PULMONARY REHABILITATION

Physiotherapy in Cardio-respiratory disorders & Intensive care

management
By: Renjith Chandrasekharan Nair
Professor of physiotherapy
School of Medical Education - CPAS
([email protected])
What is Pulmonary Rehabilitation?
“…a multidisciplinary programme of care for patients with
chronic respiratory impairment that is individually
tailored and designed to optimise each patient’s physical
and social performance and autonomy.”
• “A multidisciplinary continuum of services
directed to persons with pulmonary diseases 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”
Principle 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.
Aims

• Increase exercise tolerance

• Increase muscle strength and endurance
• Reduce dyspnoea and perception of breathlessness
• Reverse deconditioning
• Increase knowledge of lung condition and management of
the disease
• Promote self-management and coping strategies
• Improve health-related quality of life
• Improve confidence in ability to exercise
• Increase independence in daily functioning
• Promote long-term commitment to exercise
Benefits

•Improved Exercise Capacity

•Reduced perceived intensity of dyspnea
•Improve health-related QOL
•Reduced hospitalization
•Reduced anxiety and depression from COPD
•Improved upper limb function
•Benefits extend well beyond immediate period of
training.
Pulmonary Rehabilitation
Benefits in COPD (Evidence Based)

•Improves exercise capacity - Evidence A

•Improves perceived breathlessness - Evidence A
•Improves quality of life – Evidence A
•Reduces hospitalizations and LOS – Evidence A
•Reduces anxiety and depression – Evidence A
•UBE improves arm function – Evidence B
•Benefits extend beyond training period – Evidence B
•Improves survival – Evidence B
 Common Indications for
Referral to Pulmonary Rehabilitation

• Anxiety engaging in activities

• Breathlessness with activities
• Limitations – Social, Leisure, Chores, ADL’s
• Loss of Independence
• Especially those whose dyspnea is out of proportion to lung
function or those with primarily leg fatigue limiting exercise
Common conditions leading • COPD
to referral to pulmonary • Bronchiectasis
rehabilitation
• Chronic Asthma
• Post surgery
• ILD
• Neuromuscular Disease
• Cystic Fibrosis
• Exacerbations
•
Contraindications
•
PSYCHIATRIC MEDICAL
– Dementia – Unstable cardiac
– Organic Brain Syndrome – Substance abuse
– Cancer (relative)
– Liver Failure
– Neurologic or Orthopedic
condition preventing
ambulation
 Development of Disability in
COPD
• The decline in airway function may go unnoticed initially as people
adapt their lives to avoid dyspnoea

• Up to 50% of FEV1 may be lost before a person presents with

significant symptoms

• Significant disability develops late in the course of the disease when

reversal of airway obstruction is not possible.

• Dyspnoea , Limb muscle dysfunction, hypoxaemia , poor nutrition,

steroid myopathy and loss of confidence may contribute to disability
 Changes to body in COPD
• Ventilatory limitation
• Gas exchange limitation
• Cardiac dysfunction
• Skeletal muscle dysfunction
• Respiratory muscle dysfunction
 Ventilatory limitation
• Increased dead space ventilation
• Impaired gas exchange
• Increased ventilatory demands due to
peripheral muscle dysfunction
• Pathophysiology e.g. emphysema
Delayed emptying dynamic hyperinflation increased WOB
increased respiratory muscle load increased perception of respiratory
discomfort
 Gas exchange limitation
• Hypoxia
– Increases pulmonary ventilation
 Cardiac dysfunction
• Increase in RV afterload due to increased PVR
– Hypoxic vasoconstriction
– Erythrocytosis
 Skeletal muscle dysfunction
• Change in muscle fibre type
• Reduced capacity of oxidative enzymes
• Reduced number of capillaries
• Inflammatory state
• Nutrition/ body mass
 Skeletal muscle changes
• Average reduction in quadriceps strength is
decreased by 20-30% in moderate to severe
COPD
• Reduction in the proportion of type I muscle
fibres and an increase in the proportion of type
II fibres compared to age matched normal
subjects
• Reduction in capillary to fibre ratio and peak
oxygen consumption.
 Skeletal muscle cont…

• Reduction in oxidative enzyme capacity and

increased blood lactate levels at lower work
rates compared to normal subjects
• Due to intrinsic factors which result in early
activation of anaerobic glycolysis
• Prolonged periods of under nutrition which
results in a reduction in strength and
endurance
 Pulmonary Rehabilitation team
• Pulmonologist/ Physician
• Pharmacist
• Respiratory Therapist
• Physical Therapist
• Occupational Therapist
• Nutritionist
• Psychologist
• Respiratory nurse
• Community nurse/ therapist
 Exercise Training
• Does not alter underlying respiratory impairment
• Does improve dyspnea
• Targets endurance training of 60% max for 20-30
minutes, repeated 2-5 times a week
• Interval training of 2-3 minutes high intensity with equal
periods of rest or low level exercise is tolerated well.
• Unsupported arm exercise aids ADLs and respiratory
accessory muscle use.
• Respiratory muscle training benefits have not been well
established.
 Education

• Encourages active participation in health care

• Better understanding of disease

• Improved compliance
 Energy Conservation

• Energy conservation and work simplification assist in

maintaining ADLS
• Methods include
– Paced Breathing
– Body mechanics
– Advanced planning
– Prioritization of activities
– Use of assistance devices – grabbers, etc.
Medication and other therapies

• Types of medication, action, adverse effects, dose and

proper us of inhaled medications .

• Instructions in inhaler technique.

• Appropriate use of oxygen

 End of Life Education

• Poor prognosis and increased risks over time

• Decision to initiate life support brining in patient’s

own values with physician’s prognosis

• Provides patients with understanding of life sustaining

interventions and the importance of advanced
planning
 Psychosocial Intervention

• Anxiety, depression, difficulties coping with chronic

disease

• Aided by regular patient education session or support

groups

• Instruction in progressive muscle relaxation, stress

reduction, panic control
 Chest Physical Therapy
• 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
 Nutritional Assessment

• Diet history, BMI

• Over or Under weight.

• Classes in weight management and/or nutritional

counseling to improve weight management
 Outcome Assessment
• An important component of pulmonary rehabilitation,
being used to determine individual patient responses and
evaluate overall effectiveness of program.
– Dyspnea 10 pt scale, Borg scale, Visual Analog Scale
– Exercise Ability – Borg Scale, 6MDW/Progressive
exercise testing pre and post rehab.
– Health Status – Respiratory-related QOL; CRDQ
– Activity Levels –Respiratory-Specific functional
Status, Duke Functional Status Scale.
 Programme….. In a brief
• The longer the better but usually 6-12 weeks
• Twice weekly minimum
• Patient assessment
• Baseline and outcome assessments: exercise capacity (shuttle walk),
disability/health status (questionnaire)
• Exercise training upper limb and lower limb training/ respiratory
muscle training / breathing exercises
• Optimal pharmacological management
• Educational support - can include carer
• Psychological support - can include carer
• Assessment of outcome
• Programme evaluation
• Maintenance
 Pulmonary Rehabilitation
Education
• Diagnosis
• Smoking Cessation
• Pharmacology
• Respiratory Therapy
• Physical Therapy
• Occupational Therapy
• Therapeutic Recreation
• Nutrition
• Psychosocial
 Pulmonary Rehabilitation
INPATIENT
• ADVANTAGES • DISADVANTAGES
– 24 hour nursing care – Cost and insurance
– Sicker patients difficulties
– No transportation problems – Not suitable for less severe
– Family participation patients
– – Family transportation
Best for ventilator,
problems
tracheostomy patients
 Pulmonary Rehabilitation
OUTPATIENT

• ADVANTAGES • DISADVANTAGES
– Widely available – Potential transportation
– Less costly problems
– Least intrusive to family – Cannot observe home
– activities
Efficient use of staff
 Pulmonary Rehabilitation
HOME - BASED
• ADVANTAGES • DISADVANTAGES
– Convenience to patient – Cost/insurance issues
– Transportation no issue – Lack of group support
– Exercise in familiar – Lack of full spectrum of
environment may lead to multidisciplinary personnel
better adherence long term
 Pulmonary Rehabilitation
Adverse Effects

• Musculoskeletal injury
• Exercise-induced bronchospasm
• Cardiovascular event (increased risk among
COPD patients)
 6 Min walk test
• ATS guidelines
• BTS guideline
• AACVPR Guidelines for PR
• CRDQ (chronic Respiratory Diseases
Questionnaire)
• StGRQ (St.Geroge Respiratory disease
questionnaire)
 Main references supporting the course:

1. Dean, E. & Frownfelter. K. (2012). Principles and practice of

cardiopulmonary physical Therapy. USA: Mosby. 5th edition.
2. Webber, B.A. & Pryor J.A. (1993). Physiotherapy for
respiratory and cardiac problems UK: Longman Group.
3. Patricia A. Downie. (1987). Cash's Textbook of Chest, Heart
and Vascular conditions for physiotherapists. Jaypee brothers,
New Delhi. 4th edition.
 Additional references supporting the course:

1. Ellis. E. & Alison J. (1994). Key issues in cardiopulmonary

physiotherapy. UK: Longman.
2. King, AS. (1999). The Cardio-Respiratory System:
Integration of Normal and Pathological Structure and
Function. Wiley Blackwell.
3. Porter, S. (2003). Tidys Physiotherapy. Butterworth-
Heinemann; 13th edition.