3. Definition
• “Pulmonary rehabilitation is a comprehensive
intervention based on a thorough patient
assessment followed by patient tailored therapies
that include, but are not limited to, exercise training,
education, and behavior change, designed to
improve the physical and psychological condition of
people with chronic respiratory disease and to
promote the long-term adherence to health-
enhancing behaviors.”
– American Thoracic Society and the European Respiratory Society
4. • Chronic Obstructive Pulmonary Disease, a common
preventable and treatable disease, is characterized
by persistent airflow limitation that is usually
progressive and associated with an enhanced chronic
inflammatory response in the airways and the lung to
noxious particles or gases.
• Exacerbations and comorbidities contribute to the
overall severity in individual patients.
5. History
• 1974 – American College of Chest Physicians,
• 1981 – American Thoracic Society published its first
official statement on pulmonary rehabilitation.
• In 2001 the Global Initiative for Obstructive Lung
Disease endorsed pulmonary rehabilitation as a
standard therapy for COPD, and in 2003 placed this
intervention prominently in their treatment
algorithm for stable COPD.
7. Goals of Pulmonary Rehabilitation
• Increase exercise tolerance and reduce dyspnea
• Increase muscle strength and endurance
(peripheral and respiratory)
• Improve health related quality of life
• Increase independence in daily functioning
• Increase knowledge of lung condition and
promote self management
• Promote long term commitment to exercise
12. Patient Selection Criteria
• Symptomatic chronic lung disease
• Stable on standard therapy
• Functional limitation from disease
• Relationship with primary care provider
• Motivated to be actively involved in and take
responsibility for own health care
• No other interfering or unstable medical
conditions
• No arbitrary lung function or age criteria
13. Exclusion criteria
• 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
14. Setting for Pulmonary Rehabilitation
• Pulmonary rehabilitation can be provided in
– Inpatient
– Outpatient
– Individual’s home
– Community Based.
15. Barriers to enrollment
• Travel
• Transportation
• Inconvenient timing
• Depressive symptoms
• Lack of support
• Comorbidities
• provider’s support for
enrollment can influence
patient attendance and
adherence.
17. Components of Pulmonary
Rehabilitation
Patient evaluation
• Interview
• Medical evaluation
• Psychosocial assessment
• Diagnostic testing
– Pulmonary function
– Exercise
– Arterial blood
gases/oximetry
• Goal setting
• Program content
– Education
– Respiratory and chest
physiotherapy instruction
– Bronchial hygiene
– Breathing retraining
techniques
– Oxygen
• Exercise
• Psychosocial support
18. Length of Training Program
• Programs should last for a minimum of 4-12
weeks.
• Most of the studies that have shown an
improvement in exercise capacity have used
programs of 6 weeks in duration. These programs
have included at least 2 supervised sessions each
week.
19. Patient evaluation
Interview
• It serves to introduce the patient to the program,
review the medical history, and identify psychosocial
problems and needs. Family members should be
included.
20. Medical Evaluation
• Reviewing medical history helps to identify the
patient’s lung disease and assess its severity. Other
medical problems that might preclude or delay
participation may be identified. Available laboratory
data should be reviewed.
21. Psychosocial Assessment
• Successful rehabilitation
requires attention not
only to the patient’s
physical problems but
also to psychological,
emotional, and social
issues.
22. Diagnostic Testing
• Pulmonary function testing is used to
characterize lung disease and quantify
impairment.
• Exercise testing helps to assess the patient’s
exercise tolerance and to evaluate changes in
arterial blood gases with exercise.
• The noninvasive estimate of arterial oxygen
saturation by cutaneous oximetry is useful for
continuous monitoring.
23. Goals
• After a patient’s medical, physiologic, and psychosocial
state have been evaluated, specific goals should be set
that are compatible with his or her disease, needs, and
expectations.
• Family members should be included in this process so
that everyone understands what can and cannot be
achieved.
• Document changes before and after pulmonary
rehabilitation with standardized outcome measures of
exercise tolerance and symptoms or health status
24. • Program content
–Education
– Respiratory and chest
physiotherapy instruction
– Bronchial hygiene
– Breathing retraining
techniques
– Oxygen
• Exercise
• Psychosocial support
25. Education
• Normal lung function, chronic lung disease
• Proper use and care of respiratory equipment,
including nebulizers, metered dose inhalers, and
supplemental oxygen.
• Bronchial Hygiene – coughing, postural drainage,
chest vibration, and percussion
• Irritant Avoidance, including Smoking Cessation
• Prevention and Early Treatment of Respiratory
Exacerbations
26. • Indications for Calling the Health Care Provider
• Benefits of Exercise and Maintaining Physical
Activities
• Anxiety and Panic Control, including Relaxation
Techniques and Stress Management
• Encourage patients to assume responsibility for their
own care and become partners with their physician
in providing the care.
27. Types of exercise
• Endurance or aerobic
– Walking, Cycling, Stair climbing
• Strength or resistance
– Weight lifting of light loads
Exercise training
28. Endurance exercise
• The main aim of endurance training is to improve
aerobic capacity and augment the ability to perform
daily activities
Strength exercise
• When strength exercise was added to standard
exercise protocol; led to greater increase in muscle
strength and muscle mass
31. Benefits of Exercise training
Pathophysiological abnormality Benefits of exercise
training
Decreased lean body mass Increases fat free mass
Decreased TY1 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
32. Water based
(Swimming, Aqusize)
Nordic walking
(Walking with diagonal
locomotion)
T’ai Chi
(Circular movements,
Balance, Light weight)
Nonlinear periodized
(Mix of Aerobic and
Resistant exercise)
Alternate
Exercise
33. Inspiratory muscle training
Resistive IMT
Patient breaths through
hand held device with
which resistance to flow
can be increased gradually
Threshold IMT
Patient breaths through a
device equipped with a
valve which opens at a
given pressure.
Inspiratory muscle training has been shown to increase
inspiratory muscle strength and endurance and reduce
dyspnoea in patients with COPD.
34. Breathing Retraining Techniques
• Pursed Lip Breathing – shifts breathing pattern and
inhibits dynamic airway collapse.
• Diaphragm Breathing – Patients with extreme air
trapping and hyperinflation have increased WOB
with this technique
• Posture techniques
• Postural Draining – valuable in patients who produce
more than 30cc/24 hours - Coughing techniques
35. Pursed Lip Breathing
• Breath in through your
nose for about 2
seconds.
• Pucker your lips like
you’re getting ready to
blow out candles on a
birthday cake.
• Breathe out very slowly
through pursed-lips,
two to three times as
long as you breathed in.
37. Exhalation through the Flutter results in oscillations of
expiratory pressure and airflow, which vibrate the airway
walls, decrease the collapsibility of the airways and
accelerate airflow facilitating movement of mucus up the
airways
38. Psychosocial Support
• Depression is common in patients with chronic
pulmonary disorders, as are anxiety, denial, anger,
and isolation.
• Patients with psychological disorders may benefit
from individual counseling and therapy.
• Patients with significant psychiatric disease should be
referred for appropriate professional care.
39. Additional considerations
• 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 STATEMENT
40. Neuromuscular electrical stimulation
(NMES)
• In severely disabled COPD patients with
incapacitating dyspnea, 6 week NMES of muscles
involved in ambulation improved muscle strength
and endurance, whole body exercise tolerance, and
breathlessness.
• Patients who are unable or unwilling to participate in
pulmonary rehabilitation could be considered for
NMES.
41. Non invasive ventilation
• Proportional assist ventilation while exercise training,
enabled a higher training intensity, leading to a
greater maximal exercise capacity
• Addition of nocturnal domiciliary NPPV in
combination with pulmonary rehabilitation in stable
COPD patients resulted in improved exercise
tolerance and quality of life.
42. Nutritional supplementation
• Energy dense foods.
• Well distributed during the day
• Low carbohydrate diet.
• Supplementary essential amino acids increase body
weight and fat-free mass in weight-losing and frail
patients.
• A protein intake of 1.2–1.5 g/kg body weight.
• Polyunsaturated fatty acids.
43. Traditional Methods
• Tai Chi, a systematic callisthenic exercise, involves a
series of slow and rhythmic circular motions. It
emphasises use of 'mind' or concentration to control
breathing and circular body motions to facilitate flow
of internal energy (i.e. 'qi') within the body.
44. 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
45. Outcome Assessment
Primary outcomes (Subjective methods)
• Disease-specific health-related quality of life (HRQoL)
– Chronic Respiratory Disease Questionnaire (CRQ).
– St. George’s Respiratory Questionnaire (SGRQ).
– Borg scale and visual analogue scale can also be
used to assess the degree of breathlessness.
46. Secondary outcomes (Objective methods)
• Exercise testing
– Cardiopulmonary exercise testing (CPET)
– Six-minute walk test/distance (6MWT/6MWD).
– Incremental shuttle walk test (ISWT).
– Endurance shuttle walk test (ESWT).
47. Summary
• Pulmonary rehabilitation improves functional status
and reduce the disability and economic burden of
the growing number of patients with chronic lung
diseases.
• Pulmonary rehabilitation improves health-related
quality of life following an exacerbation and
substantially lowers the risk of both future
exacerbations and mortality.
49. Reference
• Fishmans Pulmonary Diseases and Disorders, 5th
edition.
• BTS Guideline on Pulmonary Rehabilitation.
• American Thoracic Society/European Respiratory
Society Statement.
• Global Initiative for Chronic Obstructive Lung
Disease.
• Clinics in Chest Medicine
(level of family and social support, the patient’s living arrangement, activities of daily living, hobbies, and employment potential)
patient’s emotional state may be evident in nonverbal communication, such as facial expression, physical appearance, handshake, and personal space
