This document provides an overview of pulmonary rehabilitation. It defines pulmonary rehabilitation as a multidisciplinary program aimed at improving the physical and psychological condition of patients with chronic respiratory diseases. The core components of pulmonary rehab include physical therapy, exercise training, education, and psychosocial support. Physical therapy techniques are used to improve breathing mechanics and reduce dyspnea. Supervised exercise training focuses on building endurance, strength, and functional capacity. Education empowers patients by teaching disease self-management. Psychosocial support addresses the emotional impacts of chronic lung disease. Research shows that pulmonary rehab improves quality of life and reduces symptoms, healthcare utilization, and mortality risk for patients with respiratory conditions like COPD.

1. By: Khushali jogani
The Sarvajanik College Of Physiotherapy,
Rampura,Surat

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.  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.  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.  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.  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.  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. Peripheral muscle dysfunction
Atrophy of muscles
Altered metabolism
Reduction in
type I &II
fibres
Corticosteroid
damage
Cachexia and
cytokine
production
Nutritional
defects

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. Inclusion
criteria
Exclusion
criteria

11.  Obstructive disease
-emyhysema
-bronchitis
-bronchiectasis etc
 Restrictive disease
-idiopathic pulmonary fibrosis
-sarcoidosis etc

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.  Patients with severe limitation in their chest mobility
 Inability to learn
 Pyschiatric instability
 Disruptive behaviour
 Unstable angina

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. -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)

18. 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

19.  General care
 Pulmonary care
 Exercise and functional training
 Education
 Pyschosocial management
 Physical therapy management

20.  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

21. -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

22. 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.

23.  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

24.  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

25.  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.

26.  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.

27.  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

28. -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.

30.  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

32.  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

34.  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

35.  Two approaches for improving respiratory muscle fatigue:
 Exercises

36.  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

37.  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.

38.  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)
-

39.  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