Pulmonary rehabilitation

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. Pulmonary Rehabilitation 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. 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. 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:-

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

21. DYSPNEA MANAGEMENT

22. Reduce ventilatory demand Reduce ventilatory impedance Improve inspiratory muscle function 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

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

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