This document provides an overview of pulmonary rehabilitation. It begins by defining pulmonary rehabilitation and describing its goals. It then discusses the various components of pulmonary rehabilitation including education, exercise training, psychosocial support, nutritional counseling, and outcome assessment. The document outlines the pathophysiology targeted by pulmonary rehabilitation and reviews evidence on the benefits of the various components. It provides guidance from professional societies on elements like patient selection, setting, exercise prescription and duration. Overall, the document presents pulmonary rehabilitation as a multidisciplinary program aimed at improving the physical and psychological condition of patients with chronic respiratory diseases through exercise and other therapies.
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”
CHEST MOBILIZATION EXERCISES, COUNTER-ROTATION TECHNIQUE, BUTTERFLY TECHNIQUE, BREATH CONTROL DURING WALKING. These Mobilization Techniques are useful to improve Chest Wall Mobility and Expansion in Patients with Restricted Chest wall movements and also Postoperative patients
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”
CHEST MOBILIZATION EXERCISES, COUNTER-ROTATION TECHNIQUE, BUTTERFLY TECHNIQUE, BREATH CONTROL DURING WALKING. These Mobilization Techniques are useful to improve Chest Wall Mobility and Expansion in Patients with Restricted Chest wall movements and also Postoperative patients
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
\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.
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.
Inspiratory Muscle Training or Respiratory Muscle Training or Ventilatory Muscle Training. IMT is the physiotherapy technique, with the help of different breathing exercises.
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
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
\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.
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.
Inspiratory Muscle Training or Respiratory Muscle Training or Ventilatory Muscle Training. IMT is the physiotherapy technique, with the help of different breathing exercises.
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
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.
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
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.
THIS PRESENTATION INCLUDES DEFINITION, INDICATIONS, CONTRAINDICATIONS, AIMS, GOALS, PR TEAM, AND COMPONENTS OF THE PULMONARY REHABILITATION. THIS PRESENTATION IS MADE ONLY FOR LEARNING AND GUIDANCE PURPOSE.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
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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.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Title: Sense of Smell
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 primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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
3. DEFINITION
Art of medical practice wherein individually tailored
multidisciplinary program is formulated, which through
accurate diagnosis, therapy, emotional support and
education; stabilizes or reverses both physio and
psychopathology of pulmonary disease in attempts to return
the patient to highest possible functional capacity allowed by
pulmonary handicap and overall life situation
4. ATS – ERS definition (2005)
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, and reduce health care costs through stabilizing
or reversing systemic manifestations of the disease
5. The Timeline………
Charles Denison (1895): After recovery from PTB; Walking each
day- Made him feel better; Increased exercise tolerance;
Reduced respiratory and pulse rate
Albert Haas (1932): Carrying heavy books; Noticed weight gain
& Feeling of well being
Haas and Cordon (1969): first showed benefits of pulmonary
rehabilitation over conventional therapy in a cohort study
ACCP (1974): definition of pulmonary rehabilitation
ACCP (1979): Detailed monograph on pulmonary rehabilitation
in JAMA
6. Education
General
Psychological
exercise
support
training
Pulmonary
Rehabilitation
components
Nutritional Breathing
advice Retraining
Outcome
Assessment
9. Mechanisms for these
morbidities
• Deconditioning
• Malnutrition
• Effects of hypoxemia
• Steroid myopathy or ICU neuropathy
• Hyperinflation
• Diaphragmatic fatigue
• Psychosocial dysfunction from anxiety, guilt, dependency and
sleep disturbances
10. Goals of Pulmonary Rehabilitation
Aims to reduce symptoms, decrease disability, increase
participation in physical and social activities and improve overall
quality of life.
These goals are achieved through patient and family education,
exercise training, psychosocial intervention and assessment of
outcomes.
The interventions are geared toward the individual problems of
each patient and administered by the multidisciplinary team.
11. Benefits of Pulmonary
Rehabilitation
Improved Exercise Capacity
Reduced perceived intensity of dyspnea
Improve health-related QOL
Reduced hospitalization and LOS
Reduced anxiety and depression from COPD
Improved upper limb function
Benefits extend well beyond immediate period of training
12. Patient Selection
Obstructive Diseases
Restrictive Diseases
Interstitial
Chest Wall
Neuromuscular
Other 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
(GOLD)
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
Outpatient
Inpatient
Home
Community Based
Choice varies depending on
- Distance to program
- Insurance payer coverage
- Patient preference
- Physical, functional,
psychosocial status of patient
15. Education
EXAMPLES OF EDUCATIONAL TOPICS
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 and Work Simplification Techniques
Eating Right
16. Education……
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
17. Exercise training
Benefits of Exercise training
Pathophysiological Benefits of exercise
abnormality training
Decreased lean body mass Increases fat free mass
Decreased TY1 fibers Normalizes proportion
Decreased cross sectional area of muscle Increases
fibers
Decreased capillary contacts to muscle Increases
fibers
Decreased capacity of oxidative enzymes Increases
Increased inflammation No effect
Increased apoptotic markers No effect
Reduced glutathione levels Increases
Lower intracellular pH, increased lactate Normalization of decline in
levels and rapid fall in pH on exercise pH
18. Exercise training
Components of exercise training:
•Lower extremity exercises
•Arm exercises
•Ventilatory muscle training
Types of exercise:
•Endurance or aerobic
•Strength or resistance
20. Arm exercise training
Arm cycle ergometer
Unsupported arm lifting
Lifting weights
Strength exercise
When strength exercise was added to
standard exercise protocol;
led to greater increase in
muscle strength and muscle mass
21. Ventilatory muscle training
Resistive IMT: Threshold IMT:
Patient breaths through hand held Patient breaths through a device
device with which resistance to equipped with a valve which
flow can be increased gradually opens at a given pressure.
• Difficult to standardize the load
• Patients may hypoventilate • Easily quantitated and
• Leads to increased Pulmonary standardized
Arterial Pressure and fall in
oxygen tension
22. Chest Physical Therapy &
Breathing Retraining
Pursed Lip Breathing – shifts breathing pattern and inhibits
dynamic airway collapse.
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
25. What does ATS-ERS & GOLD Say?
A minimum of 20 sessions should be given
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
High-intensity exercise (>60% of maximal work rate) 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)
26. ATS-ERS
Both upper and 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
27. 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
28. 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)
29. Neuromuscular electrical stimulation
(NMES)
NMES may be an adjunctive therapy for patients with severe
chronic respiratory disease who are bed bound or suffering
from extreme skeletal muscle weakness.
ATS/ERS
Guidelines
30. 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
Further studies are needed to further define its role in pulmonary
rehabilitation.
ATS/ERS
guidelines
31. Nutritional Interventions
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.
32. Body composition abnormalities
Increased activity related Energy expenditure
Hyper metabolic 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
33. Caloric supplementation
Should be considered if :
BMI less than 21 kg/m2
Involuntary weight loss of >10% during the last 6 months or
more than 5% in the past month
Depletion in FFM or lean body mass.
34. Nutritional supplementation
Energy dense foods
Well distributed during the day
No evidence of advantage of high fat diet
Patients experience less dyspnea after carbohydrate rich
supplement than fat rich supplement. (probably due to delayed
gastric emptying)
Daily protein intake should be 1.5 gm/kg for positive balance
35. What to give…….
Small Frequent Meals
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, papaya, dates, dried
apples or apricots instead of apples, watermelon
Remember Your Vegetables potatoes, beets, corn, peas, carrots
Healthy, Unsaturated Fats
Soups and Salads
36. Nutritional Interventions
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 for 4 doses
Anabolic therapy alone increases muscle mass but not exercise
capacity
37. Nutritional Interventions
Growth hormone
rhGH 0.05 mg/kg for 3 weeks in addition to 35 Kcal/kg and 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.
38. Nutritional Interventions
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
39. What the Guidelines Say…..
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)
40. Psychological considerations
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)
41. 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
42. Maintenance rehabilitation &
Repeat rehabilitation program
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
Foglio K. Chest. 2001; 119:1696–1704
43. Pulmonary Rehab. in Resource Poor
Settings
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 and 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
The 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
44. Pulmonary Rehab in Resource Poor
Settings……..
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. ACCP RECCOMENDATIONS (2007)
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. Grade of Recommendation: 1A
2. Recommendation: Pulmonary rehabilitation improves the
symptom of dyspnea in patients with COPD. Grade of
Recommendation: 1A
3. Recommendation: Pulmonary rehabilitation improves health
related quality of life in patients with COPD. Grade of
Recommendation: 1A
52. ACCP RECCOMENDATIONS (2007)
4. Recommendation: Pulmonary rehabilitation reduces the
number of hospital days and other measures of health-care
utilization in patients with COPD. Grade of Recommendation:
2B
5. Recommendation: Pulmonary rehabilitation is cost-effective in
patients with COPD. Grade of Recommendation: 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. Grade of Recommendation: 2B
53. ACCP RECCOMENDATIONS (2007)
8. Recommendation: Six to 12 weeks of pulmonary rehabilitation
produces benefits in several outcomes that decline gradually
over 12 to 18 months. (Grade of Recommendation: 1A) Some
benefits, such as health-related quality of life, remain above
control at 12 to 18 months. (Grade of Recommendation: 1C)
9. Recommendation: Longer pulmonary rehabilitation programs
(12 weeks) produce greater sustained benefits than shorter
programs. Grade of Recommendation: 2C
10. Recommendation: Maintenance strategies following
pulmonary rehabilitation have a modest effect on long-term
outcomes. Grade of Recommendation: 2C
54. ACCP RECCOMENDATIONS (2007)
11. Recommendation: Lower-extremity exercise training at higher
exercise intensity produces greater physiologic benefits than lower
intensity training in patients with COPD. Grade of Recommendation:
1B
12. Recommendation: Both low- and high intensity exercise training
produce clinical benefits for patients with COPD. Grade of
Recommendation: 1A
13. Recommendation: Addition of a strength training component to a
program of pulmonary rehabilitation increases muscle strength and
muscle mass. Strength of evidence: 1A
14. Recommendation: Current scientific evidence does not support the
routine use of anabolic agents in pulmonary rehabilitation for for
patients with COPD. Grade of Recommendation: 2C
55. ACCP RECCOMENDATIONS (2007)
15. Recommendation: Unsupported endurance training of the upper
extremities is beneficial in patients with COPD and should be
included in pulmonary rehabilitation programs. Grade of
Recommendation: 1A
16. Recommendation: The scientific evidence does not support the
routine use of inspiratory muscle training as an essential component
of pulmonary rehabilitation. Grade of Recommendation: 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. Grade of Recommendation: 1B
18. Recommendation: There is minimal evidence to support the benefits
of psychosocial interventions as a single therapeutic modality. Grade
of Recommendation: 2C
56. ACCP RECCOMENDATIONS (2007)
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. Grade of Recommendation: 1C
21. Recommendation: Administering supplemental oxygen during high-
intensity exercise programs in patients without exercise-induced
hypoxemia may improve gains in exercise endurance. Grade of
Recommendation: 2C
57. ACCP RECCOMENDATIONS (2007)
22. Recommendation: As an adjunct to exercise training in selected patients
with severe COPD, noninvasive ventilation produces modest additional
improvements in exercise performance. Grade of Recommendation: 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 other than COPD. Grade of
Recommendation: 1B
25. Statement: Although no recommendation is provided since scientific
evidence is lacking, current practice and expert opinion suggest that
pulmonary rehabilitation for patients with chronic respiratory diseases
other than COPD should be modified to include treatment strategies
specific to individual diseases and patients in addition to treatment
strategies common to both COPD and non-COPD patients.