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”

1. Dr. Prerana Chittal
Assistant Professor,
DVVPF College of
Physiotherapy,
Ahmednagar 414111

2. OBJECTIVES
• Introduction
• Definition
• Basis for pulmonary rehabilitation
• Indications and contraindications
• Goals
• Team
• Assessment
• Components

3. ATS-ERS statement, 2013
• “ 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”

4. Exercise
limitations
Ventilatory
impairments
Gas
exchange
abnormality
Respiratory
muscle
problem
Cardiac
abnormalities
Psychological
impact
Lower limb
muscle
dysfunction
4
RATIONALE

5. • Exercise intolerance is one of the main
factors limiting participation in activities of
daily living among individuals with chronic
respiratory disease.
• The cardinal symptoms that limit ex in pts
with respiratory ds. are -dyspnea
-fatigue

6. Common indications for referral to
pulmonary rehabilitation
Respiratory disease resulting in
• Anxiety engaging in activities
• Breathlessness with activity
• Limitations with:-social activities
-leisure activities
-indoor and/or outdoor chores
-basic ADL or instrumental ADL
• Loss of independence

7. Indications for pulmonary
rehabilitation
• It is indicated for those individuals with
chronic respiratory disease who have
decreased exercise tolerance, exertional
dyspnea or fatigue, and/or impairment of
activities of daily living.

8. Obstructive pulmonary disease:
• Chronic obstructive pulmonary diseases
• Asthma
• Bronchiectasis
Restrictive pulmonary disease
• Interstitial fibrosis
• Collagen vascular lung disorders
• Pneumoconiosis
• Sarcoidosis

9. Restrictive chest wall disease
• Kyphoscoliosis
• Severe obesity
• Poliomyelitis
Other conditions
• Pulmonary vascular disease
• Lung resection
• Lung transplantation
• Occupational and environmental lung disease

10. Contraindications
• Conditions that might interfere with the
patient undergoing the rehabilitative
process.
E.g. advanced arthritis, inability to learn,
disruptive behavior
• Conditions that might place the patient at
undue risk during ex training.
e.g.. Severe pulmonary HTN, unstable
angina, recent MI.

11. Alleviate
symptoms
Increase
exercise
capacity
Increase
ADL
Improve
QoL
Behavioral
change
Decision
making
11
GOALS

12. Benefits of pulmonary rehabilitation
• Improvements in exercise tolerance
• Reduction in the sensation of dyspnea
• Improvement in health related quality of life
(HRQoL)
• Improvement in peripheral muscle strength and
mass
• Reductions in number of days spent in hospital
• Pulmonary rehabilitation is a cost effective
intervention

13. • Improvement in the ability to perform
routine activities of daily living
• Reductions in exacerbations
• Reduction in anxiety and depression
• Improvements in exercise tolerance are
maintained between 6 - 12 months
• Improvements in HRQoL may be
maintained for longer

14. Program Setting
Inpatient
Outpatient
Home based rehabilitation

15. Assessment

16. ASSESSMENT
• Necessary to determine severity of the
respiratory impairment
Clinical history
Review of pertinent records
Educational assessment
Physical examination

17. Other assessments:
• Measurements of respiratory muscle
strength
• Measures of peripheral muscle strength
• Assessments of ADL
• Health status, cognitive function
• Level of anxiety or depression
• Nutritional status/ body composition

18. Assessment…
• Stress testing:-
physical performance test to measure
activity limitation; e.g. 6minute walk test

19. Assessment …
• Quality of Life:-
questionnaires
Disease
specific
Chronic resp
ds quest
(CRDQ)
St. george’
quest
Genre specific

20. The major components of
pulmonary rehabilitation are:-
1. Dyspnea management
2. Exercise training
3. Nutrition and body composition
4. Patient education
5. Cognitive Behavioral Therapy

21. DYSPNEA MANAGEMENT
Dyspnea
Fear of
activity
Decreased
activity
Decreased
CVS and
muscular
fitness
Aggravation
of
pulmonary
disease

22. 1. Reduce ventilatory demand
2. Reduce ventilatory impedance
3. Improve inspiratory muscle function
4. Alter central perception

23. Points to be considered in exercise
prescription
Frequency
Intensity
Time
Type

24. Program duration and frequency
• 20 sessions more effective than 10
• Short term intensive programs- 20
sessions in 3-4 wk found to be more
effective
• Outpatient rehabilitation 2-3 times/wk for 4
wks less effect than 7 wks
• One supervised session is ineffective
(ATS 2006)

25. • Training respiratory patients at 60 to 75%
of maximal work rate results in substantial
increases in maximal exercise capacity
and reductions in ventilation and lactate
levels at identical exercise work rates

26. Training Specificity
• Training effects have been found to be
specific to trained muscles
• Traditionally focused on lower extremity
training
• Many ADL involve UE. So UE training
should be incorporated

27. Strength and endurance
• Traditionally endurance training is used in
form of cycle/walking ex.
• Relatively longer durations of higher
intensity(>60% of max. work rate) are
adopted in endurance training
• Total effective training time should exceed
30min.-but difficult to achieve in some
patients

28. • Interval training:
• results in significantly lower symptom
scores despite high training loads,
thus maintaining the training effects

29. • Strength training has greater potential to
improve muscle mass and strength
• Session includes: 2-4 sets of 6-12 reps
with intensity of 50 to 85% of the one-
repetition maximum
• The combination of endurance and
strength training is probably the best
strategy

30. Lower extremity
• Walking and cycling are the
most common exercise
prescribed
• Intensity:
• <12yrs,elderly,ds patients-
mild to moderate
• Normals- progress from
moderate to severe
• Prescribed on basis of
HR,VO2max, RPE, MET

31. • Duration:
• Minimum of 30 min with or without breaks
• Frequency:
• 3-4 sessions a week

32. Upper extremity
• Increase strength
training with or without
weights
• Without weights-
preferred
• Free weights like
theraband etc.
• Type: pulling/pushing

33. • Upper extremity exercises along with the
other benefits help in increasing thoracic
cage mobility
• Cross training:
• Both UL and LL ex. done together

34. Ventilatory Muscle Training
• Inspiratory muscle function may be
compromised in COPD.
• Respiratory muscle strength is commonly
estimated by measuring maximal negative
inspiratory pressure (PImax), although this
is a highly effort-dependent test.

35. VMT
• 3 types
 Inspiratory resistive training
 Threshold loading
 Normocapnic hyperpnoea

36. Exercise prescription guidelines for
VMT
• Frequency: at least 5 times per week
• Intensity: >30% PImax
• Duration: 30 min per day(continuous or 15
min twice a day).
• Training device:
• Breathing frequency of 12-15 breaths per
minute is recommended.

37. Respiratory training
Pulm ms
performance
dyspnea
Ventilatory
efficiency
endurance

38. Oxygen therapy
• Hypoxemic and non-hypoxemic patients:
• Allows for higher training intensity and/or
reduced symptoms in the research setting.
• Long term O2 therapy

39. Self management education
• Prevention of exacerbations
• Breathing strategies
• Bronchial hygiene
• Medications
• symptom management
• Self-assessment
• Exercise training and benefits
• Activities of daily living and energy
conservation

40. Smoking cessation
• Smoking cessation is the single most
effective and cost-effective way to reduce
the risk of developing COPD and stop its
progression.

41. SUMMARY

42. • Aims
• Settings
• Patients included
• Components
• Dyspnea
• Patient education
• Lifestyle modification

43. EX prescription in brief
• Frequency : 3-4 times/wk
• Intensity: high intensity training
– 60-80% max. work capacity for LE
– 60% of max. work cap. For UE
• Duration: 25-30 minutes/ as tolerated
• Mode: continuous/interval, combination of
strength and endurance
• 20 sessions within 6-8 weeks
• At least 2 supervised session
• Monitor: HR, dyspnea, fatigue

44. THANK
YOU