Pulmonary rehabilitation (PR) is a comprehensive, multidisciplinary program for patients with chronic respiratory diseases. It aims to reduce symptoms, improve quality of life, and increase daily activity levels through exercise training, education, and psychosocial support. Key components of PR include aerobic endurance training, strength training, and education on disease management. Exercise programs typically involve walking, cycling, and are supervised 2-5 times per week for 4-12 weeks. Outcome assessments measure changes in dyspnea, exercise ability, health status, and activity levels. PR has been shown to improve patients' respiratory symptoms and overall health.

2. By
Samiaa Hamdy
Assistant Lecturer of Chest Diseases
Assiut University

4. The American Thoracic Society (ATS)
and the European Respiratory Society
(ERS) define pulmonary rehabilitation (PR)
as “an evidence-based, multidisciplinary,
and comprehensive intervention for
patients with chronic respiratory diseases
who are symptomatic and often have
decreased daily life activities.

5. It is a treatment structured for:
 ill patients with chronic respiratory
problems whose pulmonary function
has decreased, even after other
medical treatment.
patients who remain symptomatic,
even if their pulmonary function has
not decreased after other medical
treatment.

6. Aims of Pulmonary Rehabilitation

7. Reduces Dyspnoea
Increase exercise tolerance
Improve functional performance
Increase muscle endurance (peripheral and
respiratory)
Improve muscle strength (peripheral and
respiratory)
Promote long term commitment to exercise
Help allay patient fear and anxiety
Increase knowledge of lung condition and
promote self management
Improve health related quality of life
Increase independence in daily functioning

8. The success of rehabilitation programmes is attributed
to the multiprofessional team. Including:
physician
 physiotherapist
 nurse
 dietician
 social worker
 occupational therapist
 pharmacist
lung function technician
 psychologists
 exercise scientists.
Pulmonary Rehabilitation program staffs

9. Medical diagnosis of a chronic, but stable
respiratory condition that is under optimal
medical management. Exhibits disabling
symptoms that impede the patient’s level
of function in performing activities of
daily living (ADLs).
Target population

10. Contraindications

11. Absolute contraindications
Severe pulmonary hypertension with
dizziness or syncope on exertion
Severe congestive heart failure refractory to
medical management
Unstable coronary syndromes, or
Malignancy with bone instability or
refractory fatigue.

12. Relative contraindications
End-stage hepatic failure (where mental
status impairment and overwhelming
fatigue may occur)
Inability to learn
Psychiatric instability
Or disruptive behavior, and lack of
motivation

13.  Active smoking is not an absolute contraindication
to exercise training/PR.
 However, the inclusion of smokers in exercise
training programs remains the subject of
debate.
 Current clinical guidelines of ATS & BTS
suggest that any patient participating in PR
who is smoking actively should be strongly
encouraged to enroll in a smoking cessation
program and that smoking cessation should be
an important component of the rehabilitation
process.

14. Patients with a greater degree of ventilatory
reserve (minute ventilation measuring
[VE]/maximum voluntary ventilation achieve
greater improvements in exercise capacity
following training compared to patients with
lesser reserve, particularly if they also have
impaired peripheral muscle strength prior to
training.
One should not exclude patients with severe
dyspnea from participating in exercise training
on this basis alone.

15. Components of rehabilitation
Program

16. Exercise Training
Education
Psychosocial/behavioral intervention
Outcome Assessment

17. Exercise Training:
TYPES AND INTENSITY OF
TRAINING
Lower-limb training
Upper-limb and/or
Respiratory muscle training

18. Exercise Training:
Aerobic endurance versus strength training,(
aerobic fitness "endurance" training improves
one’s ability to sustain an exercise task at a
given work load.
Walking, running, cycling, stair climbing and
swimming are examples of endurance training
exercise.
 In contrast, strength training involves bursts
of activity over a shorter period, such as occur
during weight lifting).

19. High- Versus Low-Intensity Aerobic Fitness
"Endurance" Training (high-intensity exercise
is considered to be that which takes place at
greater than 60 percent of the patient’s
VO2max or Wmax, whereas lower intensity
exercise is conducted at lower work rates).
The optimal type and intensity of training
remains a subject of debate.

20. Upper-limb muscle training may consist of endurance
training (via arm ergometry [supported exercise], or
unsupported, arm-lifting exercise), or strength
training (weight lifting).
Reported benefits of upper-limb training include
improved arm muscle endurance and strength reduced
metabolic demand associated with arm exercise and
improved sense of well-being
ATS Statement on Pulmonary Rehabilitation
recommend that upper limb training be included
routinely as a component of the rehabilitation of
patients with COPD.

21. Respiratory Muscle Training:
Threshold-type ventilatory muscle training (VMT),
Pursed-lips breathing and diaphragmatic Breathing,
Postural Draining.
VMT usually requires the use of the muscle-training
device 15 to 30 min per day,5 or more days per week,
for at least 2 to 6 months.
When an adequate training load is delivered, VMT
can lead to improvements in inspiratory muscle
strength.

22. The most widely used modalities of exercise
training are walking and cycling, singly or in
combination, and should be considered in
terms of frequency, duration, and intensity.

23. To demonstrate a physiological training effect
outpatient courses should have:
A course duration of 4–12 weeks.
Supervised training sessions 2–5 times per week;
A session duration of 20–30 minutes;
A target exercise intensity corresponding to at
least 60% of the maximum attained power output
or VO2 peak in a preliminary progressive maximal
exercise test; alternatively,60% of the maximal
walking speed achieved on the shuttle walk test
could be used.

24. Education:
Patient education is a central feature of
pulmonary rehabilitation but is not effective alone.
It has the advantage of:
 Encourages active participation in health
care.
 Better understanding of disease.
 Improved compliance.
It also include information concerning types of
medication, action, adverse effects, dose and
proper use of inhaled medications, Instructions in
inhaler technique and appropriate use of oxygen.

25. Psychosocial Intervention:
Anxiety, depression, difficulties coping with
chronic disease
Aided by regular patient education session
or support groups
Instruction in progressive muscle
relaxation, stress reduction, panic control

26. Nutritional Assessment:
Poor nutrition frequently accompanies
advanced lung disease and is an independent
predictor of worsening mortality and health
status.
Wherever possible a measure of fat free
mass should be made to identify those
affected.
Other patients may be obese and dietary
advice to both groups may be helpful.

27. Nutritional Assessment:
Nutritional supplements can increase fat free
mass and muscle strength; the effect on
efficiency of physical training is unknown.
Anabolic agents are also being examined and
may increase muscle bulk but not exercise
capacity.

28. Outcome Assessment

29. Outcome Assessment:
An important component of pulmonary
rehabilitation, being used to determine individual
patient responses and evaluate overall effectiveness
of program.
 Dyspnea, Borg scale, Visual Analog Scale
 Exercise Ability – Borg Scale, 6MDW/Progressive
exercise testing pre and post rehab.
 Health Status – Respiratory-related QOL.
 Activity Levels –Respiratory-Specific functional
Status.

30. Outcome Assessment:
The gold standard measure is a laboratory
exercise test on either a treadmill or cycle
ergometer.
A symptom limited maximal test has been
shown to be sensitive to change following
rehabilitation (VO2max,Wmax, and lactate
threshold, and of comparing values before and
after exercise training.

31. Muscle biopsies can be used to detect structural
and metabolic changes following training.
More recently, it has been appreciated that
biomarkers such as exhaled nitric oxide (NO)
may be of use in assessing the physiologic
response to exercise training.
Increases in exhaled NO have also been
associated with improvements in exercise
tolerance following PR for persons with COPD.

32. Objectives of Exercise Programs: