Pulmonary rehabilitation (PR) is a comprehensive intervention for patients with chronic respiratory diseases to reduce symptoms, optimize function, and increase quality of life. It includes education, exercise training, nutritional counseling, and psychological support. Guidelines recommend PR programs include 20-30 sessions over 6-12 weeks with exercise 3 times per week. Exercise training, including endurance, strength, and respiratory muscle training provides benefits like increased exercise tolerance and quality of life. Nutritional interventions aim to address weight loss and malnutrition common in respiratory disease. Outcome is assessed using measures of symptoms, exercise capacity, quality of life, and nutritional status.
Application of PEP devices in Cardiorespiratory physiotherapy.
It includes types of PEP devices and their uses in physiotherapy..
It stands for positive expiratory pressure.
It includes spirometry, flutter, rc cornet, acapella, etc.
useful in various cardiorespiratory disorders like COPD, asthma , cystic fibrosis, respiratory failure etc.
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”
This is a journal article critique on a research which is entitled " INSPIRATORY MUSCLE TRAINING TO ENHANCE RECOVERY FROM MECHANICAL VENTILATION; A RANDOMIZED TRIAL"
The 6-minute walk test (6MWT) is an easy to perform and practical test that has been used in the assessment of patients with a variety of cardiopulmonary diseases including pulmonary arterial hypertension (PAH). It simply measures the distance that a patient can walk on a flat, hard surface in a period of 6 minutes.
Application of PEP devices in Cardiorespiratory physiotherapy.
It includes types of PEP devices and their uses in physiotherapy..
It stands for positive expiratory pressure.
It includes spirometry, flutter, rc cornet, acapella, etc.
useful in various cardiorespiratory disorders like COPD, asthma , cystic fibrosis, respiratory failure etc.
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”
This is a journal article critique on a research which is entitled " INSPIRATORY MUSCLE TRAINING TO ENHANCE RECOVERY FROM MECHANICAL VENTILATION; A RANDOMIZED TRIAL"
The 6-minute walk test (6MWT) is an easy to perform and practical test that has been used in the assessment of patients with a variety of cardiopulmonary diseases including pulmonary arterial hypertension (PAH). It simply measures the distance that a patient can walk on a flat, hard surface in a period of 6 minutes.
DEFINITION
Pulmonary rehabilitation is a restorative and preventive process for patients with chronic respiratory disease. It is defined as a “multi-disciplinary program of care for patients with chronic respiratory impairment that is individually tailored and designed to optimize physical and social performance and autonomy.”
Consequences of Respiratory Disease
Peripheral Muscle dysfunction
Respiratory muscle dysfunction
Nutritional abnormalities
Cardiac impairment
Skeletal disease
Sensory defects
Psychosocial dysfunction
ASSESSMENT
At the start of the pulmonary rehabilitation program, your medical history will be obtained and your fitness level will be assessed, usually by doing a walking test. From this assessment, an exercise program will be set for you at your fitness level.
Another assessment will be completed at the end of the program.
Chart Review
Patient examination
medical history
Family history
Social history
Signs & symptoms
Patient Interview (1)Use of tobacco, alcohol, and nonprescription drugs
• Usual activity level, including employment, recreation, and home
• Regularity of exercise, including availability of equipment at home)
2)The nutritional evaluation should include the following:
• Weight• Height• Calculation of BMI• Documentation of recent weight change
\It is a condition of the lung characterized by permanent dilatation of the air spaces distal to the terminal bronchioles with destruction of the walls of these airways.
Chronic Bronchitis
It is a disease characterized by daily cough with sputum for at least 3 months of the year for at least 2 consecutive years and airway obstruction which is irreversible.
physiotherapy management for chronic obstructive pulmonary disease Sunil kumar
role of physiotherapy in chronic obstructive pulmonary disease, principles of physical therapy management in copd, physiotherapy assessing and treatment for copd
DEFINITION
Pulmonary rehabilitation is a restorative and preventive process for patients with chronic respiratory disease. It is defined as a “multi-disciplinary program of care for patients with chronic respiratory impairment that is individually tailored and designed to optimize physical and social performance and autonomy.”
Consequences of Respiratory Disease
Peripheral Muscle dysfunction
Respiratory muscle dysfunction
Nutritional abnormalities
Cardiac impairment
Skeletal disease
Sensory defects
Psychosocial dysfunction
ASSESSMENT
At the start of the pulmonary rehabilitation program, your medical history will be obtained and your fitness level will be assessed, usually by doing a walking test. From this assessment, an exercise program will be set for you at your fitness level.
Another assessment will be completed at the end of the program.
Chart Review
Patient examination
medical history
Family history
Social history
Signs & symptoms
Patient Interview (1)Use of tobacco, alcohol, and nonprescription drugs
• Usual activity level, including employment, recreation, and home
• Regularity of exercise, including availability of equipment at home)
2)The nutritional evaluation should include the following:
• Weight• Height• Calculation of BMI• Documentation of recent weight change
\It is a condition of the lung characterized by permanent dilatation of the air spaces distal to the terminal bronchioles with destruction of the walls of these airways.
Chronic Bronchitis
It is a disease characterized by daily cough with sputum for at least 3 months of the year for at least 2 consecutive years and airway obstruction which is irreversible.
physiotherapy management for chronic obstructive pulmonary disease Sunil kumar
role of physiotherapy in chronic obstructive pulmonary disease, principles of physical therapy management in copd, physiotherapy assessing and treatment for copd
method of removal of secretions from the lungs. patient need to learn an art of keeping their lungs free from secretions in chronic respiratory disorders like COPD, Asthma, Bronchiectasis, Cystic fibrosis.
Patient guide: What should I expect from pulmonary rehabilitation?NHS Improvement
This guide explains the concept of PR and how to get referred to a programme, plus what happens at the classes and after the programme finishes
Patient guide December 2012
Diagnostic guidelines for peripheral arterial diseasePerimed
The aim of this document is to summarize the recommendations and diagnostic guidelines provided by different societies and associations for the assessment of peripheral arterial disease, critical limb ischemia, diabetic foot ulcers and chronic wounds.
These lecture notes were prepared by Dr. Hamdi Turkey- Pulmonologist- Department of internal medicine - Taiz university
It contains :
- The new GOLD classification of severity
- The new GOLD treatment guidelines for the treatment of
COPD
Do Not Forget To Visit Our Pages On Facebook on the following Links:
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https://www.facebook.com/groups/690331650977113/
Glimpse of Cardiac rehabilitation for health care professionals to update themselves, with aim of helping people with or without disease. Focus on primary, secondary, tertiary prevention.
Pulmonary rehabilitation is the use of exercise, education, and behavioral intervention to improve how people with chronic lung disease function in daily life and to enhance their quality of life. Pulmonary rehabilitation is a program designed for people who have chronic lung disease.
Physiotherapy Approaches and various therapies for Ankylosing Spondylitis where fusion of the spine causes restriction in movement. This presentation focuses on aqua therapy for this particular condition.
Cardiac Rehabilitation has been defined as:
Coordinated, multifaceted interventions designed to optimize a cardiac patient’s physical, psychological, and social functioning so that they may, by their own efforts, resume and maintain as normal a place as possible in the community
this power point presentation provides main emphasis on the phases of the rehabilitation post op. it will enhance the knowledge about do's and dont's during the rehabilitation phases in brief. U may ask the questions if you have in your mind in the comment section. this ppt includes upper extremity as well as lower extremity exercises and also provides easy understanding with the help of suitable and intresting diagrams
History, Pharmacokinetics and Drug Deposition, Types, Techniques, Differences between different inhalers, Pitfalls and Errors of use, and Drugs used by inhalation
Early Enteral Nutrition in Critically Ill Patients is the best for helping early recovery, decreasing hospital stay and decreasing malnutrition in ICU
How? When? Formulas used? Access forms?
How is COPD and Nutrition Overlapped and Affecting Each Other
How to Solve the Problem as a Part of Pulmonary Rehabilitation
The Presentation is Discussing these items in the form of Problem Solving
What are the main sleeping disorders and what are the sleeping disorders related to respiratory system ? how to deal with it and how to diagnose and treat?
What are the pulmonary function tests used?
What are the indications?
What are the contraindications?
How to perform each and prepare patients?
How to interpret and reach a diagnosis?
How to clean and calibrate devices?
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
2. Learning Objectives
• Definition of PR
• Benefits of PR
• Components of PR
• Selectivity of patients fit for PR
• Different programs of exercise in PR
• Nutritional plan in PR
• Different guidelines’ recommendations
5. • Evidence-based, multidisciplinary, and comprehensive
intervention for patients with chronic respiratory
diseases who are symptomatic and often have
decreased daily life activities
• Integrated into the individualized treatment of the
patient, pulmonary rehabilitation is designed to reduce
symptoms, optimize functional status, increase
participation, reduce health care costs through
stabilizing or reversing systemic manifestations of the
disease, and increase activities & QOL
ATS – ERS Definition
8. • Peripheral muscle dysfunction
• Respiratory muscle dysfunction
• Nutritional abnormalities
• Cardiac impairment
• Skeletal disease
• Sensory defects
• Psychosocial dysfunction
Consequences of
Chronic Respiratory
Disease • Deconditioning
•Malnutrition
•Effects of hypoxemia
•Steroid myopathy or
ICU neuropathy
•Hyperinflation
•Diaphragmatic fatigue
•Psychosocial dysfunction from
anxiety, guilt, dependency and
sleep disturbances
Mechanisms of these
Morbidities
9. Benefits of Pulmonary Rehabilitation
Pulmonary rehabilitation does not reverse nor have any direct effect
on the primary respiratory pathophysiology, yet it has proven to
improve the following:
10. Obstructive 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 ((GOLDGOLD))
Restrictive Diseases
Interstitial
Chest Wall
Neuromuscular
Other Diseases
Patient Selection
11. • 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
Exclusion Criteria
12. Control of symptoms of cough and fatigue:
Real time eval.: MRC breathlessness & Borg dyspnea scale
Recall of symptoms
Performance evaluation: Ability to do ADL
Directly observed or self reported + PFTs, ABG or Oximetry
Exercise tolerance:
6 minutes walking test
Cardiopulmonary exercise testing
Quality of life: (specific or non-specific)
Chronic respiratory disease questionnaire & SGRQs
SF- 36
Assessment of respiratory and peripheral muscle strength
Nutritional assessment
History, Laboratory, Anthropometric, Calorimetry (D&ID)
Baseline Evaluation
13. • Outpatient
• Inpatient
• Home
Choice varies depending on:
- Distance to program
- Insurance payer coverage
- Patient preference
- Physical, functional, psychosocial status of patient
Setting for Pulmonary Rehabilitation
14. •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 & Work Simplification Techniques
•Eating Right
1- Education
15. • Irritant Avoidance, including Smoking Cessation
• Prevention and Early Treatment of Respiratory
Exacerbations
• Indications for Calling the Health Care Provider
• Leisure, Travel, and Sexuality
• Coping with Chronic Lung Disease and End-of-Life
Planning
• Anxiety and Panic Control, including Relaxation
Techniques and Stress Management
16. 2- Exercise training
Pathophysiological abnormality Benefits of exercise training
Decreased lean body mass (N: 60-90%) Increases fat free mass
Decreased Type 1 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
Reduced glutathione levels Increases
Lower intracellular pH, increased lactate
levels and rapid fall in pH on exercise
Normalization of decline in
pH
17. Components of exercise training:
• Lower extremity exercises
• Arm exercises
• Ventilatory muscle training
Types of exercise:
• Endurance or aerobic
• Strength or resistance
18. • Walking
• Treadmill
• Stationary bicycle
• Stair climbing
• Sit & Stand
Lower extremity exercise
19. Benefits in COPD
• Increased work capability as assessed by pre & post PR
incremental treadmill protocol or 6 min walking distance
• 40 – 102% increase in endurance of maximal work rate
• Significant improvement in subjective assessment using
Borg dyspnea scale
• No changes in hemodynamics during exercise
20. • Arm cycle ergometer
• Unsupported arm lifting
• Lifting weights
Arm exercise training
21. Benefits in COPD
• Has the potential to improve arm exercise performance
& capacity by decreasing ventilatory & metabolic
demand during arm work (measured by Vo2), and by
improving arm endurance.
• Arm training improves the ventilatory contribution of
those muscles by increasing shoulder girdle muscle
strength.
• No significant effect on outcomes, such as functional
status and performance when arm training used alone.
22. Strength exercises:
When strength exercise was added to standard exercise
protocol; led to:
greater increase in muscle strength and muscle mass
(FFM) increased mid-thigh circumference
But NO additional benefit in:
Exercise capacity as assessed by 6MWD or CPET
HRQOL
Physiological parameters of heart rate or blood lactate
levels
23. Resistive non-targeted IMT:
Patient breaths through hand held
device with which resistance to
flow can be increased gradually.
Pressure Threshold IMT:
Patient breaths through a device
equipped with a valve which opens
at a given pressure.
• Difficult to standardize the load
• Patients may hypoventilate
• Leads to increased Pulmonary
Arterial Pressure and fall in
oxygen tension
• Easily quantitated and
standardized
Ventilatory muscle training
*30 breath twice daily, intensity 50% of Pimax, inc. 5% load/wk. for 6wks
24.
25. • Voluntary Isocapnic Hyperventilation (VIH):
Endurance technique; patients are asked to breathe at the highest
rate they can manage for 15 to 30 minutes. Hypocapnia and its
accompanying symptoms are prevented by adding CO2 to the
inspired air or by requiring partial rebreathing of expired air.
Can improve maximum voluntary ventilation (MVV) in COPD.
26. • Pursed Lip Breathing – shifts breathing pattern and
inhibits dynamic airway collapse. (2s inh, 4s exh)
• Posture techniques – forward leaning reduces
respiratory effort, elevating depressed diaphragm by
shifting abdominal contents.
• Diaphragm Breathing – Some patients with extreme
air trapping and hyperinflation have increased WOB
with this technique
• Postural Draining – valuable in patients who produce
more than 30cc/24 hours - Coughing techniques
Chest Physical Therapy & Breathing
Retraining
28. • Postural drainage
• Percussion
• Directed cough: as Forced expiratory technique (huffing:
small long (LL) or big short huff (UL) in cycle; 10 mins twice /d)
• Active cycle of breathing (breathing control (hands on abd.),
deep breathing exercises e’ breath hold (ribs) & huffing +/-
manual technique)
• Autogenic drainage (self drainage: unstick, collect, evacuate)
• Positive expiratory pressure (behind mucus to push)
• Incentive Spirometry
Bronchial Hygiene Techniques
Can be associated with others
30. • A minimum of 20 sessions should be given (6-12 wks)
• At least three times per week
• Twice weekly supervised plus one unsupervised home
session may also be acceptable.
• Once weekly sessions seem to be insufficient
• Each session to last 30 minutes (10-45)
• High-intensity exercise (50-60% of maximal work rate
or peak Vo2) produces greater physiologic benefit and
should be encouraged; however, low-intensity training
is also effective for those patients who cannot achieve
this level of intensity (ATS-ERS)
What do Guidelines Say?
31. • Both upper & lower extremity training should be utilized
• Lower extremity exercises like treadmill and stationary
bicycle ergometer & Arm exercises like lifting weights
and arm cycle ergometer are recommended
• The combination of endurance and strength training
generally has multiple beneficial effects and is well
tolerated; strength training would be particularly
indicated for patients with significant muscle atrophy
• Respiratory muscle training could be considered as
adjunctive therapy, primarily in patients with suspected
or proven respiratory muscle weakness (ATS/ERS)
32. • The minimum length of an effective rehabilitation
program is 6 weeks.
• Daily to weekly sessions
• Duration of 10 minutes to 45 minutes per session
• Intensity of 50% of VO2 max to maximum tolerated
• Endurance training can be accomplished through
continuous or interval exercise programs.
• The latter involve the patient doing the same total work
but divided into briefer periods of high-intensity
exercise, which is useful when performance is limited
by other comorbidities (GOLD)
33. • 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)
Additional considerations:
34. may be an adjunctive therapy for patients with severe
chronic respiratory disease who are bed bound or
suffering from extreme skeletal muscle weakness.
• 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 (ATS/ERS)
• Neuromuscular electrical stimulation (NMES):
35. Why 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.
3- Nutritional Interventions
36. Body composition abnormalities:
↑ ACTIVITY RELATED
ENERGY EXPENDITURE
HYPERMETABOLIC
STATE
DECREASED
INTAKE
IMPAIRMENT OF ENERGY
BALANCE
IMBALANCE IN PROTEIN
SYNTHESIS AND BREAKDOWN
LOSS OF FAT
LOSS OF WEIGHT: BMI <21
10% WEIGHT LOSS IN 6 MONTHS
5% WEIGHT LOSS IN 1 MONTH
LOSS OF FFM
ANTHROPOMETRY
BIOIMPEDANCE
ANALYSIS
DEXA
Lab. Investigations
CALORIC
SUPPLEMENTS
PROTEIN
SUPPLEMENT
STRENGTH
EXERCISE
ANABOLIC
STEROIDS
GROW
TH
HORM
ONE
INTERVENTIONS
37. Should be considered if :
•BMI less than 21 kg/m2
(2/3 pts referred to PR, 1/3 outpatients
are underweight and have greater impairment in HRQoL, increased
mortality independent on degree of obstruction)
•Involuntary weight loss of >10% during the last 6 months
or more than 5% in the past month (can’t depend in edema)
•Depletion in FFM or lean body mass (make QoL worse and
less tolerant to exercise even when normal weight)
Nutritional Supplementation
38. • Energy dense foods, well distributed during the day
• No evidence of advantage of high fat diet (pulmocare:
high fat low CHO formula decrease Co2 retention)
• Patients experience less dyspnea after liquid
carbohydrate rich supplement than fat rich supplement.
(probably dt delayed gastric emptying distention)
• Daily protein intake should be 1.5 gm/kg for positive
balance
• Antioxidants like vitamin C, E .. Also Vitamin D
Nutritional supplementation
39. • High-calorie snacks- creamy, rich puddings, crackers
with peanut butter, dried fruits and nuts.
• Beverages- milk-shakes, regular milk and high-calorie
fruit juices
• Breads and Cereals
• Pep up Your Protein- milk or soy protein powder to
mashed potatoes, gravies, soups and hot cereal
• Choose High-Calorie Fruits- bananas, mango, dates,
dried apples or apricots instead of apples, watermelon
• Remember Your Vegetables potatoes, beets, corn,
peas, carrots
• Healthy, Unsaturated Fats
• Soups and Salads
Small Frequent Meals
(decrease metabolic & ventilatory effort, loss of appetite)
40. Physiological 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 4 doses
•Anabolic therapy alone increases muscle mass but not
exercise capacity
Nutritional Interventions
41. - Growth hormone
•rhGH 0.05 mg/kg for 3 weeks in addition to 35 Kcal/kg &
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.
42. - Testosterone
•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
44. • Increased calorie intake is best accompanied by exercise
regimes that have a nonspecific anabolic action
• Anabolic steroids in COPD patients with weight loss
increase body weight and lean body mass; but have little
or no effect on exercise capacity. (GOLD)
• Pulmonary rehabilitation programs should address body
composition abnormalities. Intervention may be in the
form of caloric, physiologic, pharmacologic or
combination therapy. (ATS/ERS STATEMENT)
What do Guidelines Say?
45. • Screening for anxiety and depression should be part of
the initial assessment.
• Mild or moderate levels of anxiety or depression
related to the disease process may improve with
pulmonary rehabilitation
• Patients with significant psychiatric disease should be
referred for appropriate professional care (ATS/ERS
STATEMENT)
4- Psychological considerations
47. Control of symptoms of cough and fatigue:
Real time eval.: MRC breathlessness & Borg dyspnea scale
Recall of symptoms
Performance evaluation: Ability to do ADL
Directly observed or self reported
Exercise tolerance:
6 minute walking test
Cardiopulmonary exercise testing
Quality of life:
Chronic respiratory disease questionnaire
St Georges’s respiratory questionnaire
SF- 36
Assessment of respiratory and peripheral muscle strength
Nutritional assessment
Outcome Evaluation
48. • Current guidelines does not comment on maintenance
& repeat rehabilitation
• Yearly repeat rehabilitation program had shown: Short
term benefits in the form of less frequent exacerbations
• But no long term physiological effects on exercise
tolerance, dyspnea & HRQL but in 6Ms begin loss of
benefits
6- Maintenance rehabilitation &
Repeat rehabilitation program
49. • Assess the patient with spirometry, saturation, 6MWT,
weight/FFMI by biometric impedance, and bone density
by sonography, AQ 20 and PHQ questionnaire
• Treatment of osteoporosis & dietary advice by the
physician
• Exercise training by the physician or a trained staff, or an
assistant at the time of enrolment for 30 minutes
• Exercise should simulate the patient’s home environment
• The endurance and strength training can be done by
walking/ cycling, walking uphill/climbing stairs and
straight leg raise, respectively
Pulmonary Rehabilitation in
Resource Poor Settings
50. • The exercise should be guided by his ability to tolerate
exercise and 6MWT with periods of rest if desired. The
speed and distance should be increased gradually
• The patient can be educated about breathing techniques
by the physician/assistant
• The patients should exercise twice in a day for 30
minutes for at least 5 to 6 days in a week
• The patient may be given a diary to maintain
• The patient may follow up once in a week or 15 days for
reinforcement/increment/supervision of exercises
51.
52.
53.
54. 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. 1A
2. Recommendation: Pulmonary rehabilitation improves
the symptom of dyspnea in patients with COPD. 1A
3. Recommendation: Pulmonary rehabilitation improves
health related QOL in patients with COPD. 1A
ACCP RECOMENDATIONS
55. 4. Recommendation: Pulmonary rehabilitation reduces the
number of hospital days and other measures of health-
care utilization in patients with COPD. 2B
5. Recommendation: Pulmonary rehabilitation is cost-
effective in patients with COPD. 2C
6. 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. 2B
56. 8. Recommendation: Six to 12 weeks of pulmonary
rehabilitation produces benefits in several outcomes
that decline gradually over 12 to 18 months. 1A..
Some benefits, such as health-related quality of life,
remain above control at 12 to 18 months. 1C
9. Recommendation: Longer pulmonary rehabilitation
programs (12 weeks) produce greater sustained
benefits than shorter programs. 2C
10.Recommendation: Maintenance strategies following
pulmonary rehabilitation have a modest effect on long-
term outcomes. 2C
57. 11.Recommendation: Lower-extremity exercise training at
higher exercise intensity produces greater physiologic
benefits than lower intensity training in patients with
COPD. 1B
12.Recommendation: Both low- and high intensity exercise
training produce clinical benefits for patients with
COPD. 1A
13.Recommendation: Addition of a strength training
component to a program of pulmonary rehabilitation
increases muscle strength and muscle mass. 1A
14.Recommendation: Current scientific evidence does not
support the routine use of anabolic agents in
pulmonary rehabilitation for patients with COPD. 2C
58. 15.Recommendation: Unsupported endurance training of
the upper extremities is beneficial in patients with
COPD and should be included in pulmonary
rehabilitation programs. 1A
16.Recommendation: Scientific evidence does not support
the routine use of inspiratory muscle training as an
essential component of pulmonary rehabilitation. 1B
17.Recommendation: Education should be an integral
component of pulmonary rehabilitation. Education
should include information on collaborative self-
management and prevention and treatment of
exacerbations. 1B
18.Recommendation: There is minimal evidence to
support the benefits of psychosocial interventions as a
single therapeutic modality. 2C
59. 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
COPD
20.Recommendation: Supplemental oxygen should be
used during rehabilitative exercise training in patients
with severe exercise-induced hypoxemia. 1C
21.Recommendation: Administering supplemental oxygen
during high-intensity exercise programs in patients
without exercise-induced hypoxemia may improve
gains in exercise endurance. 2C
60. 22.Recommendation: As an adjunct to exercise training in
selected patients with severe COPD, noninvasive
ventilation produces modest additional improvements
in exercise performance. 2B
23.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 (CRD) other than COPD. 1B
25.Statement: Although no recommendation is provided
expert opinion suggest that PR for pts with CRD other
than COPD should be modified to include ttt strategies
specific to individual diseases & pts in addition to ttt
strategies common to both COPD & non-COPD pts.