pulmonary rehabilitation is a comprehensive intervention based on a
thorough patient assessment followed by patient-tailored therapies, which
include, but are not limited to, exercise training, education, and behavior
change, designed to improve the physical and psychological condition of
people with chronic respiratory disease and to promote the long-term
adherence of health-enhancing behaviors.” - American Thoracic Society (2013)

4. GOALS OF P.R. PROGRAM
Must be specific and pertinent to his or her lifestyle, needs, and personal
interests.
Possible only after a thorough evaluation of the patient’s disease state and
clinical course, physical examination, and patient–family interview.
Assist the patient in identifying realistic goals that can be described in
behavioural terms and measured as outcomes for rehabilitation.

5. Should be designed to make the most impact on daily function and enhance
the quality of life.
Should be realistic in nature.
Outcome measures should be used to assess the progress of the pulmonary
rehabilitation program.

6. SCOPE AND BENEFITS
 Reduces Symptoms.
 Reduces hospitalizations.
 Increased functional capacity.
 Increased knowledge about pulmonary diseases and their management.
 Increased exercise tolerance and performance.
 Enhanced ability to perform ADLs.
 Improves Quality of life.
 Improved Psychosocial symptoms.
 Ability to Return to work for some patients.

7. EVIDENCE-BASED GUIDELINES ON
PULMONARY REHABILITATION
A program of exercise training for the muscles of ambulation is recommended
as a mandatory component of pulmonary rehabilitation for patients with COPD.
Pulmonary rehabilitation improves the symptom of dyspnea in patients with
COPD.
Pulmonary rehabilitation improves health-related quality of life in patients with
COPD.
Pulmonary rehabilitation reduces the number of hospital days and other
measures of health care utilization in patients with COPD.

8. Pulmonary rehabilitation is cost-effective in patients with COPD.
There is insufficient evidence to determine if pulmonary rehabilitation improves
survival in patients with COPD.
There are psychosocial benefits from comprehensive pulmonary rehabilitation
programs in patients with COPD.
6 to 12 weeks of pulmonary rehabilitation produces benefits in several
outcomes that decline gradually over 12 to 18 months.
Some benefits, such as health-related quality of life, remain above control at 12
to 18 months

9. Longer pulmonary rehabilitation programs (12 weeks) produce greater
sustained benefits than shorter programs.
 Maintenance strategies following pulmonary rehabilitation have a modest effect
on long-term outcomes.
Lower-extremity exercise training at higher exercise intensity produces greater
physiological benefits than lower-intensity training in patients with COPD.
Both low- and high-intensity exercise training produce clinical benefits for
patients with COPD.
Addition of a strength training component to a program of pulmonary
rehabilitation increases muscle strength and muscle mass.

10. PULMONARY
REHABILITATION
TEAM

11. PULMONARY
REHABILITATION
TEAM
Pulmonologist
Specialized
Nurse
Physiotherapist
Occupational
Therapist
Speech
Therapist
Dietician
Psychologist
Social Worker
Respiratory
Therapist

12. INDICATIONS
COPD
Post ARDS pulmonary fibrosis
Lung cancer
Selected neuromuscular disease
Perioperative states e.g.
thoracoabdominal surgery
Post-polio syndrome
Asthma
Bronchiectasis
Chest wall disease
Cystic fibrosis
Interstitial lung disease
Pre-lung and post-lung transplantation and lung
volume reduction surgery

13. CONTRAINDICATIONS
Arthritis
Inability to learn
Cognitive disabilities
Disruptive behavior
Severe pulmonary HTN
Unstable angina
Recent myocardial infarction

14. OUTCOME MEASURES
USED

16. ASSESSMENT
The ideal candidate for pulmonary rehabilitation is chosen by a thorough assessment that
involves-
Patient interview
Medical history
Physical exam
Diagnostic tests
Symptom assessment

17. Musculoskeletal and exercise assessment
Activities of daily living assessment
Education assessment
Psychosocial assessment
Goal development

18. Patient Interview
An in-depth interview with the patient and his family or significant other is
necessary to set the stage for the assessment.
The importance of the initial interview cannot be overstated. Not only are
important data obtained, but the foundations of trust and credibility are
established at this time.
The interview allows the patient to interact on a personal level with the
rehabilitation staff.
Coming in for the interview allows the patient to see where the program is
located and possibly meet rehabilitation graduates.

19. Medical History
The medical history provides information on the
severity of respiratory diseases, such as
Symptom burden
Exacerbations
Medication requirements
Supplemental oxygen use
Physical limitations
Health resource utilization.

20. Components of the Medical History
Respiratory history
Comorbidities (especially coronary artery disease, diabetes, osteoporosis, and
sleep apnoea)
Other medical and surgical histories
Family history of respiratory disease
Use of medical resources (e.g., hospitalizations, urgent care or emergency
room visits, physician visits)

21. All current medications including over-the-counter drugs and herbal
supplements; (this includes the dose, route, and frequency)
Oxygen use: how it is prescribed and how the patient actually uses it
Allergies and drug intolerances
Smoking history
Occupational, environmental, and recreational exposures
Alcohol and other substance abuse history
Social supports

22. Physical Examination
Physical assessment adds important information to data obtained from the
patient’s history and from record and laboratory review.
Vital signs: blood pressure, pulse, respiratory rate, temperature
Height; weight; BMI, either calculated (weight [in kg] divided by height [in
meters] squared [kg/m2]) or determined from a table
Arterial oxygen saturation measured with pulse oximetry at rest and with
activity
Breathing pattern
Use of accessory muscles for respiration

23. Chest examination: inspection, palpation, percussion, symmetry, diaphragm
position, breath sounds, adventitious sounds (crackles, wheezes, rhonchi),
duration of the expiratory phase, forced expiratory time
Cardiac exam: cardiac rate and rhythm, murmur, gallops, jugular venous
distention
Presence of finger clubbing
Upper- and lower-extremity evaluation: signs of vascular insufficiency, joint
disease, musculoskeletal dysfunction, range of motion, muscle atrophy, Edema

24. Diagnostic tests
Spirometry
Oxygen saturation at rest and with walking exercise upon program entry
Chest radiograph
Electrocardiogram
Field test of exercise capacity, such as the 6-minute walk test or the shuttle walk
test, upon program entry
Screening assessment of anxiety and depression, such as the Beck Depression
Inventory or the Hospital Anxiety and Depression Scale, upon program entry
CBC

25. Symptom Assessment
Information from symptom assessment is often utilized in goal setting, may be
used to document outcomes, and may be used by third-party payers to
determine the medical necessity for the service.
The following is a list of items to include in the symptom assessment:
Dyspnea
Fatigue
Cough and sputum production
Wheeze
Haemoptysis
Chest pain

26. Postnasal drainage
Reflux, heartburn
Edema
Dysphagia
Extremity pain or weakness
Feelings of anxiety, panic, fear, isolation
Depressive symptoms

27. Musculoskeletal and Exercise Assessment
The safety of an exercise training program and the appropriateness of the exercise
prescription are determined by a thorough initial musculoskeletal assessment.
The following is a list of the information to be obtained in the exercise
assessment:
Physical limitations (e.g., strength, range of motion, posture, functional abilities,
and activities)
Orthopaedic limitations
Transferring abilities
Exercise tolerance
Exercise hypoxemia including the need for supplemental oxygen therapy
Gait and balance

28. Commonly used exercise tests
 Walk distance tests- Timed Walk Tests(6-minute walk test), Shuttle walk distance test
 Incremental maximal exercise tests
 Submaximal exercise tests

29. Absolute Contraindications
• A recent significant change in the resting ECG suggesting significant ischemia,
recent myocardial infarction (within 2 days), or other acute cardiac event
• Unstable angina
• Uncontrolled cardiac arrhythmias causing symptoms or hemodynamic compromise
• Severe symptomatic aortic stenosis
• Uncontrolled symptomatic heart failure
• Acute pulmonary embolus or pulmonary infarction
• Acute myocarditis or pericarditis
• Suspected or known dissecting aneurysm
• Acute infections

30. Relative Contraindications
• Left main coronary artery stenosis
• Moderate stenotic valvular heart disease
• Electrolyte abnormalities (e.g., hypokalemia, hypomagnesemia)
• Severe arterial hypertension (i.e., systolic BP of >200 mmHg or diastolic BP of
>110 mmHg)
at rest
• Tachyarrhythmias or bradyarrhythmias
• Hypertrophic cardiomyopathy and other forms of outflow tract obstruction
• Neuromuscular, musculoskeletal, or rheumatoid disorders that are
exacerbated by exercise
• High-degree atrioventricular block
• Ventricular aneurysm
• Uncontrolled metabolic disease (e.g., diabetes,
thyrotoxicosis, or myxedema)
• Chronic infectious disease (e.g., mononucleosis, hepatitis, AIDS)

31. Absolute Precautions
• Unstable angina* or myocardial infarction during the previous month
• Resting pulse oximetry (SpO2)% < 88% on room air or while breathing the
prescribed level of supplemental oxygen. The referring doctor should be notified
and exercise assessment should not proceed.
• Physical disability preventing safe performance
Relative Precautions
• Resting heart rate >125 bests/min after 10
minutes rest
• Systolic blood pressure >200 mmHg + diastolic
blood pressure >110/100 mmHg

32. Exercise Test Termination Criteria
• Onset of angina or angina-like symptoms
• Signs of poor perfusion including lightheadedness, confusion, ataxia, pallor, central
cyanosis, nausea, cold clammy skin, sweating
• Patient requests to terminate test (e.g., intolerable dyspnea which is not relieved by rest
and causes patient distress)
• Physical or verbal manifestations of severe fatigue
• Development of an abnormal gait pattern (e.g., leg cramps, staggering)
• Tachycardia (i.e., heart rate >220 – age)
• SpO2 < 88% on room air**
• Failure of heart rate to increase with exercise (unless the patient has a fixed rate
pacemaker)

33. Activities of Daily Living Assessment
Symptoms of respiratory disease such as dyspnea
and fatigue often lead to a decreased ability and
willingness to perform activities of daily living
(ADLs).
ADLs assessment should include which activities
have been limited or eliminated because of the
disease, its comorbidity, or its therapy.
Elimination of activity often depends on the
level of distressing symptoms it engenders and its
importance to the patient.

34. ADLs assessment includes
distress during, limitations
in, or elimination of the
following:
Basic ADLs, such as
dressing, bathing, walking,
eating
Household chores
Leisure activities
Job-related activities
Sexual activity

35. Nutrition Assessment
Patients with respiratory disease frequently have alterations in
their nutritional status and BMI.
Accordingly, the nutritional assessment should include at least
the measurement of height, and weight, calculation of BMI
(weight [kg]/height [m2]), and documentation of a recent and
significant (>3 lbs.) weight change.

36. Additional notations regarding nutrition may include
Dysphasia
Dentition
 Mastication problems
 Gastroesophageal reflux
Altered taste of food due to oxygen use
Dyspnoea while eating

37.  Fluid intake
Person responsible for buying and cooking food,
Alcohol consumption
Caffeine consumption
 Laboratory values for serum albumin and prealbumin
Drug-food interactions
Use of nutritional or herbal supplements

38. Education Assessment
Assessing the educational needs of pulmonary
rehabilitation patients begins with a determination
of how they understand and manage their disease.
This provides the information needed to formulate
the education component of the program.
It also can be used to establish a baseline for
evaluating change in knowledge and self-efficacy;
thus, it can be used in documenting outcomes.

39. Following is a list of items included in the education assessment:
Knowledge of the disease and its treatment
Self-efficacy
Barriers to learning: visual or hearing problems, cognitive impairment, language
barrier, illiteracy
Cultural diversity

40. Psychosocial Assessment
Addresses several areas: motivation level, emotional
distress, family and home situation, substance abuse,
cognitive impairment, interpersonal conflict, other
psychopathology (e.g., depression, anxiety), significant
neuropsychological impairment (e.g., memory, attention and
concentration, problem-solving impairments during daily
activities), coping style, and sexual dysfunction.
Failure to detect and address the presence of significant
psychosocial pathology may result in poor progress in
rehabilitation.

41. The following is a list of items included in the psychosocial assessment:
Anxiety and depression
Interpersonal conflict
Family and home situation
Motivation for pulmonary rehabilitation
Substance abuse, addictive disorders
Neuropsychological impairments
Coping skills
Sexual dysfunction

42. OBSTRUCTIVE DISEASES RESTRICTIVE DISEASES OTHER CONDITIONS
COPD INTERSTITIAL FIBROSIS LUNG CANCER
PERSISTENT ASTHMA OCCUPATIONAL LUNG DISEASE PRIMARY PULMONARY HTN
BRONCHIECTASIS SARCOIDOSIS PRE AND POST THORACIC SURGERY
CYSTIC FIBROSIS KYPHOSCOLIOSIS LUNG TRANSPLANTATION
BRONCHILITIS
OBLITERANS
ANKYLOSING SPONDYLITIS LUNG VOLUME REDUCTION SURGERY
PARKINSON’S DISEASE VENTILATOR DEPENDENCY
POSTPOLIO SYNDROME
AMYOTROPHIC LATERAL SCOLIOSIS
DIAPHRAGMATIC DYSFUNCTION
MULTIPLE SCLEROSIS
POST TUBERCULOSIS SYNDROME

43. COMPONENTS OF
PULMONARY
REHABILITATION

44. EXERCISE TRAINING
RATIONALE
The presence of skeletal muscle dysfunction
provides a rationale for exercise training for
patients with COPD, even in the presence of
significant cardiopulmonary limitations imposed by
irreversible derangements of lung structure or
function.
Consequently, all pulmonary patients can benefit
from skeletal muscle exercise training. Optimizing
oxygenation and bronchodilation will enhance the
exercise training effects by permitting exercise at
higher intensities. A supervised exercise program
can also address other factors limiting exercise in
these patients, such as fear of dyspnea and
psychological issues

45. PRINCIPLES
Exercise training in pulmonary rehabilitation should encompass
Both upper- and lower-extremity endurance training,
Strength training,
Respiratory muscle training.
Duration, frequency, mode, and intensity of exercise should be included in the
patient’s individualized exercise prescription, based on disease severity, degree
of conditioning, functional evaluation, and initial exercise test data.

46. UPPER AND LOWER EXTREMITY TRAINING
It is most beneficial to direct exercise training to those muscles involved in
functional living. This typically includes training the muscles of both the lower
and upper extremities.
The health-related components of a comprehensive exercise program include
cardiovascular and pulmonary (endurance) exercise, muscle strengthening, and
flexibility.

47. Exercise that improves neuromuscular ability, such as balance and
coordination to decrease fall risk, is equally important with the pulmonary
population, particularly as the general population ages.
Lower-extremity training involves large muscle groups; this modality
can improve ambulatory stamina, balance, and performance in ADLs.

48. Types of lower-extremity training include the following:
• Walking
• Stationary cycling
• Bicycling
• Stair climbing
• Swimming
Exercise training of the lower extremities often results in dramatic increases in exercise
tolerance of patients with COPD and other respiratory diseases.
Exercise training of the arms is also beneficial in patients with chronic lung disease, although
virtually all the evidence comes from patients with COPD. Patients with moderate to severe
COPD, especially those with the mechanical disadvantage of the diaphragm due to lung
hyperinflation, have difficulty performing ADLs that involve the use of the upper extremities.

49. Arm elevation is associated with high metabolic and ventilatory demand, and
activities involving the arms can lead to irregular or dyssynchronous breathing. This
happens because some arm muscles are also accessory muscles of inspiration.
Benefits of upper-extremity training in COPD include improved arm muscle endurance
and strength, reduced metabolic demand associated with arm exercise, and an
increased sense of well-being.
In general, the benefits of upper-extremity training are task-specific. Because of its
benefits,upper-extremity training is recommended in conjunction with lower-
extremity training as a routine component of pulmonary rehabilitation.

50. Caution must be taken with upper-extremity ergometry in certain
rehabilitation patients.
Chronic lung disease patients who have been on long-term steroid therapy
lose bone density.
These patients become osteoporotic, particularly in the thoracic vertebrae,
and are susceptible to increased wear and tear of these vertebral segments,
which, in turn, may increase risk of compression fracture.
Postoperative surgical pulmonary patients are generally restricted from arm
ergometry for 6 weeks to allow internal and external incisional healing.

51. STRENGTH TRAINING
Beneficent for patients with chronic lung disease
Leads to improvement in muscle strength, increased exercise endurance, fewer
symptoms during ADL’s
Lower extremity strengthening may be augmented through aerobic training
such as cycling, stair climbing, bench stepping, and walking. Strength training
should be started with low resistance and progressed first by increasing
repetitions, for example, 10 to 20 repetitions, before adding more weight.

52. Upper body (trunk and upper extremity) training requires more ventilatory
work, and patients are more likely to hold their breath, develop asynchronous
breathing patterns, and become dyspneic. However, clinical studies have
demonstrated that patients with respiratory disorders can train successfully with
upper body resistive work, which produces improvements in dyspnea, fatigue,
and respiratory muscle function.
The strengthening program should start with light weights (dumbbells, pulleys,
elastic bands, weighted wands) and, again, advance first by increasing the
number of repetitions. For stronger patients or patients not on special exercise
precautions, weight machines can be used. Rotating days between machines for
upper extremity and lower extremity exercise may also improve tolerance for
the strengthening program.

54. FLEXIBILITY, POSTURE, AND BODY
MECHANICS
Along with strengthening the upper and lower extremities, various exercises to
develop and maintain proper posture and good body symmetry should also be
incorporated into a rehabilitation program.
Moderate strength training improves a patient’s ability to complete everyday
tasks such as personal grooming and carrying groceries.
A lack of flexibility in particular muscle groups and an imbalance in the
muscular development of others can result in poor posture.
The common postural deficit of rounded shoulders may be caused by a lack of
muscular endurance in the shoulder girdle abductors (i.e., middle trapezius and
rhomboids), with a concomitant inflexibility in the anterior shoulder girdle
muscles (i.e., pectorals).

55.  Focusing on strengthening the former muscle groups and increasing flexibility
in the latter will aid in resuming proper postural alignment, resulting in
improved respiratory mechanics.
 Balance training becomes more applicable to an aging chronic lung disease
population. Fall risk is prevalent. More than one-third of adults 65 and older
fall each year in the United States.
 Regular exercise that includes strength training and balance exercise is
particularly effective in reducing fall risk.

56.  Incorporating flexibility exercises with the goal of increasing the range of
motion is an integral component of the exercise program.
 Stretching exercises targeting specific muscle groups are recommended to
ensure good posture and proper body mechanics and to minimize the
incidence of joint and muscle injury. Modified yoga may be
 A useful practice for many chronic lung disease patients to achieve whole-
body stretches while coordinating breathing.

57. RESPIRATORY MUSCLE TRAINING
With any exercise, respiratory muscle activity increases; thus, the respiratory
muscles are exercised.
Some studies have demonstrated that resistance breathing leads to an increase in
respiratory muscle strength and endurance as well as a reduction in dyspnea.
This therapy may be considered for respiratory patients with documented
respiratory muscle weakness (e.g., due to cachexia or corticosteroid use) or persons
who remain symptomatic, with dyspnea and exercise limitation despite peripheral
muscle endurance and strength training.

58. Types of respiratory muscle training include flow resistive training (breathing
through a progressively smaller orifice), threshold loading training (a preset
inspiratory pressure, usually at some fraction of the maximal inspiratory
pressure, is required), and isocapneic hyperventilation.
Suggested guidelines for employing resistive inspiratory muscle training
include a frequency of 4 or 5 days a week; intensities of 30 to 40% of PImax
(maximal inspiratory pressure measured at the mouth); and a duration of one
30-minute session per day or two 15-minute sessions over at least 2 months.

60. BREATHING RETRAINING
An important principle in relieving dyspnea is to avoid breath holding, the Valsalva
maneuver, or unnecessary talking during the task.
 Pursed-lip breathing is useful for patients whenever an increase in breathing effort is
noticed or to facilitate a paced breathing pattern. This naturally slows down respirations
and decreases minute ventilation, relieving dyspnea in some patients.
Exhalations through pursed lips during walking, lifting, pushing, or pulling activities
prevents breath holding and straining. Patients with restrictive lung disease experience
greater work breathing as a result of progressive stiffness decreased compliance and
scarring of lung tissue.

62. Breathing retraining or teaching the patient to use a specific breathing strategy is not
always easy. When successfully retrained in a new breathing pattern, the patient is likely to
resume his or her inherent breathing pattern when attention is diverted to a task and away
from breathing. This is normal behavior; the patient should still be encouraged to use daily
“practice sessions” of breathing retraining using newly learned mechanics.
Many patients with severe COPD have flattened diaphragms due to lung hyperinflation. A
forward-leaning position may offer postural relief from dyspnea by improving the function of
a flattened diaphragm.

63. ENERGY CONSERVATION TECHNIQUES
ADLs that are difficult to perform are evaluated and modified. Usually done for bathroom,
kitchen, and bedroom
Basic concepts include
-work areas with appropriate seat height
- placing equipment in places that are accessible to the patient
- locating a table for sliding heavy items
- Locating chairs at places where rests are needed. E.g. End of stairs, beside the bathtub.
- Using adaptive equipment to simplify tasks and improve comfort. E.g. bath seat, handheld
shower head, wheel cart for laundry items, wheeled walker, etc.

64. - Improve ventilation for bathroom, kitchen, or other areas in which fumes, dust,
smoke, or steam might cause respiratory symptoms.
-To perform any other activity the tasks are divided into smaller tasks and
analyzed with regard to the most energy-efficient method of work.
Basic concepts include-
Instruct in paced breathing techniques
Slow down the pace
Setting priorities and organizing activities to minimize wasted movement
Planning appropriate amounts of time to complete tasks, including rest breaks.

65. PSYCHOSOCIAL INTERVENTION
Need- increased risk of anxiety, depression
Feeling of hopelessness
Inability to cope
Difficulty solving problems
Failure to adhere to the program
Teach to recognize symptoms of stress and anxiety
Relaxation technique
Muscle relaxation, imagery, yoga
Relaxation tapes
Patients with significant psychosocial disturbances should be referred to the
appropriate mental health practitioner for detailed assessment and treatment

66. SMOKING CESSATION
Nicotine dependence is often tied to the psychoactive impact of nicotine.
Smoking stimulates neurochemical pathways associated with cognitive
stimulation, memory, pleasure, mood control, anxiety reduction, relaxation, and
appetite suppression.
Smoking’s pleasurable effects are reinforced by the conditioned response
associated with environmental triggers, including alcohol use.
Conversely, nicotine withdrawal is associated with anxiety, restlessness,
irritability, impaired concentration, depressed mood, insomnia, headache,
increased appetite, and weight gain.

67. The focus of pharmacological and behavioral management of nicotine
dependence is to reduce withdrawal symptoms and promote behaviors linked
with successful long-term cessation.
Use of combined pharmacological and behavioral interventions improves the
chances of successful long-term cessation.

68. A combination of behavioral and pharmacological treatments is recommended
for optimal management of nicotine dependence and improved quit rates. Tools
used to determine nicotine dependence include the Fagerstrom Tolerance
Questionnaire and the Fagerstrom Test for Nicotine Dependence. Initial patient
assessment should include the following:
• The patient’s desire to quit
• The number of cigarettes smoked daily
• Whether the patient smokes within 30 minutes of awakening
• Previous quit attempts including methods,effectiveness, and relapse triggers

69. Transdermal patches provide extended release of nicotine over 24 hours.
Patches are applied daily to nonhairy skin, and the sites are rotated regularly
to avoid irritation.
Symptoms of insomnia and vivid dreams may be controlled by the removal of
the patch at bedtime.
For persons smoking fewer than 10 cigarettes daily, 7 to 14 mg patches are
recommended.
For those smoking more than 10 cigarettes daily, 21 mg patches are
recommended.
Many people begin on a 21 mg patch and taper to a lower strength (14 and 7
mg) over 8 or more weeks.

71.  Nicotine gum provides rapid relief from craving, with peak serum
nicotine levels achieved in 20 minutes.
 The gum is chewed until flavor is tasted and then is parked between
the cheek and gums.
 The gum is chewed intermittently for up to 30 minutes. For people
who smoke more than 25 cigarettes a day, 4 mg gum is
recommended; 2 mg gum is appropriate for those who smoke less.

73.  Nicotine lozenges offer an alternative to gum for those with dentures or poor
dentition. The lozenge is dissolved in the mouth over 30 minutes by wetting and
parking it between the cheek and gums.
 The 4 mg lozenge is recommended for those who smoke within 30 minutes of
awakening.
 One or two lozenges are normally used per hour for 6 weeks (minimum of 9 per
day), with a gradual dose reduction over 6 weeks.
 Nicotine inhalers offer the advantage of addressing both physical and emotional
nicotine dependence.
 The recommended dose is 6 to 16 cartridges a day for 6 to 12 weeks. Local mouth
and throat irritation are common, and bronchospasm may occur.

75. Nicotine nasal spray provides a rapid rise in nicotine concentration, with a peak concentration
10 minutes after use. One spray in each nostril one or two times per hour as needed is
recommended for approximately 3 months.
The minimum recommended treatment is 8 doses per day, with a maximum of 40 doses per
day or 5 doses per hour.
Side effects include nasal and throat irritation, rhinitis, sneezing, and tearing.

77.  Bupropion is thought to reduce craving by enhancing CNS noradrenergic and
dopaminergic release.
 Bupropion is generally begun 1 week before the quit date, with a usual dose of 150
mg daily for three days followed by 150 mg twice daily for 7 to 12 weeks or longer.
 Bupropion may be a preferred choice for persons with depression or concerns about
weight gain from cessation.
 Side effects include insomnia, agitation, dry mouth, and headache. Bupropion
lowers the seizure threshold and is contraindicated in persons with a history of
seizure disorder or eating disorder.

78. Varenicline is a partial nicotine receptor agonist that binds to and partially
stimulates nicotine receptors.
 It acts to reduce both nicotine withdrawal symptoms and the rewarding
sensations of cigarette smoking.
Side effects include nausea and abnormal dreams.
Nausea may be reduced by gradually titrating the dose upward over one week
from 0.5 mg daily for 3 days to 0.5 mg twice daily for 3 days to 1 mg twice daily.

79. A framework for healthcare providers to help patients stop smoking is
the five As:
1. Ask
2. Advise
3. Assess
4. Assist
5. Arrange

80. NUTRITIONAL INTERVENTION
Most patients are underweight
32-63% of patients are referred for PR
Higher caloric requirement- energy and protein rich diet required
To enhance the benefits of exercise training
Must include dietary fibres, fruits and vegetables in daily diet

81. BRONCHODILATORS
Anticholinergic agents
Short-acting- Ipratropium bromide
Long-acting- Tiotropium
Beta-adrenergic agonists
Short acting e.g., salbutamol, fenoterol, terbutaline
Long-acting salmeterol or formeterol
Combination therapy-inhaled ipratropium bromide and beta-2 adrenergic
agonists is potentially more effective and safer

82. Theophylline
 Oral one is less effective than bronchodilator
 Available in sustained release preparation
Corticosteroids
 Anti-inflammatory action
 Systemic or inhaled form
 Inhaled one more effective and lesser side effects
Antibiotics
 To avoid chronic infection of LRT
 Prophylactic and therapeutic use
Mucolytic agents
 N-Acetycysteine, Guafenesin

83. SELF- MANAGEMENT
To encourage behavioural changes that lead to improved health and a commitment to
long-term adherence to self-assessment and management
Important characteristics to include in self-management education are as follows:
Encourage active rather than passive learner participation (e.g., include group
discussions instead of all classes in lecture format).
Use repetition liberally.
Utilize a variety of presentation styles: visual, auditory, models and demonstrations,
and active participation with return demonstrations (see, hear, do).

84. Supply written material for reinforcement and for sharing with the family and
caregiver.
Encourage interaction between participants (fellow classmates and pulmonary
rehabilitation professionals).
Take advantage of teachable moments (e.g., discuss prevention of
exacerbations and when to call the doctor when a patient returns after a
hospitalization for an exacerbation).

85. NEW APPROACHES

86. WATER BASED REHABILITATION
A significant number of people with COPD have an
inability, or difficulty, to participate in land-based
exercise training due to the presence of comorbid
pathologies, physical impairments, or pain, which
can be exacerbated by weight-bearing exercise.
Exercise in water is suitable for people with COPD
with difficulties performing weight-bearing exercises
and those with limitation to movement on land,
because of the low physical impact of the water
environment which allows freedom of movement
and provides important health and well-being
benefits

88. Hydrotherapy pools are kept typically 33.5°–34.5° Celsius (at thermoneutral
temperature)
Water-based exercise demonstrated similar improvements to land-based
exercise training in increasing functional exercise capacity (measured by the 6-
minute walk test) and peak exercise capacity (measured by the incremental
shuttle walk test).
Moreover, water-based exercise training significantly improved endurance
exercise capacity (measured by the endurance shuttle walk test) when
compared to land-based exercise training, indicating that the water environment
provided a greater endurance training stimulus than dry land exercise training.

89. WHOLE BODY VIBRATION TRAINING
It is characterized by an external stimulation inducing an oscillation vibration to
a subject standing on a vibrating platform.
 Its benefit include enhanced postural control, balance performance, and
improved inter-muscular coordination like the complex interplay of
agonists and antagonists.
 WBVT has also been shown to be an effective training modality to
counteract immobility-related muscle atrophy and loss of bone density.
Is a beneficial training mode in a large variety of chronic diseases and
conditions such as osteoporosis, fibromyalgia, cystic fibrosis, multiple sclerosis,
type 2 diabetes, pelvic weakness, chronic low back pain, and others.

91. NEUROMUSCULAR ELECTRICAL
STIMULATION
It permits local muscle training at a low cost for the cardiorespiratory system, making
exercise accessible and suited to patients with severe breathlessness on minimal exertion.
 Training intensity, not current intensity or any other stimulation parameter, should be
considered the main determinant of the clinical effectiveness of NMES.
NMES is an effective treatment for muscle weakness and wasting, which in some patients
translates to an improvement in functional exercise capacity.
The advantages and specific benefits of NMES are most relevant to severely impaired
patients, for example, those unable to walk or complete conventional exercise training on a
frequent basis.

93. SEDENTARISM AND LIGHT MUSCLE
ACTIVITY
>1.5 MET and 4- 8 hours of no activity or rest
We require interventions that reduce sedentary time- that controls behavior pattern in
patients. For the same purpose behaviour change wheel is used by clinicians.
It is used to guide processes that can inform the development of individualized and
pragmatic strategies that can be deployed to achieve personalized goals related to breaking
up and/or reducing sitting time. The patients are also part of the decision-making process

95. REFERENCES
Ries AL, Bauldoff GS, Carlin BW, Casaburi R, Emery CF, Mahler DA, Make B,
Rochester CL, ZuWallack R, Herrerias C. Pulmonary rehabilitation: joint ACCP/AACVPR
evidence-based clinical practice guidelines. Chest. 2007 May 1;131(5):4S-2S.
Donner C, Ambrosino N, Goldstein RS, editors. Pulmonary rehabilitation. CRC Press;
2020 Jul 14.
 Chapter no. 16 Pulmonary Rehabilitation Hillegass E. Essentials of Cardiopulmonary
Physical Therapy-E-Book. Elsevier Health Sciences; 2022.
Hill NS. Pulmonary rehabilitation. Proceedings of the American Thoracic Society. 2006
Mar;3(1):66-74.