Aziza pulmonary rehabilitation

PULMONARY REHAB

1. JAMIA MILLIA ISLAMIA CENTRE OF PHYSIOTHERAPY AND REHABILITATION SCIENCES PHYSIOTHERAPY IN CARDIOPULMONARY CONDITIONS (402) SUBMITTED TO: DR. JAMAL ALI MOIZ SUBMITTED BY: AZIZA NAZNEEN CLASS: BPT IV YEAR PULMONARY REHABILITATION

2. INTRODUCTION ATS and ERS define pulmonary rehabilitation as, “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.” Pulmonary rehabilitation is implemented by a dedicated, interdisciplinary team, including physicians and other health care professionals; the latter may include physiotherapists, respiratory therapists, nurses, psychologists, behavioral specialist, exercise physiologists, nutritionists, occupational therapists, and social workers. The intervention should be individualized to the unique needs of the patient, based on initial and ongoing assessments, including disease severity, complexity, and comorbidities. 2

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4. GOALS 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 . BENEFITS 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 Reduction in anxiety and depression Pulmonary rehabilitation is cost effective intervention 4

5. INDICATIONS It is indicated to those individuals with chronic respiratory diseases who have decreased exercise tolerance, exertional dyspnea or fatigue, and/or impairment of ADL. Obstructive pulmonary disease: COPD Asthma Bronchiectasis Restrictive pulmonary diseases Interstitial fibrosis Collagen vascular lung disorders Pneumoconiosis Sarcoidosis Restrictive chest wall diseases Kyphoscoliosis Severe obesity Poliomyelitis 5

6. Other conditions Pulmonary vascular diseases Lung resection Lung transplantation Occupational and environmental lung diseases CONTRAINDICATIONS Patients with severe orthopedic or neurological disorders limiting their mobility Severe pulmonary arterial hypertension Exercise induced syncope Unstable angina or recent MI Refractory fatigue Inablity to learn, psychiatric instability and disruptive behavior 6

7. ASSESSMENT Necessary to determine severity of the respiratory impairment Clinical history Physical examination Other assesments ; Measurements of respiratory muscle strength Measures of peripheral muscle strength Assessment of ADL: directly observed or self reported, PFT, ABG or oximetry Control of symptoms of cough and fatigue: real time evaluation – MRC breathlessness & Borg dyspnea scale Health status, cognitive function Level of anxiety or depression Nutritional status/ body composition Stress testing: physical performance test to measure activity limitation. Eg . 6 minute walk test, cardiopulmonary exercise testing Quality of life; questionnaire. Eg , chronic respiratory disease questionnaire(CRDQ) 7

8. EDUCATION Breathing strategies Normal lung function and pathophysiology of lung disease Proper use of medications, including oxygen Bronchial hygiene technique Benefits of exercise and maintaining physical activities Energy consevation and work simplification techniques Eating right Prevention of exacerbations Irritant avoidance, including smoking cessation Anxiety and panic control, including relaxation techniques and stress management 8

9. EXERCISE TRAINING COMPONENETS OF EXERCISE TRAINING Lower extremity exercise Arm exercises Ventilatory muscle training TYPES OF EXERCISE Endurance or aerobic Strength or resistance 9

10. LOWER EXTREMITY TRAINING Walking Treadmill Stationary bicycle Stair climbing Sit & stand ARM EXERCISE TRAINING Arm cycle ergometer Unsupported arm lifting Lifting weights STRENTH EXERCISE When strength exercise was added to standard exercise protocol; led to greater increase in muscle strength and muscle mass 10

11. VENTILATORY MUSCLE TRAINING Inspiratory muscle function may be compromised in COPD Respiratory muscle strength is commonly estimated by measuring maximal negative inspiratory pressure, although this is a highly effort – dependent test. 3 types : inspiratory resistive training, threshold loading, normocapnic hyperpnoea RESISTIVE IMT : patient breaths through hand held device with which resistance to flow can be increased gradually THRESHOLD IMT : patient breaths through a device equipped with a valve which opens at a given pressure NORMOCAPNIC HYPERCAPNEA : this method requires individuals to maintain high target levels of ventilation upto 30 minutes. EXERCISE PRESCRIPTION GUIDELINES FOR VMT FREQUENCY : 5 times per week INTENSITY : >30% Pimax DURATION : 30 min per day (continuous or 15 min twice a day) Breathing frequency of 12-15 breaths per minute is recommended. 11

12. CHEST PHYSIOTHERAPY & BREATHING RETRAINING PURSED LIP BREATHING – shifts breathing pattern and inhibits dynamic airway collapse POSTURE TECHNIQUE – 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 DRAINAGE NEUROMUSCULAR ELECTRICAL STIMULATION (NMES) NMES may be an adjunctive therapy for patients with severe chronic repiratory disease who are bed bound or suffering from extreme skeletal muscle weakness.(ATS/ERS guidelines) 12

13. ATS & ERS GUIDELINES A minimum of 20 sessions should be given Atleast 3 times per week Twice weekly supervised and one unsupervised home session may also be acceptable 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 Both upper and lower extremity should be utilised 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. 13

14. 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, regardeless of whether or not oxygen desaturation during exercise occurs, often allows for higher training intensity an/or reduced symptoms in the research setting 14

15. NUTRITIONAL ADVICE Energy dense foods Well distributed during the day Patient experience less dyspnea after carbohydrate richsupplementation Daily protein intake should be 1.5 gm/kg for positive balance\ Small frequent meals Anabolic steroids in COPD patients with weight loss increase body weight and lean body mass; but have little or no effect on exercise capacity Pulmonary rehabilitation programs should address body composition abnormalities. Intervention may be in the form of caloric, physiologic, pharmacologic or combination therapy. (ATS/ERS STATEMENT) 15

16. PSYCHOLOGICAL CONSIDERATIONS Screening for anxiety and depression should be part of 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) 16

17. OUTCOME ASSESSMENT Provide 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 componenets of pulmonary rehabilitation that patients find most useful. The questionnaire should also provide patients with a variety of answering options. Exercise capacity measurements 17

18. SUMMARY PROPER PATIENT SELECTION PATIENT ASSESSMENT INDIVIDUALIZATION OF PROGRAMME EXERCISE TRAINING: LEG AND ARM EXERCISES VENTILATORY MUSCLE TRAINING CALORIC SUPPLEMENTS ANABOLIC STEROIDS SELF MANAGEMENT EDUCATION PSYCHOLOGICAL ASPECTS DEPRESSION ANXIETY OUTCOME ASSESSMENT: SYMPTOMS EXERCISE PERFORMANCE QUALITY OF LIFE 18

19. REFERENCE Nici L, Donner C, Wouters E, Zuwallack R, Ambrosino N, Bourbeau J, Carone M, Celli B, Engelen M, Fahy B, et al.; ATS/ERS Pulmonary Rehabilitation Writing Committee. American Thoracic Society/ European Respiratory Society Statement on Pulmonary Rehabilitation. Am J Respir Crit Care Med 2006;173:1390–1413. Nici L, ZuWallack R; American Thoracic Society Subcommittee on Integrated Care of the COPD Patient. An Official American Thoracic Society Workshop Report: the integrated care of the COPD patient. Proc Am Thorac Soc 2012;9:9–18 . Gröne O, Garcia- Barbero M; WHO European Office for Integrated Health Care Services. Integrated care: a position paper of the WHO European Office for Integrated Health Care Services. Int J Integr Care 2001;1:e21 19