Pulmonary rehabilitation

1. PULMONARY
REHABILITATION
Presenter: Sneha B S
Moderator: Mr. Nafeez Syed
Evaluator: Dr. Prem. V.

2. Introduction

3. Definition
“Pulmonary rehabilitation is an evidence-based,
multidisciplinary, and comprehensive intervention for patients
with chronic respiratory diseases who are symptomatic and
often have decreased daily life activities. Integrated into the
individualized treatment of the patient, pulmonary
rehabilitation is designed to reduce symptoms, optimize
functional status, increase participation, and reduce health care
costs through stabilizing or reversing systemic manifestations
of the disease.”

4. Means…
This definition focuses on three important features of successful
rehabilitation:
1. Multidisciplinary: Pulmonary rehabilitation programs utilize
expertise from various healthcare disciplines that is integrated into
a comprehensive, cohesive program tailored to the needs of each
patient.
2. Individual: Patients with disabling lung disease require individual
assessment of needs, individual attention, and a program designed
to meet realistic individual goals.
3. Attention to physical and social function: To be successful,
pulmonary rehabilitation pays attention to psychological,
emotional, and social problems as well as physical disability, and
helps to optimize medical therapy to improve lung function and
exercise tolerance

5. Team Members
• Physicians
• Physical therapists
• Respiratory therapists
• Occupational therapists
• Nursing staff
• Clinical Psychologists
• Exercise specialists
• Nutrition Expert

6. Indications
COPD
Non-COPD conditions
• Asthma
• Chest wall disease
• Cystic fibrosis
• Interstitial lung disease
including post-ARDS
pulmonary fibrosis
• Lung cancer
• Selected neuromuscular
diseases
• Perioperative states (e.g.,
thoracic, abdominal surgery)
• Prelung and postlung
transplantation
• Prelung and postlung volume
reduction surgery

7. Candidacy
INCLUSION EXCLUSION
Respiratory disease resulting in:
• Anxiety engaging in activities
• Breathlessness with activities
• Limitations with:
– Social activities
– Leisure activities
– Indoor and/or outdoor chores
– Basic or instrumental activities of
daily living
• Loss of independence
• Conditions that might interfere
with the patient undergoing the
rehabilitative process
• E.g. Co-morbidities such as
advanced arthritis, the inability to
learn, or disruptive behavior
• Conditions that might place the
patient at undue risk during
exercise training.
• E.g. severe pulmonary
hypertension, unstable angina

8. Common Problems of a patient with chronic
respiratory disease
1. Exercise Limitations
Includes
• Symptoms of dyspnea and fatigue
• Ventilatory limitations
• Gas exchange limitations
• Cardiac Dysfunction
• Skeletal muscle dysfunction
• Respiratory muscle dysfuntion

9. 2. Body composition abnormalities
Includes
• Reduction in free fat mass of the body
• Muscle wasting is predominant
• Cachexia
• Loss of appetite
• Significant weight loss
3. Social and Psychological impact
Includes
• Increased risk of anxiety, depression
• Frustration with poor health and inability to participate in
activities can present in the form of pessimism, irritability,
hostile attitude towards others
• Limitations in sexual activity due to physical restrictions
• Overall social set back is seen

10. To reduce symptoms in
individuals with
chronic respiratory
disease, even in the
face of irreversible
abnormalities of lung
architecture
To evaluate and
initiate, as
appropriate, physical
intervention to
improve body
composition, exercise
tolerance and
encourage efficient
energy expenditure
To reduce the health-
care costs and reduce
the frequency of
admission, minimize
dependence on
significant others and
community agencies
To provide educational
sessions for patients,
families and significant
others regarding
disease processes,
medication and
therapeutic techniques
To maximize
independent
functioning in
activities of daily
living aiming to
improve the Quality
of Life

11. ASSESSMENT

12. Includes
1. History :- Medical; surgical; occupational; personal
2. Smoking history
3. Drug History
4. Vitals; BMI
5. Subjective assessment
6. EXERCISE CAPACITY
7. Investigations:- PFT; ABG; CXR
8. Nutritional assessment
9. Cognitive assessment
10. Appropriate OUTCOME MEASURES

13. Exercise Testing
Exercise test is important to:
• Assess the level of disability
• Identify the limitation to continued exercise
• Aid in the prescription of a training regimen
• Identify any benefits of rehabilitation
EXERCISE TESTING CAN BE DONE IN TWO WAYS:
1. Field tests
2. Laboratory tests

14. Field tests:
• These are simple submaximal tests that can be performed by
the therapist in a non laboratory setting
• Use of a validated Oximetry on exercise testing is advisable
because resting S.02 is not a predictor of exercise
desaturation
• If oxygen is required at rest, an increment of 1-2 L/min
is often needed on exercise.
• For severely impaired patients, a brief test such as sit-to-
stand or stand-up-and-go can be used.
Some of the tests are;
a) Shuttle
b) Six-minute walk distance
c) Stair climbing

15. • Shuttle:. Participants are asked to walk around a 10-metre oval circuit,
with two cones at each The speed of walking is dictated by a taped
bleep which increases in line with the participant raising their speed
gradually from 1 to 5 miles per hour. The physiotherapist walks alongside
for the first minute to discourage the participant from exceeding the initial
speed. Thereafter, if the cone is reached early the participant waits for the
beep before continuing. The end point is when symptoms prevent the
participant completing a circuit in the time allowed. Ideally the
maximum should be reached within 10-15 minutes.
• Six-minute distance: For endurance testing, participants are asked to
walk for 6 minutes as fast as reasonably possible along a measured flat
corridor, following standardized instructions. Three or four practice walks
are needed, with 20 minute rests in between. Repeat tests should be
performed at the same time in relation to any bronchodilator drugs. A
15% change in distance is said to be clinically meaningful.
• Stair climbing: The stair climbing test is done under the same conditions
and involves counting the number of steps that can be climbed up and
down in 2 minutes.

16. Laboratory Tests
• Exercise testing based on treadmill -walking or
cycle ergometer is performed monitoring minute
ventilation, HR, BP, Sa02, blood gases and
oxygen consumption (V02).
• Maximal oxygen uptake is the 'gold' standard
measure secured during laboratory-based testing
• Disadvantage- Cost and complexity
Precautions of Exercise testing;
1. Relative contraindications
2. Absolute contraindications
3. Termination guidelines

17. CONTRAINDICATIONS

18. INDICATIONS TO TERMINATE AN EXERCISE TEST
• Onset of angina or angina-like symptoms
• Drop in systolic blood pressure of >10 mm Hg from baseline
blood pressure despite an increase in workload
• Excessive rise in blood pressure : systolic pressure>250mmHg
or diastolic pressure>115mmHg
• Shortness of breath, wheezing, leg cramps, or claudication
• Signs of poor perfusion: light-headedness, confusion, ataxia,
pallor, Cyanosis, nausea, or cold and clammy skin
• Failure of heart rate to increase with increased exercise
intensity
• Noticeable change in heart rhythm
• Subject requests to stop
• Physical or verbal manifestations of severe fatigue
• Failure of the testing equipment

19. • Outcomes assessment in pulmonary rehabilitation
may be evaluated from three different perspectives:
those of the patient, the program, and society
• The patient-centered outcomes should reflect the
following:
• (1) control of symptoms,
• (2)the ability to perform daily activities,
• (3) exercise performance,
• (4) quality of life
Outcome Measures

20. Symptom evaluating outcome measures
• The two major symptoms in patients referred to
pulmonary rehabilitation are dyspnea and fatigue
• They can be assessed in two ways: (1) in “real time” or
(2) through recall
• Real-time evaluation of symptoms will only answer the
question of how short of breath or fatigued the patient is
at the moment of testing. The Borg scale and the Visual
Analog Scale are most commonly used
• Recall of symptoms, such as dyspnea or fatigue, is
usually accomplished through the use of questionnaires.
• Patients to rate their overall dyspnea experience, whereas
others ask about dyspnea related to activities

21. Performance Evaluating Outcome Measure
• Direct observation of patients performing activities and
note the rate, speed, or efficiency with which an activity
is performed.
• However, this is time consuming, difficult to standardize,
and often impractical.
• An emerging method of evaluating activities in the non-
laboratory setting is the use of activity monitors or
motion detector which provides an objective measure of
patients’ daily activity.
• Monitors range from simple, such as a pedometer, which
evaluates the number of steps a patient takes, to more
complex devices that measure movement in three planes,
such as a triaxial accelerometer.

22. Quality-of-Life Measurements
• Quality of life can be defined as “the gap between that
which is desired in life and that which is achieved”
• HRQL focuses on those areas of life that are affected by
health status, and reflects the impact of respiratory
disease (including comorbidities and treatment) on the
ability to perform or enjoy activities of daily living
• There are well-validated generic and specific quality-of-
life tool for use in the pulmonary rehabilitation setting.
• The most widely used respiratory-specific HRQL
questionnaires are the Chronic Respiratory Disease
Questionnaire (CRQ) and the Saint George’s Respiratory
Questionnaire (SGRQ)
• SF-36 is the most commonly used generic QOL tool.

24. COMPONENTS OF
REHABILITATION

25. PR
EXERCISE
TRAINING
OPTIMIZING
BODY
COMPOSITION
SELF
MANAGEMENT
STRATEGIES
PSYCHOSOCI
AL
INTERVENTIO
N

26. Exercise Training
• Exercise training is the best available means of
improving muscle function in COPD and other
chronic respiratory diseases
• Exercise training programs must address the
individual patient’s limitation to exercise, which may
include ventilator limitations, gas exchange
abnormalities, and skeletal or respiratory muscle
dysfunction.
• Exercise training may also improve motivation for
exercise, reduce mood disturbance, decrease
symptoms, and improve cardiovascular function

27. Even when a conventional training response is not
anticipated, the three principles of training are
followed:
• Overload :- intensity must be greater than the
muscle's normal load
• Reversibility :- cessation of training loses the
benefit gained
• Specificity, i.e. only the specific activities
practised will show improvement
Four components make up the exercise
prescription: mode, intensity, duration and
frequency.

28. • Studies show a outpatient exercise training with two
or three weekly sessions for 4 weeks showed less
benefit than similar training for 7 weeks
Guidelines:
• A minimum of 20 sessions should be given at least
three times per week to achieve physiologic benefits
• Twice weekly supervised plus one unsupervised
home session may also be acceptable
FREQUENCY / DURATION

29. INTENSITY

30. TYPE / MODE
• The mode of exercise relates to the participants'
lifestyles
• For Aerobic training- Some choose walking, stair
climbing or occupation-based exercise.
• Some prefer the stationary bike or treadmill
because they feel in control, can use oxygen
easily and have support for their shoulder girdle.
• Upper limb exercise needs to be included
• Circuit training can involve six to ten exercise
stations
• Exercises are best alternated between upper/
lower limb exercises, and easy/difficult exercises

31. Endurance
• Endurance training in the form of cycling or walking exercises
is the most commonly applied exercise training modality in
pulmonary rehabilitation.
• Long exercise sessions at high levels of intensity 60%
maximal with the total effective training time should ideally
exceed 30 minutes.
• Some patients may be difficult to achieve this target training
time or intensity, even with close supervision in which case
interval training may be a reasonable alternative.
• Interval training is a modification of endurance training where
the longer exercise session is replaced by several smaller
sessions separated by periods of rest or lower intensity
exercise.
• Interval training results in significantly lower symptom scores
despite high absolute training loads, thus maintaining the
training effects.

32. Strength Training
• Strength (or resistance) training also appears to be
worthwhile in patients with chronic respiratory
disease as it helps to to improve muscle mass and
strength than endurance training
• Training sessions generally include two to four sets
of 6 to 12 repetitions at intensities ranging from 50
to 85% of one repetition maximum
• The combination of endurance and strength training
is probably the best strategy to treat peripheral
muscle dysfunction in chronic respiratory disease,
because it results in combined improvements in
muscle strength and whole body endurance, without
unduly increasing training time.

33. • Supervised training sessions usually last for 30-
60 minutes but, for home practice, respiratory
patients find it more acceptable to exercise for
one or more short sessions a day with brief warm
up and cool down periods.
• Severely breathless people may prefer interval
training, which alternates 15- to 30-second
episodes of exercise with rest
TIME

34. ADDITIONAL STRATEGIES TO IMPROVE THE
EXERCISE CAPACITY
Bronchodilator therapy:
• In individuals with airflow limitation, optimal
bronchodilator therapy should be given prior to exercise
training to enhance performance.
Oxygen:
• Oxygen supplementation during pulmonary
rehabilitation, regardless of whether or not oxygen
desaturation during exercise occurs, often allows for
higher training intensity and/or reduced symptoms in the
research setting.
.

35. Noninvasive mechanical ventilation:
• Noninvasive positive pressure ventilation (NPPV) reduces
breathlessness and increases exercise tolerance in certain
patients with chronic respiratory disease
Respiratory muscle training.
• Three types of inspiratory muscle training have been reported:
inspiratory resistive training, threshold loading , and
normocapnic hyperpnea
Neuromuscular electrical stimulation
• Neuromuscular electrical stimulation (NMES) involves
passive stimulation of contraction of the peripheral muscles to
elicit beneficial training effects.
• Indicative in patients with respiratory disease who are
bedbound or suffering from extreme skeletal muscle
weakness.

36. • Patient education remains a core component of
comprehensive pulmonary rehabilitation.
• Education permeates all aspects of pulmonary
rehabilitation, beginning at the time of diagnosis and
continuing through end-of-life care.
• It is a shared responsibility among the patient,
family, primary care physician, specialist, and
nonphysician health care providers
Self Management Education

37. Some of the topics that are dealt are:
• Breathing Strategies
• Normal Lung Function and Pathophysiology of Lung Disease
• Proper Use of Medications, including Oxygen
• Bronchial Hygiene Techniques
• Benefits of Exercise and Maintaining Physical Activities
• Energy Conservation and Work Simplification Techniques
• Eating Right
• Irritant Avoidance, including Smoking Cessation
• Prevention and Early Treatment of Respiratory Exacerbations
• Indications for Calling the Health Care Provider
• Leisure, Travel, and Sexuality
• Coping with Chronic Lung Disease and End-of-Life Planning
• Anxiety and Panic Control, including Relaxation Techniques and
Stress Management

38. INTERVENTIONS
1. Prevention and early treatment of exacerbations
• Exacerbations can result in a more rapid decline of lung
function, increased peripheral muscle weakness, decreased
quality of life, increased health care costs, and increased
mortality.
• Patients should be instructed to respond early in the course of
an exacerbation by activating their predetermined action plan.
• Initiating pulmonary rehabilitation immediately after the
COPD exacerbation may reduce subsequent health care
utilization
2. End-of-life decision making
• Pulmonary rehabilitation has been identified as an appropriate
setting for the discussion of advance care planning and
palliative care

39. 3. Breathing strategies
• Breathing strategies refer to a range of techniques,
including pursed-lip breathing; active expiration,
diaphragmatic breathing, adapting specific body positions,
and coordinating paced breathing with activities.
• These techniques aim to improve regional ventilation, gas
exchange, respiratory muscle function, dyspnea, exercise
tolerance, and quality of life.
• Pursed-lip breathing attempts to prolong active expiration
through half-opened lips, thus helping to prevent airway
collapse reduces respiratory rate, dyspnea, and PaCO2,
while improving tidal volume and oxygen saturation in
resting conditions.

40. • Active expiration and body positioning techniques attempt to
decrease dyspnea, possibly by improving the length–tension
relationships or geometry of the diaphragm.
• Diaphragmatic breathing techniques require the patient to move the
abdominal wall out during inspiration and to reduce upper rib cage
motion.
• The goal is to improve chest wall motion and the distribution of
ventilation, thereby decreasing the energy cost of breathing Forward
leaning has been noted clinically to be effective in COPD and is
probably the most adopted body position.
• Use of a rollator/walker while ambulating allows forward leaning
with arm support, decreases dyspnea, and increases exercise capacity
• Pacing of Breathing with activities and energy conservation are also
addressed

41. 4. Bronchial hygiene techniques
• For some patients, mucus hypersecretion and
impaired mucociliary transport are distinctive
features of their lung disease.
• Instruction in the importance of bronchial hygiene
and training in drainage techniques are appropriate
for these patients.
• Combination of postural drainage, percussion, and
forced expiration improved airway clearance.

42. Improving the Body composition
The rationale for addressing and treating body composition
abnormalities in patients with chronic lung disease is based on
the following:
• the high prevalence and association with morbidity and
mortality
• the higher caloric requirements from exercise training in
pulmonary rehabilitation, which may further aggravate these
abnormalities (without supplementation); and
• the enhanced benefits, which will result from structured
exercise training
Physiologic interventions
• Strength training may selectively increase FFM by stimulation
of protein synthesis via insulin like growth factor 1 (IGF-1) or
targets downstream of IGF-1 signaling

43. Caloric supplementation.
• Caloric support is indicated to match elevated energy
requirements to maintain or restore body weight and fat mass
• Nutritional supplementation should initially consist of
adaptation in the patient’s dietary habits and the administration
of energy-dense supplements.
• Caloric supplementation indicated when BMI less than 21
kg/m2. Involuntary weight loss of more than 10% during the
last 6 months or more than 5% in the past month, or depletion
in FFM or lean body mass.
Pharmacologic interventions
• Anabolic steroids treatment
• Growth hormone
• Progestational agent megesterol acetate

44. Psychosocial Intervention
• Screening for anxiety and depression should be part of the initial assessment.
Screening questionnaires, such as the Hospital Anxiety and Depression
Questionnaire or the Beck Depression Inventory, may aid in the recognition
of significant anxiety and depression
• Patients should be taught to recognize symptoms of stress and be capable of
stress-management techniques.
• Relaxation training can be accomplished through techniques such as muscle
relaxation, imagery, or yoga and it should be integrated into the patient’s
daily routine, for tackling dyspnea and controlling panic.
• Useful crisis management skills include active listening, calming exercises,
anticipatory guidance regarding upcoming stressors, problem solving, and
identifying resources and support systems.
• For those having significant interpersonal or family conflicts, referral to a
clinical social worker, psychologist, or other counselor for
family/relationship counseling is recommended.

45. EVIDENCE : PULMONARY
REHABILITATION
1a
1b
1c
2a
2b
3a
3b
4
5

46. Joint ACCP/AACVPR Evidence-Based
Clinical Practice Guidelines
• This provides a systematic, evidence-based review of
the pulmonary rehabilitation literature that updates
the 1997 guidelines published by the American
College of Chest Physicians (ACCP) and the
American Association of Cardiovascular and
Pulmonary Rehabilitation
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47. Thank You