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Pulmonary Rehabilitation

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What is PR?
What are the uses?
What are the parameters?
How to perform?
How to evaluate?

Published in: Health & Medicine

Pulmonary Rehabilitation

  1. 1. By Riham Hazem Raafat Lecturer of Chest Diseases Ainshams University
  2. 2. Learning Objectives • Definition of PR • Benefits of PR • Components of PR • Selectivity of patients fit for PR • Different programs of exercise in PR • Nutritional plan in PR • Different guidelines’ recommendations
  3. 3. DISEASE IMPAIRMENT DISABILITY HANDICAP TREATMENT REHABILITATION REHABILITATION
  4. 4. Spiral of Disability
  5. 5. • 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, reduce health care costs through stabilizing or reversing systemic manifestations of the disease, and increase activities & QOL ATS – ERS Definition
  6. 6. General exercise training
  7. 7. Pathophysiology
  8. 8. • Peripheral muscle dysfunction • Respiratory muscle dysfunction • Nutritional abnormalities • Cardiac impairment • Skeletal disease • Sensory defects • Psychosocial dysfunction Consequences of Chronic Respiratory Disease • Deconditioning •Malnutrition •Effects of hypoxemia •Steroid myopathy or ICU neuropathy •Hyperinflation •Diaphragmatic fatigue •Psychosocial dysfunction from anxiety, guilt, dependency and sleep disturbances Mechanisms of these Morbidities
  9. 9. Benefits of Pulmonary Rehabilitation Pulmonary rehabilitation does not reverse nor have any direct effect on the primary respiratory pathophysiology, yet it has proven to improve the following:
  10. 10. Obstructive Diseases: COPD patients at all stages of disease appear to benefit from exercise training programs improving with respect to both exercise tolerance and symptoms of dyspnea and fatigue ((GOLDGOLD)) Restrictive Diseases Interstitial Chest Wall Neuromuscular Other Diseases Patient Selection
  11. 11. • Patients with severe orthopedic or neurological disorders limiting their mobility • Severe pulmonary arterial hypertension • Exercise induced syncope • Unstable angina or recent MI • Refractory fatigue • Inability to learn, psychiatric instability and disruptive behavior Exclusion Criteria
  12. 12.  Control of symptoms of cough and fatigue:  Real time eval.: MRC breathlessness & Borg dyspnea scale  Recall of symptoms  Performance evaluation: Ability to do ADL  Directly observed or self reported + PFTs, ABG or Oximetry  Exercise tolerance:  6 minutes walking test  Cardiopulmonary exercise testing  Quality of life: (specific or non-specific)  Chronic respiratory disease questionnaire & SGRQs  SF- 36  Assessment of respiratory and peripheral muscle strength  Nutritional assessment  History, Laboratory, Anthropometric, Calorimetry (D&ID) Baseline Evaluation
  13. 13. • Outpatient • Inpatient • Home Choice varies depending on: - Distance to program - Insurance payer coverage - Patient preference - Physical, functional, psychosocial status of patient Setting for Pulmonary Rehabilitation
  14. 14. •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 & Work Simplification Techniques •Eating Right 1- Education
  15. 15. • 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
  16. 16. 2- Exercise training Pathophysiological abnormality Benefits of exercise training Decreased lean body mass (N: 60-90%) Increases fat free mass Decreased Type 1 fibers Normalizes proportion Decreased cross sectional area of muscle fibers Increases Decreased capillary contacts to muscle fibers Increases Decreased capacity of oxidative enzymes Increases Increased inflammation No effect Increased apoptotic markers No effect Reduced glutathione levels Increases Lower intracellular pH, increased lactate levels and rapid fall in pH on exercise Normalization of decline in pH
  17. 17. Components of exercise training: • Lower extremity exercises • Arm exercises • Ventilatory muscle training Types of exercise: • Endurance or aerobic • Strength or resistance
  18. 18. • Walking • Treadmill • Stationary bicycle • Stair climbing • Sit & Stand Lower extremity exercise
  19. 19. Benefits in COPD • Increased work capability as assessed by pre & post PR incremental treadmill protocol or 6 min walking distance • 40 – 102% increase in endurance of maximal work rate • Significant improvement in subjective assessment using Borg dyspnea scale • No changes in hemodynamics during exercise
  20. 20. • Arm cycle ergometer • Unsupported arm lifting • Lifting weights Arm exercise training
  21. 21. Benefits in COPD • Has the potential to improve arm exercise performance & capacity by decreasing ventilatory & metabolic demand during arm work (measured by Vo2), and by improving arm endurance. • Arm training improves the ventilatory contribution of those muscles by increasing shoulder girdle muscle strength. • No significant effect on outcomes, such as functional status and performance when arm training used alone.
  22. 22. Strength exercises: When strength exercise was added to standard exercise protocol; led to: greater increase in muscle strength and muscle mass (FFM)  increased mid-thigh circumference But NO additional benefit in:  Exercise capacity as assessed by 6MWD or CPET  HRQOL  Physiological parameters of heart rate or blood lactate levels
  23. 23. Resistive non-targeted IMT: Patient breaths through hand held device with which resistance to flow can be increased gradually. Pressure Threshold IMT: Patient breaths through a device equipped with a valve which opens at a given pressure. • Difficult to standardize the load • Patients may hypoventilate • Leads to increased Pulmonary Arterial Pressure and fall in oxygen tension • Easily quantitated and standardized Ventilatory muscle training *30 breath twice daily, intensity 50% of Pimax, inc. 5% load/wk. for 6wks
  24. 24. • Voluntary Isocapnic Hyperventilation (VIH): Endurance technique; patients are asked to breathe at the highest rate they can manage for 15 to 30 minutes. Hypocapnia and its accompanying symptoms are prevented by adding CO2 to the inspired air or by requiring partial rebreathing of expired air. Can improve maximum voluntary ventilation (MVV) in COPD.
  25. 25. • Pursed Lip Breathing – shifts breathing pattern and inhibits dynamic airway collapse. (2s inh, 4s exh) • Posture techniques – forward leaning reduces respiratory effort, elevating depressed diaphragm by shifting abdominal contents. • Diaphragm Breathing – Some patients with extreme air trapping and hyperinflation have increased WOB with this technique • Postural Draining – valuable in patients who produce more than 30cc/24 hours - Coughing techniques Chest Physical Therapy & Breathing Retraining
  26. 26. Pursed Lip Diaphragmatic Breathing
  27. 27. • Postural drainage • Percussion • Directed cough: as Forced expiratory technique (huffing: small long (LL) or big short huff (UL) in cycle; 10 mins twice /d) • Active cycle of breathing (breathing control (hands on abd.), deep breathing exercises e’ breath hold (ribs) & huffing +/- manual technique) • Autogenic drainage (self drainage: unstick, collect, evacuate) • Positive expiratory pressure (behind mucus to push) • Incentive Spirometry Bronchial Hygiene Techniques Can be associated with others
  28. 28. Vibratory PEP Flutter device Acapella
  29. 29. • A minimum of 20 sessions should be given (6-12 wks) • At least three times per week • Twice weekly supervised plus one unsupervised home session may also be acceptable. • Once weekly sessions seem to be insufficient • Each session to last 30 minutes (10-45) • High-intensity exercise (50-60% of maximal work rate or peak Vo2) produces greater physiologic benefit and should be encouraged; however, low-intensity training is also effective for those patients who cannot achieve this level of intensity (ATS-ERS) What do Guidelines Say?
  30. 30. • Both upper & lower extremity training should be utilized • Lower extremity exercises like treadmill and stationary bicycle ergometer & Arm exercises like lifting weights and arm cycle ergometer are recommended • The combination of endurance and strength training generally has multiple beneficial effects and is well tolerated; strength training would be particularly indicated for patients with significant muscle atrophy • Respiratory muscle training could be considered as adjunctive therapy, primarily in patients with suspected or proven respiratory muscle weakness (ATS/ERS)
  31. 31. • The minimum length of an effective rehabilitation program is 6 weeks. • Daily to weekly sessions • Duration of 10 minutes to 45 minutes per session • Intensity of 50% of VO2 max to maximum tolerated • Endurance training can be accomplished through continuous or interval exercise programs. • The latter involve the patient doing the same total work but divided into briefer periods of high-intensity exercise, which is useful when performance is limited by other comorbidities (GOLD)
  32. 32. • Optimal bronchodilator therapy should be given prior to exercise training to enhance performance. • Patients who are receiving long-term oxygen therapy should have this continued during exercise training, but may need increased flow rates. • 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. (ATS/ERS) Additional considerations:
  33. 33. may be an adjunctive therapy for patients with severe chronic respiratory disease who are bed bound or suffering from extreme skeletal muscle weakness. • Non invasive mechanical ventilation: Because NPPV is a very difficult and labor-intensive intervention, it should be used only in those with demonstrated benefit from this therapy (ATS/ERS) • Neuromuscular electrical stimulation (NMES):
  34. 34. Why intervene? •High prevalence and association with morbidity and mortality •Higher caloric requirements from exercise training in pulmonary rehabilitation, which may further aggravate these abnormalities (without supplementation) •Enhanced benefits, which will result from structured exercise training. 3- Nutritional Interventions
  35. 35. Body composition abnormalities: ↑ ACTIVITY RELATED ENERGY EXPENDITURE HYPERMETABOLIC STATE DECREASED INTAKE IMPAIRMENT OF ENERGY BALANCE IMBALANCE IN PROTEIN SYNTHESIS AND BREAKDOWN LOSS OF FAT LOSS OF WEIGHT: BMI <21 10% WEIGHT LOSS IN 6 MONTHS 5% WEIGHT LOSS IN 1 MONTH LOSS OF FFM ANTHROPOMETRY BIOIMPEDANCE ANALYSIS DEXA Lab. Investigations CALORIC SUPPLEMENTS PROTEIN SUPPLEMENT STRENGTH EXERCISE ANABOLIC STEROIDS GROW TH HORM ONE INTERVENTIONS
  36. 36. Should be considered if : •BMI less than 21 kg/m2 (2/3 pts referred to PR, 1/3 outpatients are underweight and have greater impairment in HRQoL, increased mortality independent on degree of obstruction) •Involuntary weight loss of >10% during the last 6 months or more than 5% in the past month (can’t depend in edema) •Depletion in FFM or lean body mass (make QoL worse and less tolerant to exercise even when normal weight) Nutritional Supplementation
  37. 37. • Energy dense foods, well distributed during the day • No evidence of advantage of high fat diet (pulmocare: high fat low CHO formula  decrease Co2 retention) • Patients experience less dyspnea after liquid carbohydrate rich supplement than fat rich supplement. (probably dt delayed gastric emptying  distention) • Daily protein intake should be 1.5 gm/kg for positive balance • Antioxidants like vitamin C, E .. Also Vitamin D Nutritional supplementation
  38. 38. • High-calorie snacks- creamy, rich puddings, crackers with peanut butter, dried fruits and nuts. • Beverages- milk-shakes, regular milk and high-calorie fruit juices • Breads and Cereals • Pep up Your Protein- milk or soy protein powder to mashed potatoes, gravies, soups and hot cereal • Choose High-Calorie Fruits- bananas, mango, dates, dried apples or apricots instead of apples, watermelon • Remember Your Vegetables potatoes, beets, corn, peas, carrots • Healthy, Unsaturated Fats • Soups and Salads Small Frequent Meals (decrease metabolic & ventilatory effort, loss of appetite)
  39. 39. Physiological intervention: Strength exercise •Addition of strength training lead to increase in strength and mid thigh circumference (measured by CT) Pharmacological intervention : - Anabolic steroids •Anabolic steroids •Nandrolone decanoate - 50 mg for male; 25 mg for females; 2 Weekly 4 doses •Anabolic therapy alone increases muscle mass but not exercise capacity Nutritional Interventions
  40. 40. - Growth hormone •rhGH 0.05 mg/kg for 3 weeks in addition to 35 Kcal/kg & 1gm protein/kg per day has shown to increase fat free mass •But does not improve muscle strength or exercise tolerance (hand grip and maximal exercise) and no change in well being of the patient.
  41. 41. - Testosterone •Testosterone 100 mg weekly for ten weeks in men with low testosterone levels 320 ng/ml showed weight gain of 2.3 kg •Addition of exercise to testosterone has augmented weight gain to 3.3 kg •Physiological consequences and long term effects not studied
  42. 42. INTERVENTION WEIGHT GAIN FFM GAIN EXERCISE CAPACITY CALORIC SUPP. + - - CALORIC SUPPLEMENTATION + EXERCISE TRAINING ++ + + STRENGTH EXERCISE - + - ANABOLIC STEROIDS ++ ++ - ANABOLIC STEROIDS + EXERCISE ++ +++ ?
  43. 43. • Increased calorie intake is best accompanied by exercise regimes that have a nonspecific anabolic action • Anabolic steroids in COPD patients with weight loss increase body weight and lean body mass; but have little or no effect on exercise capacity. (GOLD) • Pulmonary rehabilitation programs should address body composition abnormalities. Intervention may be in the form of caloric, physiologic, pharmacologic or combination therapy. (ATS/ERS STATEMENT) What do Guidelines Say?
  44. 44. • Screening for anxiety and depression should be part of the initial assessment. • Mild or moderate levels of anxiety or depression related to the disease process may improve with pulmonary rehabilitation • Patients with significant psychiatric disease should be referred for appropriate professional care (ATS/ERS STATEMENT) 4- Psychological considerations
  45. 45. 5- Outcome Assessment
  46. 46.  Control of symptoms of cough and fatigue:  Real time eval.: MRC breathlessness & Borg dyspnea scale  Recall of symptoms  Performance evaluation: Ability to do ADL  Directly observed or self reported  Exercise tolerance:  6 minute walking test  Cardiopulmonary exercise testing  Quality of life:  Chronic respiratory disease questionnaire  St Georges’s respiratory questionnaire  SF- 36  Assessment of respiratory and peripheral muscle strength  Nutritional assessment Outcome Evaluation
  47. 47. • Current guidelines does not comment on maintenance & repeat rehabilitation • Yearly repeat rehabilitation program had shown: Short term benefits in the form of less frequent exacerbations • But no long term physiological effects on exercise tolerance, dyspnea & HRQL but in 6Ms begin loss of benefits 6- Maintenance rehabilitation & Repeat rehabilitation program
  48. 48. • Assess the patient with spirometry, saturation, 6MWT, weight/FFMI by biometric impedance, and bone density by sonography, AQ 20 and PHQ questionnaire • Treatment of osteoporosis & dietary advice by the physician • Exercise training by the physician or a trained staff, or an assistant at the time of enrolment for 30 minutes • Exercise should simulate the patient’s home environment • The endurance and strength training can be done by walking/ cycling, walking uphill/climbing stairs and straight leg raise, respectively Pulmonary Rehabilitation in Resource Poor Settings
  49. 49. • The exercise should be guided by his ability to tolerate exercise and 6MWT with periods of rest if desired. The speed and distance should be increased gradually • The patient can be educated about breathing techniques by the physician/assistant • The patients should exercise twice in a day for 30 minutes for at least 5 to 6 days in a week • The patient may be given a diary to maintain • The patient may follow up once in a week or 15 days for reinforcement/increment/supervision of exercises
  50. 50. 1. Recommendation: A program of exercise training of the muscles of ambulation is recommended as a mandatory component of pulmonary rehabilitation for patients with COPD. 1A 2. Recommendation: Pulmonary rehabilitation improves the symptom of dyspnea in patients with COPD. 1A 3. Recommendation: Pulmonary rehabilitation improves health related QOL in patients with COPD. 1A ACCP RECOMENDATIONS
  51. 51. 4. Recommendation: Pulmonary rehabilitation reduces the number of hospital days and other measures of health- care utilization in patients with COPD. 2B 5. Recommendation: Pulmonary rehabilitation is cost- effective in patients with COPD. 2C 6. Statement: There is insufficient evidence to determine if pulmonary rehabilitation improves survival in patients with COPD. No recommendation is provided. 7. Recommendation: There are psychosocial benefits from comprehensive pulmonary rehabilitation programs in patients with COPD. 2B
  52. 52. 8. Recommendation: Six to 12 weeks of pulmonary rehabilitation produces benefits in several outcomes that decline gradually over 12 to 18 months. 1A.. Some benefits, such as health-related quality of life, remain above control at 12 to 18 months. 1C 9. Recommendation: Longer pulmonary rehabilitation programs (12 weeks) produce greater sustained benefits than shorter programs. 2C 10.Recommendation: Maintenance strategies following pulmonary rehabilitation have a modest effect on long- term outcomes. 2C
  53. 53. 11.Recommendation: Lower-extremity exercise training at higher exercise intensity produces greater physiologic benefits than lower intensity training in patients with COPD. 1B 12.Recommendation: Both low- and high intensity exercise training produce clinical benefits for patients with COPD. 1A 13.Recommendation: Addition of a strength training component to a program of pulmonary rehabilitation increases muscle strength and muscle mass. 1A 14.Recommendation: Current scientific evidence does not support the routine use of anabolic agents in pulmonary rehabilitation for patients with COPD. 2C
  54. 54. 15.Recommendation: Unsupported endurance training of the upper extremities is beneficial in patients with COPD and should be included in pulmonary rehabilitation programs. 1A 16.Recommendation: Scientific evidence does not support the routine use of inspiratory muscle training as an essential component of pulmonary rehabilitation. 1B 17.Recommendation: Education should be an integral component of pulmonary rehabilitation. Education should include information on collaborative self- management and prevention and treatment of exacerbations. 1B 18.Recommendation: There is minimal evidence to support the benefits of psychosocial interventions as a single therapeutic modality. 2C
  55. 55. 19.Statement: Although no recommendation is provided since scientific evidence is lacking, current practice and expert opinion support the inclusion of psychosocial interventions as a component of comprehensive pulmonary rehabilitation programs for patients with COPD 20.Recommendation: Supplemental oxygen should be used during rehabilitative exercise training in patients with severe exercise-induced hypoxemia. 1C 21.Recommendation: Administering supplemental oxygen during high-intensity exercise programs in patients without exercise-induced hypoxemia may improve gains in exercise endurance. 2C
  56. 56. 22.Recommendation: As an adjunct to exercise training in selected patients with severe COPD, noninvasive ventilation produces modest additional improvements in exercise performance. 2B 23.Statement: There is insufficient evidence to support the routine use of nutritional supplementation in pulmonary rehabilitation of patients with COPD. No recommendation is provided. 24.Recommendations: Pulmonary rehabilitation is beneficial for some patients with chronic respiratory diseases (CRD) other than COPD. 1B 25.Statement: Although no recommendation is provided expert opinion suggest that PR for pts with CRD other than COPD should be modified to include ttt strategies specific to individual diseases & pts in addition to ttt strategies common to both COPD & non-COPD pts.

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