Pulmonary rehabilitation

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pulmonary rehabilitation
Khushali Jogani
The Sarvajanik College Physiotherapy,
Rmpura,Surat.

Published in: Education, Health & Medicine

Pulmonary rehabilitation

  1. 1. By: Khushali jogani The Sarvajanik College Of Physiotherapy, Rampura,Surat
  2. 2.  Introduction  Definitions  Team members  Symptoms  Pathophysiology  Aims or goals of Pulmonary Rehabilitation  Selection of patient  Assessment  Pulmonary rehabilitation components  Physical therapy care  Recent advances  References
  3. 3.  Rehabilitation programs for patients with pulmonary disease have existed for more than 25 years.  The American Thoracic Society position paper and most of the research have shown the benefits of rehabilitation for patients with COPD.  The need for early detection and treatment of respiratory dysfunction is widely accepted.
  4. 4.  Rehabilitation research is beginning to emphasize functional outcomes such as improvement in lung function, heart function, to improve maximal aerobic capacity and decrease mortality rate.  It is concerned with the issues of disability.
  5. 5.  Pulmonary Rehabilitation as defined by National Institute of Health(1994) is “A multi-disciplinary continuum of services directed to persons with pulmonary disease and their families, usually by an interdisciplinary team of specialists, with the goal of achieving and maintaining the individual’s maximum level of independence and functioning in the community”  Physiotherapists play an integral part in management by giving the techniques aimed to reduce the work of breathing and improving disability.
  6. 6.  It is an holistic approach to treatment of patients and their families with respiratory disease and requires number of health professionals such as:  The Advisory Board  The Medical Director  The Program Director  The Respiratory Care Specialist  The Exercise Specialist  The nutritionist or Dietitian  The Behavior Specialist
  7. 7.  The main symptom is dyspnoea which is associated with anxiety and fear. Limitations during daily life and reductions in exercise tolerance  Leg fatigue at lower work intensities compared to normals.
  8. 8. Peripheral muscle dysfunction Atrophy of muscles Altered metabolism Reduction in type I &II fibres Corticosteroid damage Cachexia and cytokine production Nutritional defects
  9. 9.  Reduce dyspnoea  Increase muscle endurance(peripheral and respiratory)  Improve muscle strength(peripheral and respiratory)  Ensure long term commitment to exercise  To remove fear and anxiety  Increase knowledge of lung condition and promote self-management  Improve nutritional status and health status
  10. 10. Inclusion criteria Exclusion criteria
  11. 11.  Obstructive disease -emyhysema -bronchitis -bronchiectasis etc  Restrictive disease -idiopathic pulmonary fibrosis -sarcoidosis etc
  12. 12.  Exposure to risks for COPD -cigarette smoking -occupational exposure -air pollution -infections of lungs -impaired immune defenses  Chest wall - chest wall surgeries - Intra-thoracic surgeries  All patients with respiratory symptoms of wheezing, coughing or dyspnoea require preventive care.
  13. 13.  Patients with severe limitation in their chest mobility  Inability to learn  Pyschiatric instability  Disruptive behaviour  Unstable angina
  14. 14.  Assessment of patient should be done and than followed by problem list, goals should be made for proper pulmonary rehabilitation.  It includes: 1. history (history of presenting illness, previous medical history, drug history, family history, social history) 2.subjective assessment
  15. 15. -breathlessness (dyspnoea), cough,sputum and haemoptysis, wheeze, chest pain, incontinence and other symptoms like fever headache and peripheral oedema -activity of daily living of patient by: London Chest Activity Of Daily Living Scale (Garrod et al 2000) -activity of health related quality of life by: Chronic Respiratory Questionnaire(Guyatt et al 1987) and St George’s Respiratory Questionnaire(Jones et al 1991) -for dyspnoea by: Baseline and Transition Dyspnoea Index(BDI)(Mahier et al 1984) and Medical Research Council Breathlessness Score(Fletcher et al 1960), Borg Scale Of Perceived Dyspnoea(Borg 1982)
  16. 16. 3.Objective assessment - general observation like patient’s position, any drips, drains, oxygen supply etc -observation of chest shape, breathing pattern, chest movement -palpation of trachea position, chest expansion -percussion -auscultation(breath sounds, any abnormal sounds, heart sounds) -exercise capacity of patient -examination of heart rate, blood pressure, respiratory rate,spirometry 4.Test results -ABG analysis, chest radiographs
  17. 17.  General care  Pulmonary care  Exercise and functional training  Education  Pyschosocial management  Physical therapy management
  18. 18.  General care -As soon as patient comes, evaluation should be done for medical and physical diagnosis -Prescription of medicine and oxygen support -Preventive care(smoking cessation, adequate hydration, proper nutrition etc)  Pulmonary care -respiratory treatment techniques for clearing accumulated pulmonary secretions include: -bronchial drainage -breathing techniques
  19. 19. -cough facilitation -postures to improve breathing -relaxation techniques -respiratory assistance devices to rest the breathing muscles at night or during exercise  Exercise and functional testing -instructions for energy conservation, activity pacing and use of adaptive equipment to optimize the patient ability for daily activities  Education -to provide knowledge and instruction to their family members and patient regarding disease, its effect, treatment etc
  20. 20. Psychosocial management -its important as chronic disease places stress on family members as well as for patient -so to provide them with coping strategies, stress reduction, management techniques, behavioral strategies, and financial assistance as possible Physical therapy management -physical therapy not only conduct exercise sessions, they can also provide education regarding educational sessions, smoking cessation programs, weight control and stress management and relaxation techniques.
  21. 21.  It depends whether exercises are to be prescribed for strength and endurance and than see the muscle response.  It is based on three components :  1)frequency of training  2)duration of training  3)Intensity of training  4)Mode of exercise
  22. 22.  How often? Daily /*2 week/*3 week  How long? 4 weeks/8 weeks/12 weeks  Length of sessions 40-60 minutes  Time of day afternoons/mornings  Exercise? Resisted/unloaded training/aerobic/walking  Intensity? Limited by dyspnoea (borg scale)/by VO2 peak  Regimen? Endurance/maximal  Assessment? Physiological/ functional
  23. 23.  Physiological response to training  Improved mechanical efficiency Improvement in mechanical efficiency can improve stride length and gait coordination.  Cardiovascular Reduction in heart rate, minute ventilation ,lowering of onset of lactic acidosis, lowering maximum oxygen uptake.  Muscle changes With endurance training , submaximal sustained effort result in transformation from type IIb to type IIa fibres, increasing their oxidative capacity. With strength training, increase in size of muscle cells and number of myofibrils. So to improve oxygen uptake and ability to maintain aerobic muscle metabolism for prolonged period.
  24. 24.  To measure exercise tolerance, laboratory test and field test can be used.  It is needed to set intensity ,assess the benefit of rehabilitation program, motivate the patient with exercise  Laboratory test measuring maximal oxygen consumption, heart rate, workload, arterial oxygenation, blood lactate levels  Field test like 12 min walking test and shuttle walking test are used.
  25. 25.  Pulmonary care Indications: 1) removal of excessive secretions that lead to: -obstruction of airways -ventillatory defects -produce symptoms of cough -increase respiratory infections -deterioration of lung function 2)when secretions are copious ,patients are chronic
  26. 26. -following treatment can be given based on patients evaluation  Modified bronchial drainage position. foams or cushions can be used to assume trendelenburg position.  For percussion and vibration if adequate assistance is not there, palm cups, mechanical percussors, high frequency chest compression system  Series of deep breathing exercise, forced expirations(huffing), coughing, ACBT, autogenic drainage use of mask providing positive expiratory pressure.  Sustained exercise  Diaphragmatic breathing, pursed lip breathing can be given to improve lung function.
  27. 27.  To see whether patients can do it effectively and independently  Short term goals  Long term goals  Functional training  Indications  For this -environment modification -task modification -relief of dyspnoea
  28. 28.  Physical conditioning  Goals  According to patient condition,i.e -patients with mild lung disease -patients with moderate lung disease -patient with severe lung disease  Strengthening  Goals  Lower extremity strengthening  Upper extremity strengthening
  29. 29.  Flexibility  Due to COPD, there is significant changes in posture and reduced mobility  Indications  Exercises  Purpose  Respiratory muscle exercise  Exercise for improving respiratory muscle function are important component of pulmonary rehabilitation.  The increased work of breathing and chest wall changes with COPD make respiratory muscle fatigue
  30. 30.  Two approaches for improving respiratory muscle fatigue:  Exercises
  31. 31.  Progressive Resistance Exercise in Physical Therapy: A Summary of Systematic Reviews Nicholas F Taylor, Karen J Dodd and Diane L Damiano PHYS THER. 2005; 85:1208-1223  Result showed that PRE was shown to improve the ability to generate force, with moderate to large effect sizes that may carry over into an improved ability to perform daily activities
  32. 32.  Impact of inspiratory muscle training in patients with COPD: what is the evidence? (R. Gosselink, J. De Vos, S.P. van den Heuvel, J. Segers,M. Decramer,G. Kwakkel)  A meta-analysis including 32 randomised controlled trials on the effects of inspiratory muscle training (IMT) in chronic obstructive pulmonary disease (COPD) patients was performed.  IMT improves inspiratory muscle strength and endurance, functional exercise capacity,dyspnoea and quality of life. Inspiratory muscle endurance training was shown to be less effective than respiratory muscle strength training. In patients with inspiratory muscle weakness the addition of IMT to a general exercise training program improved PI,max and tended to improve exercise performance.
  33. 33.  H.Steven Sadowsky,Ellen A. Hillegass. Essentials of cardiopulmonary physical therapy.  Jennifer A Pryor,S Ammani Prasad.Physiotherapy for respiratory and cardiac problems(3rd edition)  Robert.L.Williams,James K. Stroller,Robert M.kacmarek. Fundamentals of respiratory care(9th edition)  Scot Irwin,Jan Stephen Tecklin.Cardiopulmonary physical therapy(2nd edition) -
  34. 34.  Susan B O’Sullivan,Thomas J Schmitz.Physical Rehabilitation(5th edition)  R. Gosselink,J. De Vos, S.P. van den Heuvel,J. Segers,M. Decramer and G. Kwakkel. Impact of inspiratory muscle training in patients with COPD: what is the evidence? Eur Respir J 2011; 37: 416–425  Nicholas F Taylor, Karen J Dodd and Diane L Damiano. Progressive Resistance Exercise in Physical Therapy: A Summary of Systematic Reviews. PHYS THER. 2005; 85:1208-1223

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