Pulmonary Rehabilitation pptx


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Pulmonary Rehabilitation Talk in Cochin Thoracic Society

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  • really useful for my studies...
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Pulmonary Rehabilitation pptx

  1. 1. Dr Subin Ahmed MDAssistant Professor AIMS
  2. 2. DEFINITIONArt of medical practice wherein individually tailoredmultidisciplinary program is formulated, which throughaccurate diagnosis, therapy, emotional support andeducation; stabilizes or reverses both physio andpsychopathology of pulmonary disease in attempts to returnthe patient to highest possible functional capacity allowed bypulmonary handicap and overall life situation
  3. 3. ATS – ERS definition (2005)Evidence-based, multidisciplinary, and comprehensiveintervention for patients with chronic respiratory diseases whoare symptomatic and often have decreased daily life activitiesIntegrated into the individualized treatment of thepatient, pulmonary rehabilitation is designed to reducesymptoms, optimize functional status, increaseparticipation, and reduce health care costs through stabilizingor reversing systemic manifestations of the disease
  4. 4. The Timeline………Charles Denison (1895): After recovery from PTB; Walking eachday- Made him feel better; Increased exercise tolerance;Reduced respiratory and pulse rateAlbert Haas (1932): Carrying heavy books; Noticed weight gain& Feeling of well beingHaas and Cordon (1969): first showed benefits of pulmonaryrehabilitation over conventional therapy in a cohort studyACCP (1974): definition of pulmonary rehabilitationACCP (1979): Detailed monograph on pulmonary rehabilitationin JAMA
  5. 5. Education GeneralPsychological exercise support training Pulmonary Rehabilitation components Nutritional Breathing advice Retraining Outcome Assessment
  7. 7. Consequences of Respiratory Disease• Peripheral Muscle dysfunction• Respiratory muscle dysfunction• Nutritional abnormalities• Cardiac impairment• Skeletal disease• Sensory defects• Psychosocial dysfunction
  8. 8. Mechanisms for these morbidities• Deconditioning• Malnutrition• Effects of hypoxemia• Steroid myopathy or ICU neuropathy• Hyperinflation• Diaphragmatic fatigue• Psychosocial dysfunction from anxiety, guilt, dependency and sleep disturbances
  9. 9. Goals of Pulmonary Rehabilitation Aims to reduce symptoms, decrease disability, increase participation in physical and social activities and improve overall quality of life. These goals are achieved through patient and family education, exercise training, psychosocial intervention and assessment of outcomes. The interventions are geared toward the individual problems of each patient and administered by the multidisciplinary team.
  10. 10. Benefits of Pulmonary RehabilitationImproved Exercise CapacityReduced perceived intensity of dyspneaImprove health-related QOLReduced hospitalization and LOSReduced anxiety and depression from COPDImproved upper limb functionBenefits extend well beyond immediate period of training
  11. 11. Patient Selection Obstructive Diseases Restrictive Diseases  Interstitial  Chest Wall  Neuromuscular Other 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 (GOLD)
  12. 12. Exclusion criteriaPatients with severe orthopedic or neurological disorderslimiting their mobilitySevere pulmonary arterial hypertensionExercise induced syncopeUnstable angina or recent MIRefractory fatigueInability to learn, psychiatric instability and disruptive behavior
  13. 13. Setting for Pulmonary RehabilitationOutpatientInpatientHomeCommunity BasedChoice varies depending on- Distance to program- Insurance payer coverage- Patient preference- Physical, functional, psychosocial status of patient
  14. 14. EducationEXAMPLES OF EDUCATIONAL TOPICS 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
  15. 15. Education……Irritant Avoidance, including Smoking CessationPrevention and Early Treatment of Respiratory ExacerbationsIndications for Calling the Health Care ProviderLeisure, Travel, and SexualityCoping with Chronic Lung Disease and End-of-Life PlanningAnxiety and Panic Control, including Relaxation Techniquesand Stress Management
  16. 16. Exercise training Benefits of Exercise trainingPathophysiological Benefits of exerciseabnormality trainingDecreased lean body mass Increases fat free massDecreased TY1 fibers Normalizes proportionDecreased cross sectional area of muscle IncreasesfibersDecreased capillary contacts to muscle IncreasesfibersDecreased capacity of oxidative enzymes IncreasesIncreased inflammation No effectIncreased apoptotic markers No effectReduced glutathione levels IncreasesLower intracellular pH, increased lactate Normalization of decline inlevels and rapid fall in pH on exercise pH
  17. 17. Exercise trainingComponents of exercise training:•Lower extremity exercises•Arm exercises•Ventilatory muscle trainingTypes of exercise:•Endurance or aerobic•Strength or resistance
  18. 18. Lower extremity exerciseWalkingTreadmillStationary bicycleStair climbingSit & Stand
  19. 19. Arm exercise training Arm cycle ergometer Unsupported arm lifting Lifting weightsStrength exerciseWhen strength exercise was added tostandard exercise protocol;led to greater increase inmuscle strength and muscle mass
  20. 20. Ventilatory muscle trainingResistive IMT: Threshold IMT:Patient breaths through hand held Patient breaths through a devicedevice with which resistance to equipped with a valve whichflow can be increased gradually opens at a given pressure.• Difficult to standardize the load• Patients may hypoventilate • Easily quantitated and• Leads to increased Pulmonary standardized Arterial Pressure and fall in oxygen tension
  21. 21. Chest Physical Therapy & Breathing RetrainingPursed Lip Breathing – shifts breathing pattern and inhibitsdynamic airway collapse.Posture techniques – forward leaning reduces respiratoryeffort, elevating depressed diaphragm by shifting abdominalcontents.Diaphragm Breathing – Some patients with extreme air trappingand hyperinflation have increased WOB with this techniquePostural Draining – valuable in patients who produce more than30cc/24 hours - Coughing techniques
  22. 22. Pursed Lip Flutter Device
  23. 23. Bronchial hygiene techniquesPostural drainagePercussion & vibrationDirected coughForced expiratory technique (huff cough)Active cycle of breathingAutogenic drainagePositive expiratory pressure
  24. 24. What does ATS-ERS & GOLD Say?A minimum of 20 sessions should be givenAt least three times per weekTwice weekly supervised plus one unsupervised home sessionmay also be acceptable.Once weekly sessions seem to be insufficientEach session to last 30 minutesHigh-intensity exercise (>60% of maximal work rate) producesgreater physiologic benefit and should be encouraged; however,low-intensity training is also effective for those patients whocannot achieve this level of intensity (ATS-ERS)
  25. 25. ATS-ERSBoth upper and lower extremity training should be utilizedLower extremity exercises like treadmill and stationary bicycleergometer & Arm exercises like lifting weights and arm cycle ergometerare recommendedThe combination of endurance and strength training generally hasmultiple beneficial effects and is well tolerated; strength training wouldbe particularly indicated for patients with significant muscle atrophyRespiratory muscle training could be considered as adjunctive therapy,primarily in patients with suspected or proven respiratory muscleweakness
  26. 26. The minimum length of an effective rehabilitation program is 6 weeks.Daily to weekly sessionsDuration of 10 minutes to 45 minutes per sessionIntensity of 50% of VO2 max to maximum toleratedEndurance training can be accomplished through continuous orinterval exercise programs.The latter involve the patient doing the same total work but divided intobriefer periods of high-intensity exercise, which is useful whenperformance is limited by other comorbidities
  27. 27. Additional considerationsOptimal bronchodilator therapy should be given prior to exercisetraining to enhance performance.Patients who are receiving long-term oxygen therapy should havethis continued during exercise training, but may need increasedflow rates.Oxygen supplementation during pulmonary rehabilitation,regardless of whether or not oxygen desaturation during exerciseoccurs, often allows for higher training intensity and/or reducedsymptoms in the research setting. (ATS/ERS STATEMENT)
  28. 28. Neuromuscular electrical stimulation (NMES) NMES may be an adjunctive therapy for patients with severe chronic respiratory disease who are bed bound or suffering from extreme skeletal muscle weakness. ATS/ERS Guidelines
  29. 29. 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 Further studies are needed to further define its role in pulmonary rehabilitation. ATS/ERSguidelines
  30. 30. Nutritional InterventionsWhy 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.
  31. 31. Body composition abnormalitiesIncreased activity related Energy expenditureHyper metabolic stateDecreased intakeImpairment of Energy balanceImbalance in Protein synthesis and breakdownLoss of fat; Loss of weight : BMI < 21 • 10% weight loss in 6 months • 5% weight loss in 1 month
  32. 32. Caloric supplementationShould be considered if : BMI less than 21 kg/m2 Involuntary weight loss of >10% during the last 6 months or more than 5% in the past month Depletion in FFM or lean body mass.
  33. 33. Nutritional supplementationEnergy dense foodsWell distributed during the dayNo evidence of advantage of high fat dietPatients experience less dyspnea after carbohydrate richsupplement than fat rich supplement. (probably due to delayedgastric emptying)Daily protein intake should be 1.5 gm/kg for positive balance
  34. 34. What to give……. Small Frequent MealsHigh-calorie snacks- creamy, rich puddings, crackers with peanutbutter, dried fruits and nuts.Beverages- milk-shakes, regular milk and high-calorie fruit juices,Breads and CerealsPep up Your Protein- milk or soy protein powder to mashed potatoes,gravies, soups and hot cerealChoose High-Calorie Fruits- bananas, mango, papaya, dates, driedapples or apricots instead of apples, watermelonRemember Your Vegetables potatoes, beets, corn, peas, carrotsHealthy, Unsaturated FatsSoups and Salads
  35. 35. Nutritional InterventionsPhysiological 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 for 4 doses Anabolic therapy alone increases muscle mass but not exercise capacity
  36. 36. Nutritional InterventionsGrowth hormone rhGH 0.05 mg/kg for 3 weeks in addition to 35 Kcal/kg and 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.
  37. 37. Nutritional InterventionsTestosterone 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
  38. 38. What the Guidelines Say…..Increased calorie intake is best accompanied by exercise regimesthat have a nonspecific anabolic actionAnabolic steroids in COPD patients with weight loss increase bodyweight and lean body mass; but have little or no effect on exercisecapacity. (GOLD)Pulmonary rehabilitation programs should address body compositionabnormalities. Intervention may be in the form of caloric, physiologic,pharmacologic or combination therapy. (ATS/ERS STATEMENT)
  39. 39. Psychological considerationsScreening for anxiety and depression should be part of theinitial assessment.Mild or moderate levels of anxiety or depression related to thedisease process may improve with pulmonary rehabilitationPatients with significant psychiatric disease should bereferred for appropriate professional care (ATS/ERSSTATEMENT)
  40. 40. Outcome Assessment Providing patients with an opportunity to give feedback about the program is a useful measure of quality control. Patient feedback also allows coordinators to evaluate the components of pulmonary rehabilitation that patients find most useful. The questionnaire should also provide patients with a variety of answering options Exercise capacity measurement
  41. 41. Maintenance rehabilitation & Repeat rehabilitation programCurrent guidelines does not comment on maintenance &repeat rehabilitationYearly repeat rehabilitation program had shown: Short termbenefits in the form of less frequent exacerbationsBut no long term physiological effects on exercise tolerance,dyspnea & HRQL Foglio K. Chest. 2001; 119:1696–1704
  42. 42. Pulmonary Rehab. in Resource Poor SettingsAssess the patient with spirometry, saturation, 6MWT, weight/FFMIby biometric impedance, and bone density by sonography, AQ 20and PHQ questionnaireTreatment of osteoporosis and dietary advice by the physicianExercise training by the physician or a trained staff, or an assistant atthe time of enrolment for 30 minutesThe exercise should simulate the patient’s home environmentThe endurance and strength training can be done by walking/cycling, walking uphill/climbing stairs and straight leg raise,respectively
  43. 43. Pulmonary Rehab in Resource Poor Settings……..The exercise should be guided by his ability to tolerate exercise and6MWT with periods of rest if desired. The speed and distanceshould be increased graduallyThe patient can be educated about breathing techniques by thephysician/assistantThe patients should exercise twice in a day for 30 minutes for atleast 5 to 6 days in a weekThe patient may be given a diary to maintainThe patient may follow up once in a week or 15 days forreinforcement/increment/supervision of exercises
  44. 44. What Does ACCP Say……..???
  45. 45. ACCP RECCOMENDATIONS (2007)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. Grade of Recommendation: 1A2. Recommendation: Pulmonary rehabilitation improves the symptom of dyspnea in patients with COPD. Grade of Recommendation: 1A3. Recommendation: Pulmonary rehabilitation improves health related quality of life in patients with COPD. Grade of Recommendation: 1A
  46. 46. ACCP RECCOMENDATIONS (2007)4. Recommendation: Pulmonary rehabilitation reduces the number of hospital days and other measures of health-care utilization in patients with COPD. Grade of Recommendation: 2B5. Recommendation: Pulmonary rehabilitation is cost-effective in patients with COPD. Grade of Recommendation: 2C6. 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. Grade of Recommendation: 2B
  47. 47. ACCP RECCOMENDATIONS (2007)8. Recommendation: Six to 12 weeks of pulmonary rehabilitation produces benefits in several outcomes that decline gradually over 12 to 18 months. (Grade of Recommendation: 1A) Some benefits, such as health-related quality of life, remain above control at 12 to 18 months. (Grade of Recommendation: 1C)9. Recommendation: Longer pulmonary rehabilitation programs (12 weeks) produce greater sustained benefits than shorter programs. Grade of Recommendation: 2C10. Recommendation: Maintenance strategies following pulmonary rehabilitation have a modest effect on long-term outcomes. Grade of Recommendation: 2C
  48. 48. ACCP RECCOMENDATIONS (2007)11. Recommendation: Lower-extremity exercise training at higher exercise intensity produces greater physiologic benefits than lower intensity training in patients with COPD. Grade of Recommendation: 1B12. Recommendation: Both low- and high intensity exercise training produce clinical benefits for patients with COPD. Grade of Recommendation: 1A13. Recommendation: Addition of a strength training component to a program of pulmonary rehabilitation increases muscle strength and muscle mass. Strength of evidence: 1A14. Recommendation: Current scientific evidence does not support the routine use of anabolic agents in pulmonary rehabilitation for for patients with COPD. Grade of Recommendation: 2C
  49. 49. ACCP RECCOMENDATIONS (2007)15. Recommendation: Unsupported endurance training of the upper extremities is beneficial in patients with COPD and should be included in pulmonary rehabilitation programs. Grade of Recommendation: 1A16. Recommendation: The scientific evidence does not support the routine use of inspiratory muscle training as an essential component of pulmonary rehabilitation. Grade of Recommendation: 1B17. Recommendation: Education should be an integral component of pulmonary rehabilitation. Education should include information on collaborative self-management and prevention and treatment of exacerbations. Grade of Recommendation: 1B18. Recommendation: There is minimal evidence to support the benefits of psychosocial interventions as a single therapeutic modality. Grade of Recommendation: 2C
  50. 50. ACCP RECCOMENDATIONS (2007)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 COPD20. Recommendation: Supplemental oxygen should be used during rehabilitative exercise training in patients with severe exercise- induced hypoxemia. Grade of Recommendation: 1C21. Recommendation: Administering supplemental oxygen during high- intensity exercise programs in patients without exercise-induced hypoxemia may improve gains in exercise endurance. Grade of Recommendation: 2C
  51. 51. ACCP RECCOMENDATIONS (2007)22. Recommendation: As an adjunct to exercise training in selected patients with severe COPD, noninvasive ventilation produces modest additional improvements in exercise performance. Grade of Recommendation: 2B23. 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 other than COPD. Grade of Recommendation: 1B25. Statement: Although no recommendation is provided since scientific evidence is lacking, current practice and expert opinion suggest that pulmonary rehabilitation for patients with chronic respiratory diseases other than COPD should be modified to include treatment strategies specific to individual diseases and patients in addition to treatment strategies common to both COPD and non-COPD patients.