Pulmonary Rehabilitation.pptx @Dr.Muskan Rastogi (PT) BPT,MPT(OBG)

PULMONARY REHABILITATION BASICS

1. PULMONARY REHABILITATION MUSKAN RASTOGI 222139001

2. CONTENTS

3. DEFINITION “Pulmonary rehabilitation is a comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies, which 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 of health-enhancing behaviors .” - American Thoracic Society (2013)

4. GOALS OF P.R. PROGRAM Must be specific and pertinent to his or her lifestyle, needs, and personal interests. Possible only after a thorough evaluation of the patient’s disease state and clinical course, physical examination, and patient–family interview. Assist the patient in identifying realistic goals that can be described in behavioural terms and measured as outcomes for rehabilitation.

5. Should be designed to make the most impact on daily function and enhance the quality of life. Should be realistic in nature. Outcome measures should be used to assess the progress of the pulmonary rehabilitation program.

6. SCOPE AND BENEFITS Reduces Symptoms . Reduces hospitalizations . Increased functional capacity . Increased knowledge about pulmonary diseases and their management. Increased exercise tolerance and performance . Enhanced ability to perform ADLs . Improves Quality of life . Improved Psychosocial symptoms . Ability to Return to work for some patients.

7. EVIDENCE-BASED GUIDELINES ON PULMONARY REHABILITATION A program of exercise training for the muscles of ambulation is recommended as a mandatory component of pulmonary rehabilitation for patients with COPD. Pulmonary rehabilitation improves the symptom of dyspnea in patients with COPD. Pulmonary rehabilitation improves health-related quality of life in patients with COPD. Pulmonary rehabilitation reduces the number of hospital days and other measures of health care utilization in patients with COPD.

8. Pulmonary rehabilitation is cost-effective in patients with COPD. There is insufficient evidence to determine if pulmonary rehabilitation improves survival in patients with COPD . There are psychosocial benefits from comprehensive pulmonary rehabilitation programs in patients with COPD. 6 to 12 weeks of pulmonary rehabilitation produces benefits in several outcomes that decline gradually over 12 to 18 months. Some benefits, such as health-related quality of life , remain above control at 12 to 18 months

9. Longer pulmonary rehabilitation programs (12 weeks) produce greater sustained benefits than shorter programs. Maintenance strategies following pulmonary rehabilitation have a modest effect on long-term outcomes. Lower-extremity exercise training at higher exercise intensity produces greater physiological benefits than lower-intensity training in patients with COPD. Both low- and high-intensity exercise training produce clinical benefits for patients with COPD. Addition of a strength training component to a program of pulmonary rehabilitation increases muscle strength and muscle mass .

10. PULMONARY REHABILITATION TEAM

11. INDICATIONS COPD Post ARDS pulmonary fibrosis Lung cancer Selected neuromuscular disease Perioperative states e.g. thoracoabdominal surgery Post-polio syndrome Asthma Bronchiectasis Chest wall disease Cystic fibrosis Interstitial lung disease Pre-lung and post-lung transplantation and lung volume reduction surgery

12. CONTRAINDICATIONS Arthritis Inability to learn Cognitive disabilities Disruptive behavior Severe pulmonary HTN Unstable angina Recent myocardial infarction

13. OUTCOME MEASURES USED

14. ASSESSMENT The ideal candidate for pulmonary rehabilitation is chosen by a thorough assessment that involves- Patient interview Medical history Physical exam Diagnostic tests Symptom assessment

15. Musculoskeletal and exercise assessment Activities of daily living assessment Education assessment Psychosocial assessment Goal development

16. Patient Interview An in-depth interview with the patient and his family or significant other is necessary to set the stage for the assessment. The importance of the initial interview cannot be overstated. Not only are important data obtained, but the foundations of trust and credibility are established at this time . The interview allows the patient to interact on a personal level with the rehabilitation staff. Coming in for the interview allows the patient to see where the program is located and possibly meet rehabilitation graduates .

17. Medical History The medical history provides information on the severity of respiratory diseases, such as Symptom burden Exacerbations Medication requirements Supplemental oxygen use Physical limitations Health resource utilization.

18. Components of the Medical History Respiratory history Comorbidities (especially coronary artery disease, diabetes, osteoporosis, and sleep apnoea) Other medical and surgical histories Family history of respiratory disease Use of medical resources (e.g., hospitalizations, urgent care or emergency room visits, physician visits)

19. All current medications including over-the-counter drugs and herbal supplements; (this includes the dose, route, and frequency) Oxygen use: how it is prescribed and how the patient actually uses it Allergies and drug intolerances Smoking history Occupational, environmental, and recreational exposures Alcohol and other substance abuse history Social supports

20. Physical Examination Physical assessment adds important information to data obtained from the patient’s history and from record and laboratory review. Vital signs: blood pressure, pulse, respiratory rate, temperature Height; weight; BMI, either calculated (weight [in kg] divided by height [in meters] squared [kg/m2]) or determined from a table Arterial oxygen saturation measured with pulse oximetry at rest and with activity Breathing pattern Use of accessory muscles for respiration

21. Chest examination: inspection, palpation, percussion, symmetry, diaphragm position, breath sounds, adventitious sounds (crackles, wheezes, rhonchi), duration of the expiratory phase, forced expiratory time Cardiac exam: cardiac rate and rhythm, murmur, gallops, jugular venous distention Presence of finger clubbing Upper- and lower-extremity evaluation: signs of vascular insufficiency, joint disease, musculoskeletal dysfunction, range of motion, muscle atrophy, Edema

22. Diagnostic tests Spirometry Oxygen saturation at rest and with walking exercise upon program entry Chest radiograph Electrocardiogram Field test of exercise capacity, such as the 6-minute walk test or the shuttle walk test, upon program entry Screening assessment of anxiety and depression, such as the Beck Depression Inventory or the Hospital Anxiety and Depression Scale, upon program entry CBC

23. Symptom Assessment Information from symptom assessment is often utilized in goal setting, may be used to document outcomes, and may be used by third-party payers to determine the medical necessity for the service. The following is a list of items to include in the symptom assessment: Dyspnea Fatigue Cough and sputum production Wheeze Haemoptysis Chest pain

24. Postnasal drainage Reflux, heartburn Edema Dysphagia Extremity pain or weakness Feelings of anxiety, panic, fear, isolation Depressive symptoms

25. Musculoskeletal and Exercise Assessment The safety of an exercise training program and the appropriateness of the exercise prescription are determined by a thorough initial musculoskeletal assessment. The following is a list of the information to be obtained in the exercise assessment: Physical limitations (e.g., strength, range of motion, posture, functional abilities, and activities) Orthopaedic limitations Transferring abilities Exercise tolerance Exercise hypoxemia including the need for supplemental oxygen therapy Gait and balance

26. Commonly used exercise tests Walk distance tests- Timed Walk Tests(6-minute walk test), Shuttle walk distance test Incremental maximal exercise tests Submaximal exercise tests

27. Absolute Contraindications • A recent significant change in the resting ECG suggesting significant ischemia, recent myocardial infarction (within 2 days), or other acute cardiac event • Unstable angina • Uncontrolled cardiac arrhythmias causing symptoms or hemodynamic compromise • Severe symptomatic aortic stenosis • Uncontrolled symptomatic heart failure • Acute pulmonary embolus or pulmonary infarction • Acute myocarditis or pericarditis • Suspected or known dissecting aneurysm • Acute infections

28. Relative Contraindications • Left main coronary artery stenosis • Moderate stenotic valvular heart disease • Electrolyte abnormalities (e.g., hypokalemia , hypomagnesemia) • Severe arterial hypertension (i.e., systolic BP of >200 mmHg or diastolic BP of >110 mmHg) at rest • Tachyarrhythmias or bradyarrhythmias • Hypertrophic cardiomyopathy and other forms of outflow tract obstruction • Neuromuscular, musculoskeletal, or rheumatoid disorders that are exacerbated by exercise • High-degree atrioventricular block • Ventricular aneurysm • Uncontrolled metabolic disease (e.g., diabetes, thyrotoxicosis, or myxedema ) • Chronic infectious disease (e.g., mononucleosis, hepatitis, AIDS)

29. Absolute Precautions • Unstable angina* or myocardial infarction during the previous month • Resting pulse oximetry (SpO2)% < 88% on room air or while breathing the prescribed level of supplemental oxygen. The referring doctor should be notified and exercise assessment should not proceed. • Physical disability preventing safe performance Relative Precautions • Resting heart rate >125 bests/min after 10 minutes rest • Systolic blood pressure >200 mmHg + diastolic blood pressure >110/100 mmHg

30. Exercise Test Termination Criteria • Onset of angina or angina-like symptoms • Signs of poor perfusion including lightheadedness, confusion, ataxia, pallor, central cyanosis, nausea, cold clammy skin, sweating • Patient requests to terminate test (e.g., intolerable dyspnea which is not relieved by rest and causes patient distress) • Physical or verbal manifestations of severe fatigue • Development of an abnormal gait pattern (e.g., leg cramps, staggering) • Tachycardia (i.e., heart rate >220 – age) • SpO2 < 88% on room air** • Failure of heart rate to increase with exercise (unless the patient has a fixed rate pacemaker)

31. Activities of Daily Living Assessment Symptoms of respiratory disease such as dyspnea and fatigue often lead to a decreased ability and willingness to perform activities of daily living (ADLs). ADLs assessment should include which activities have been limited or eliminated because of the disease, its comorbidity, or its therapy. Elimination of activity often depends on the level of distressing symptoms it engenders and its importance to the patient.

32. ADLs assessment includes distress during, limitations in, or elimination of the following: Basic ADLs, such as dressing, bathing, walking, eating Household chores Leisure activities Job-related activities Sexual activity

33. Nutrition Assessment Patients with respiratory disease frequently have alterations in their nutritional status and BMI. Accordingly, the nutritional assessment should include at least the measurement of height, and weight, calculation of BMI (weight [kg]/height [m2]), and documentation of a recent and significant (>3 lbs.) weight change.

34. Additional notations regarding nutrition may include Dysphasia Dentition Mastication problems Gastroesophageal reflux Altered taste of food due to oxygen use Dyspnoea while eating

35. Fluid intake Person responsible for buying and cooking food, Alcohol consumption Caffeine consumption Laboratory values for serum albumin and prealbumin Drug-food interactions Use of nutritional or herbal supplements

36. Education Assessment Assessing the educational needs of pulmonary rehabilitation patients begins with a determination of how they understand and manage their disease. This provides the information needed to formulate the education component of the program. It also can be used to establish a baseline for evaluating change in knowledge and self-efficacy; thus, it can be used in documenting outcomes.

37. Following is a list of items included in the education assessment: Knowledge of the disease and its treatment Self-efficacy Barriers to learning: visual or hearing problems, cognitive impairment, language barrier, illiteracy C ultural diversity

38. Psychosocial Assessment Addresses several areas : motivation level, emotional distress, family and home situation, substance abuse, cognitive impairment, interpersonal conflict, other psychopathology (e.g., depression, anxiety), significant neuropsychological impairment (e.g., memory, attention and concentration, problem-solving impairments during daily activities), coping style, and sexual dysfunction. Failure to detect and address the presence of significant psychosocial pathology may result in poor progress in rehabilitation .

39. The following is a list of items included in the psychosocial assessment: Anxiety and depression Interpersonal conflict Family and home situation Motivation for pulmonary rehabilitation Substance abuse, addictive disorders Neuropsychological impairments Coping skills Sexual dysfunction

40. OBSTRUCTIVE DISEASES RESTRICTIVE DISEASES OTHER CONDITIONS COPD INTERSTITIAL FIBROSIS LUNG CANCER PERSISTENT ASTHMA OCCUPATIONAL LUNG DISEASE PRIMARY PULMONARY HTN BRONCHIECTASIS SARCOIDOSIS PRE AND POST THORACIC SURGERY CYSTIC FIBROSIS KYPHOSCOLIOSIS LUNG TRANSPLANTATION BRONCHILITIS OBLITERANS ANKYLOSING SPONDYLITIS LUNG VOLUME REDUCTION SURGERY PARKINSON’S DISEASE VENTILATOR DEPENDENCY POSTPOLIO SYNDROME AMYOTROPHIC LATERAL SCOLIOSIS DIAPHRAGMATIC DYSFUNCTION MULTIPLE SCLEROSIS POST TUBERCULOSIS SYNDROME

41. COMPONENTS OF PULMONARY REHABILITATION

42. EXERCISE TRAINING RATIONALE The presence of skeletal muscle dysfunction provides a rationale for exercise training for patients with COPD, even in the presence of significant cardiopulmonary limitations imposed by irreversible derangements of lung structure or function. Consequently, all pulmonary patients can benefit from skeletal muscle exercise training. Optimizing oxygenation and bronchodilation will enhance the exercise training effects by permitting exercise at higher intensities. A supervised exercise program can also address other factors limiting exercise in these patients, such as fear of dyspnea and psychological issues

43. PRINCIPLES Exercise training in pulmonary rehabilitation should encompass Both upper- and lower-extremity endurance training, Strength training, Respiratory muscle training. Duration, frequency, mode, and intensity of exercise should be included in the patient’s individualized exercise prescription, based on disease severity, degree of conditioning, functional evaluation, and initial exercise test data.

44. UPPER AND LOWER EXTREMITY TRAINING It is most beneficial to direct exercise training to those muscles involved in functional living. This typically includes training the muscles of both the lower and upper extremities. The health-related components of a comprehensive exercise program include cardiovascular and pulmonary (endurance) exercise, muscle strengthening, and flexibility.

45. Exercise that improves neuromuscular ability, such as balance and coordination to decrease fall risk, is equally important with the pulmonary population, particularly as the general population ages. Lower-extremity training involves large muscle groups; this modality can improve ambulatory stamina, balance, and performance in ADLs.

46. Types of lower-extremity training include the following: • Walking • Stationary cycling • Bicycling • Stair climbing • Swimming Exercise training of the lower extremities often results in dramatic increases in exercise tolerance of patients with COPD and other respiratory diseases. Exercise training of the arms is also beneficial in patients with chronic lung disease, although virtually all the evidence comes from patients with COPD. Patients with moderate to severe COPD, especially those with the mechanical disadvantage of the diaphragm due to lung hyperinflation, have difficulty performing ADLs that involve the use of the upper extremities.

47. Arm elevation is associated with high metabolic and ventilatory demand, and activities involving the arms can lead to irregular or dyssynchronous breathing. This happens because some arm muscles are also accessory muscles of inspiration. Benefits of upper-extremity training in COPD include improved arm muscle endurance and strength, reduced metabolic demand associated with arm exercise, and an increased sense of well-being. In general, the benefits of upper-extremity training are task-specific. Because of its benefits,upper -extremity training is recommended in conjunction with lower-extremity training as a routine component of pulmonary rehabilitation.

48. Caution must be taken with upper-extremity ergometry in certain rehabilitation patients. Chronic lung disease patients who have been on long-term steroid therapy lose bone density. These patients become osteoporotic, particularly in the thoracic vertebrae, and are susceptible to increased wear and tear of these vertebral segments, which, in turn, may increase risk of compression fracture. Postoperative surgical pulmonary patients are generally restricted from arm ergometry for 6 weeks to allow internal and external incisional healing.

49. STRENGTH TRAINING Beneficent for patients with chronic lung disease Leads to improvement in muscle strength, increased exercise endurance, fewer symptoms during ADL’s Lower extremity strengthening may be augmented through aerobic training such as cycling, stair climbing, bench stepping, and walking. Strength training should be started with low resistance and progressed first by increasing repetitions, for example, 10 to 20 repetitions, before adding more weight.

50. Upper body (trunk and upper extremity) training requires more ventilatory work, and patients are more likely to hold their breath, develop asynchronous breathing patterns, and become dyspneic. However, clinical studies have demonstrated that patients with respiratory disorders can train successfully with upper body resistive work, which produces improvements in dyspnea, fatigue, and respiratory muscle function. The strengthening program should start with light weights (dumbbells, pulleys, elastic bands, weighted wands) and, again, advance first by increasing the number of repetitions. For stronger patients or patients not on special exercise precautions, weight machines can be used. Rotating days between machines for upper extremity and lower extremity exercise may also improve tolerance for the strengthening program.

51. FLEXIBILITY, POSTURE, AND BODY MECHANICS Along with strengthening the upper and lower extremities, various exercises to develop and maintain proper posture and good body symmetry should also be incorporated into a rehabilitation program. Moderate strength training improves a patient’s ability to complete everyday tasks such as personal grooming and carrying groceries. A lack of flexibility in particular muscle groups and an imbalance in the muscular development of others can result in poor posture. The common postural deficit of rounded shoulders may be caused by a lack of muscular endurance in the shoulder girdle abductors (i.e., middle trapezius and rhomboids), with a concomitant inflexibility in the anterior shoulder girdle muscles (i.e., pectorals).

52. Focusing on strengthening the former muscle groups and increasing flexibility in the latter will aid in resuming proper postural alignment, resulting in improved respiratory mechanics. Balance training becomes more applicable to an aging chronic lung disease population. Fall risk is prevalent. More than one-third of adults 65 and older fall each year in the United States. Regular exercise that includes strength training and balance exercise is particularly effective in reducing fall risk.

53. Incorporating flexibility exercises with the goal of increasing the range of motion is an integral component of the exercise program. Stretching exercises targeting specific muscle groups are recommended to ensure good posture and proper body mechanics and to minimize the incidence of joint and muscle injury. Modified yoga may be A useful practice for many chronic lung disease patients to achieve whole-body stretches while coordinating breathing.

54. RESPIRATORY MUSCLE TRAINING With any exercise, respiratory muscle activity increases; thus, the respiratory muscles are exercised. Some studies have demonstrated that resistance breathing leads to an increase in respiratory muscle strength and endurance as well as a reduction in dyspnea. This therapy may be considered for respiratory patients with documented respiratory muscle weakness (e.g., due to cachexia or corticosteroid use) or persons who remain symptomatic, with dyspnea and exercise limitation despite peripheral muscle endurance and strength training.

55. Types of respiratory muscle training include flow resistive training (breathing through a progressively smaller orifice), threshold loading training (a preset inspiratory pressure, usually at some fraction of the maximal inspiratory pressure, is required), and isocapneic hyperventilation. Suggested guidelines for employing resistive inspiratory muscle training include a frequency of 4 or 5 days a week; intensities of 30 to 40% of P I max (maximal inspiratory pressure measured at the mouth); and a duration of one 30-minute session per day or two 15-minute sessions over at least 2 months.

56. BREATHING RETRAINING An important principle in relieving dyspnea is to avoid breath holding, the Valsalva maneuver, or unnecessary talking during the task. Pursed-lip breathing is useful for patients whenever an increase in breathing effort is noticed or to facilitate a paced breathing pattern. This naturally slows down respirations and decreases minute ventilation, relieving dyspnea in some patients. Exhalations through pursed lips during walking, lifting, pushing, or pulling activities prevents breath holding and straining. Patients with restrictive lung disease experience greater work breathing as a result of progressive stiffness decreased compliance and scarring of lung tissue.

57. Breathing retraining or teaching the patient to use a specific breathing strategy is not always easy. When successfully retrained in a new breathing pattern, the patient is likely to resume his or her inherent breathing pattern when attention is diverted to a task and away from breathing. This is normal behavior; the patient should still be encouraged to use daily “practice sessions” of breathing retraining using newly learned mechanics. Many patients with severe COPD have flattened diaphragms due to lung hyperinflation. A forward-leaning position may offer postural relief from dyspnea by improving the function of a flattened diaphragm.

58. ENERGY CONSERVATION TECHNIQUES ADLs that are difficult to perform are evaluated and modified. Usually done for bathroom, kitchen, and bedroom Basic concepts include -work areas with appropriate seat height - placing equipment in places that are accessible to the patient - locating a table for sliding heavy items - Locating chairs at places where rests are needed. E.g. End of stairs, beside the bathtub. - Using adaptive equipment to simplify tasks and improve comfort. E.g. bath seat, handheld shower head, wheel cart for laundry items, wheeled walker, etc.

59. - Improve ventilation for bathroom, kitchen, or other areas in which fumes, dust, smoke, or steam might cause respiratory symptoms. -To perform any other activity the tasks are divided into smaller tasks and analyzed with regard to the most energy-efficient method of work. Basic concepts include- Instruct in paced breathing techniques Slow down the pace Setting priorities and organizing activities to minimize wasted movement Planning appropriate amounts of time to complete tasks, including rest breaks.

60. PSYCHOSOCIAL INTERVENTION Need- increased risk of anxiety, depression Feeling of hopelessness Inability to cope Difficulty solving problems Failure to adhere to the program Teach to recognize symptoms of stress and anxiety Relaxation technique Muscle relaxation, imagery, yoga Relaxation tapes Patients with significant psychosocial disturbances should be referred to the appropriate mental health practitioner for detailed assessment and treatment

61. SMOKING CESSATION Nicotine dependence is often tied to the psychoactive impact of nicotine. Smoking stimulates neurochemical pathways associated with cognitive stimulation, memory, pleasure, mood control, anxiety reduction, relaxation, and appetite suppression. Smoking’s pleasurable effects are reinforced by the conditioned response associated with environmental triggers, including alcohol use. Conversely, nicotine withdrawal is associated with anxiety, restlessness, irritability, impaired concentration, depressed mood, insomnia, headache, increased appetite, and weight gain.

62. The focus of pharmacological and behavioral management of nicotine dependence is to reduce withdrawal symptoms and promote behaviors linked with successful long-term cessation. Use of combined pharmacological and behavioral interventions improves the chances of successful long-term cessation.

63. A combination of behavioral and pharmacological treatments is recommended for optimal management of nicotine dependence and improved quit rates. Tools used to determine nicotine dependence include the Fagerstrom Tolerance Questionnaire and the Fagerstrom Test for Nicotine Dependence . Initial patient assessment should include the following: • The patient’s desire to quit • The number of cigarettes smoked daily • Whether the patient smokes within 30 minutes of awakening • Previous quit attempts including methods, effectiveness, and relapse triggers

64. Transdermal patches provide extended release of nicotine over 24 hours. Patches are applied daily to nonhairy skin, and the sites are rotated regularly to avoid irritation. Symptoms of insomnia and vivid dreams may be controlled by the removal of the patch at bedtime. For persons smoking fewer than 10 cigarettes daily, 7 to 14 mg patches are recommended. For those smoking more than 10 cigarettes daily, 21 mg patches are recommended. Many people begin on a 21 mg patch and taper to a lower strength (14 and 7 mg) over 8 or more weeks.

65. Nicotine gum provides rapid relief from craving, with peak serum nicotine levels achieved in 20 minutes. The gum is chewed until flavor is tasted and then is parked between the cheek and gums. The gum is chewed intermittently for up to 30 minutes. For people who smoke more than 25 cigarettes a day, 4 mg gum is recommended; 2 mg gum is appropriate for those who smoke less.

66. Nicotine lozenges offer an alternative to gum for those with dentures or poor dentition. The lozenge is dissolved in the mouth over 30 minutes by wetting and parking it between the cheek and gums. The 4 mg lozenge is recommended for those who smoke within 30 minutes of awakening. One or two lozenges are normally used per hour for 6 weeks (minimum of 9 per day), with a gradual dose reduction over 6 weeks. Nicotine inhalers offer the advantage of addressing both physical and emotional nicotine dependence. The recommended dose is 6 to 16 cartridges a day for 6 to 12 weeks. Local mouth and throat irritation are common, and bronchospasm may occur.

67. Nicotine nasal spray provides a rapid rise in nicotine concentration, with a peak concentration 10 minutes after use. One spray in each nostril one or two times per hour as needed is recommended for approximately 3 months. The minimum recommended treatment is 8 doses per day, with a maximum of 40 doses per day or 5 doses per hour. Side effects include nasal and throat irritation, rhinitis, sneezing, and tearing.

68. Bupropion is thought to reduce craving by enhancing CNS noradrenergic and dopaminergic release. Bupropion is generally begun 1 week before the quit date, with a usual dose of 150 mg daily for three days followed by 150 mg twice daily for 7 to 12 weeks or longer. Bupropion may be a preferred choice for persons with depression or concerns about weight gain from cessation. Side effects include insomnia, agitation, dry mouth, and headache. Bupropion lowers the seizure threshold and is contraindicated in persons with a history of seizure disorder or eating disorder.

69. Varenicline is a partial nicotine receptor agonist that binds to and partially stimulates nicotine receptors. It acts to reduce both nicotine withdrawal symptoms and the rewarding sensations of cigarette smoking. Side effects include nausea and abnormal dreams. Nausea may be reduced by gradually titrating the dose upward over one week from 0.5 mg daily for 3 days to 0.5 mg twice daily for 3 days to 1 mg twice daily.

70. A framework for healthcare providers to help patients stop smoking is the five As: 1. Ask 2. Advise 3. Assess 4. Assist 5. Arrange

71. NUTRITIONAL INTERVENTION Most patients are underweight 32-63% of patients are referred for PR Higher caloric requirement- energy and protein rich diet required To enhance the benefits of exercise training Must include dietary fibres, fruits and vegetables in daily diet

72. BRONCHODILATORS Anticholinergic agents Short-acting- Ipratropium bromide Long-acting- Tiotropium Beta-adrenergic agonists Short acting e.g., salbutamol, fenoterol , terbutaline Long-acting salmeterol or formeterol Combination therapy-inhaled ipratropium bromide and beta-2 adrenergic agonists is potentially more effective and safer

73. Theophylline Oral one is less effective than bronchodilator Available in sustained release preparation Corticosteroids Anti-inflammatory action Systemic or inhaled form Inhaled one more effective and lesser side effects Antibiotics To avoid chronic infection of LRT Prophylactic and therapeutic use Mucolytic agents N- Acetycysteine , Guafenesin

74. SELF- MANAGEMENT To encourage behavioural changes that lead to improved health and a commitment to long-term adherence to self-assessment and management Important characteristics to include in self-management education are as follows: Encourage active rather than passive learner participation (e.g., include group discussions instead of all classes in lecture format). Use repetition liberally. Utilize a variety of presentation styles : visual, auditory, models and demonstrations, and active participation with return demonstrations (see, hear, do).

75. Supply written material for reinforcement and for sharing with the family and caregiver . Encourage interaction between participants (fellow classmates and pulmonary rehabilitation professionals). Take advantage of teachable moments (e.g., discuss prevention of exacerbations and when to call the doctor when a patient returns after a hospitalization for an exacerbation).

76. NEW APPROACHES

77. WATER BASED REHABILITATION A significant number of people with COPD have an inability, or difficulty, to participate in land-based exercise training due to the presence of comorbid pathologies, physical impairments, or pain, which can be exacerbated by weight-bearing exercise. Exercise in water is suitable for people with COPD with difficulties performing weight-bearing exercises and those with limitation to movement on land, because of the low physical impact of the water environment which allows freedom of movement and provides important health and well-being benefits

78. Hydrotherapy pools are kept typically 33.5°–34.5° Celsius (at thermoneutral temperature) Water-based exercise demonstrated similar improvements to land-based exercise training in increasing functional exercise capacity (measured by the 6-minute walk test) and peak exercise capacity (measured by the incremental shuttle walk test). Moreover, water-based exercise training significantly improved endurance exercise capacity (measured by the endurance shuttle walk test) when compared to land-based exercise training, indicating that the water environment provided a greater endurance training stimulus than dry land exercise training.

79. WHOLE BODY VIBRATION TRAINING It is characterized by an external stimula­tion inducing an oscillation vibration to a subject standing on a vibrating platform. Its benefit include enhanced postural control, balance per­formance, and improved inter-muscular coordination like the complex interplay of agonists and antagonists. WBVT has also been shown to be an effective training modality to counteract immobility-related muscle atrophy and loss of bone density. Is a beneficial training mode in a large variety of chronic diseases and conditions such as osteoporosis, fibromyalgia, cystic fibrosis, multiple sclero­sis, type 2 diabetes, pelvic weakness, chronic low back pain, and others.

80. NEUROMUSCULAR ELECTRICAL STIMULATION It permits local muscle training at a low cost for the cardiorespiratory system, making exercise accessible and suited to patients with severe breathlessness on minimal exertion. Training intensity, not current intensity or any other stimulation parameter, should be considered the main determinant of the clinical effectiveness of NMES. NMES is an effective treatment for muscle weakness and wasting, which in some patients translates to an improvement in functional exercise capacity. The advantages and specific benefits of NMES are most relevant to severely impaired patients, for example, those unable to walk or complete conventional exercise training on a frequent basis.

81. SEDENTARISM AND LIGHT MUSCLE ACTIVITY >1.5 MET and 4- 8 hours of no activity or rest We require inter ventions that reduce sedentary time- that controls behavior pattern in patients. For the same purpose behaviour change wheel is used by clinicians. It is used to guide processes that can inform the development of individualized and pragmatic strategies that can be deployed to achieve personalized goals related to breaking up and/or reducing sitting time. The patients are also part of the decision-making process

82. REFERENCES Ries AL, Bauldoff GS, Carlin BW, Casaburi R, Emery CF, Mahler DA, Make B, Rochester CL, ZuWallack R, Herrerias C. Pulmonary rehabilitation: joint ACCP/AACVPR evidence-based clinical practice guidelines. Chest. 2007 May 1;131(5):4S-2S. Donner C, Ambrosino N, Goldstein RS, editors. Pulmonary rehabilitation. CRC Press; 2020 Jul 14. Chapter no. 16 Pulmonary Rehabilitation Hillegass E. Essentials of Cardiopulmonary Physical Therapy-E-Book. Elsevier Health Sciences; 2022. Hill NS. Pulmonary rehabilitation. Proceedings of the American Thoracic Society. 2006 Mar;3(1):66-74.

83. THANK YOU