Pulmonary rehabilitation

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

1. PULMONARY REHABILIATION

2. 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

3. 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 .

4. 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

5. Chest evaluation should include the following: • Auscultation of lung and heart sounds • Cough assessment • Inspection of breathing pattern Musculoskeletal and integumentary evaluation should include the following: • Joint range of motion • Gross strength assessment of extremities and trunk • Posture • Gait • Skin inspection • Edema inspection

6. FUNCTIONAL EXAMINATION Assess patients symptoms to determine systemic origin of individuals impairment Assessment of the patient determine his or her physiological response to varying levels of activity (ADLs). To quantify the level of disability Objective documentation of patients functional abilities and limitations Documentations of increased oxygen requirements and assessment of medication efficacy and other practical uses of exercise testing. • Balance and gait assessment • Prior level of function • Need for adaptive equipment • Fall risk • Leisure, social and family activity

7. EXERCISE TESTING It is used diagnostically for chronic bronchitis, pulmonary emphysema, pulmonary infiltration ,alveolitis , fibrosis , pulmonary thrombo embolism and in hypertension This is safe and effective method of evaluating symptoms , diagnosing impairment and designing treatment programs

8. LOW LEVEL EXERCISE TEST TWO STAGE INTERMITTENT TEST STAGE ONE BASELINE ASSESMENT Treadmill 1 to 2 mile per hour Ergometer-0.25 to 0.5 kp/min at 40 to 60 rpm Subject walks , rides for 6 min Monitor every 2 min for heart rate, rhythm , resp.rate , blood pressure ,o2 saturation , breathing pattern , musculoskeletal response STAGE TWO MAXIMUM FUNCTION TREADMIL & ERGOMETER Increase workload to elicit maximum cardiopulmonary response

9. Gradually increase the workload Repeat monitoring as above Record time and workload at test completion Record factors producing limitation (e.g. fall in systolic blood pressure with increased workload or dyspnea,discoordinated breathing pattern and resp rate of 40) TIMED WALK TEST(6 OR 12 MIN) Walk as far and fast as possible Record distance walked, monitor vital signs and o2 saturation while walking.

10. PULMONARY REHAB OUTCOME MEASURES

11. EXERCISE LIMITS INTERPRETATION CONSIDERATIONS Resp.rate 50 to 60 Worsening of dis coordinated breathing pattern Bronchospasm Wheezing Decreased FEV1 Change in ventilator muscle use ECG abnormality Dyspnea Increase heart rate Falling blood pressure

12. Angina Hypertension Decrease o2 saturation Increase Pao2, Nausea, Dizziness

13. GRADE DYSPNEA LEVELS: RANCHOS LOS AMIGOS Grade Description The subject is unaware of the need to breath 1+ The subject has a slight awareness of the need to breath. The subject can hold a conversation without difficulty 2+ The subject definitely is aware of the need to breathe. Rate and depth of breathing increases and accessory muscles begin to function. Subject breathes in mid sentence or shortens sentences in order to breathe. 3+ Breathing is rapid and deep. Accessory muscle are prominently functioning. Conversation is short and choppy and subject must breathe after three or four words. 4+ Conversation at this point is difficult to elicit from the subject. One word answers or inability to speak is common. The subject may nod to indicate yes or no.

14. AIMS 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.

15. 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

16. INCLUSION CRITERIA 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)

17. 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

18. EDUCATION Breathing Strategies Normal Lung Function and Path physiology 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 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

19. PHASE I AND PHASEII BASED ON DYSPNEA GRADING SCALE PHASE I(MILD AND MODERATE ) GENERALS GOALS Decrease respiratory symptoms and complications Encouraging independence through self-management and control over daily functioning Improve physical conditioning and exercise performance Improve emotional well being Reducing hospitalizations

20. COMPONENTS OF A RESPIRATORY REHABILITATION PROGRAM Components Description Secretion removal technique MANUAL Postural Drainage Percussion Shaking/ Vibration Airway Clearance: coughing, huffing Ventilatory muscle training Ventilatory Muscle trainers Breathing-reeducation Pacing Breathing exercises: Diaphragmatic Segmental Breathing Pursed Lip Breathing Sustained Maximal Inspiration (SMI)

21. Components Description Energy saving techniques Paced Breathing Optimizing body mechanics Advanced planning Prioritization of activities Use of assisted devices Physical Exercise Variables to consider: Mode Duration Intensity Frequency Recommended: sustained aerobic exercise LE activities UE activities Arm ergometry Free weights Smoking Cessation Behavior modification Smoking cessation strategies Nutrition Screening Encourage reduction of body fat mass in obese patients Anthropometry Biochemical tests Nutrition counseling

22. PHASE II (SEVERE DYSPNEA) INDICATIONS( impairments may be manifested as) Dyspnea experienced during rest or exertion Hypoxemia or hypercapnia Reduced exercise tolerance or a decline in the patient’s ability to perform ADL An unexpected deterioration or worsening symptoms against a background of long-standing dyspnea and a reduced but stable exercise tolerance level The need for surgical intervention ( pre- and postoperative lung resection, transplantation , or volume reduction) Chronic respiratory failure and the need to initiate mechanical ventilation Ventilator dependence Increasing need for acute care intervention including emergency room visits, hospitalizations, and unscheduled physician office visits

23. CONTRAINDICATIONS Ischemic heart disease, acute cor pulmonale pulmonary HPN, significant hepatic dysfunction, metastatic CA, renal failure, severe cognitive deficits and psychiatric disease that interferes with memory and compliance. The decision to provide or withhold PR should be based on a thorough, individualized assessment Substance abuse without the desire to cease Physical limitations such as poor eyesight, impaired hearing, a speech impediment or orthopedic impairment may require modification of the PR setting but should not interfere with participation in a PR program .

24. GOALS FOR PHASE 2 -REHABILITATION INTERVENTIONS FOR PATIENTS WITH PULMONARY CONDITIONS Increase understanding of patient and family of disease process, expectations, goals and outcome Maximize independence in secretion clearance Facilitate optimal respiratory function Increase cardiovascular endurance Increase strength, power and endurance of peripheral muscles .Maximize tolerance to functional mobility Improve performance of physical tasks, and ADL Increase strength, power and endurance of ventilatory muscles

25. Improve independence in airway clearance and self-management of pulmonary disease Decreased work of breathing Facilitate independence with performing and monitoring exercise Improve decision making ability requiring use of health care resources Enhanced self-management of symptoms and self- management of pulmonary disease

26. TREATMENT PRECAUTIONS Watch for dyspnea or tachycardia Watch for cyanosis and refer to physician immediately Avoid chills and drafts Avoid exposure to fumes, cigarette smoke, and other respiratory irritants Avoid excessive fatigue Administer oxygen as prescribed with appropriate safeguards Be aware of the side effects of drugs: i.e. bronchodilators that may cause tachycardia

27. Goal Treatment approaches Maintain or improve upper extremity strength , ROM and tolerance Graded upper extremity exercise and PREs while the patient is seated Perform exercises that incorporate breathing Supervised training program Maximize or increase patient’s independence in ADL Energy conservation techniques Work simplification techniques Teach patient to perform movements and positions found to reduce dyspnea Breathing techniques most helpful: slow abdominal diaphragmatic breathing with exhalation against pursed lips

28. Goal Treatment approaches Teach patient use of adaptive equipment as appropriate Use of long-handled equipment to assist in bathing and dressing the lower extremities Bath bench ( for taking a bath) Adaptations Assist the patient and family with psychological adjustment to disease Support and encouragement Constructive outlets Constructive and creative thinking /develop self-assurance of patients Ensure safety and accessibility in the home Home modifications Increase the patient’s and family’s knowledge of rehabilitation process for the patient with COPD Instruct in information on principles of: dyspnea relief, energy conservation and work simplification, activity configuration for planning daily activities, importance of exercise, lifestyle modification and patient’s limitations

29. Goal Treatment approaches Increase patient’s endurance Increase the number of reps, increasing time out of bed and time spent participating in the treatment Pacing and energy conservation techniques Explored a vocational interests and assess adaptations Assist the patient in learning relaxation techniques Relaxation techniques Biofeedback Improve the patient's ability to cope with cognitive deficits Cognitive rehabilitation Increase the patient’s independence and accessibility within the community Outings Solve architectural barriers

30. EXERCISE PRESCRIPTION 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.

31. 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 ergo meter 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.

32. 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 co-morbidities .

33. 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.

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