Pulmonary rehablitation

PULMONARYPULMONARYREHABILITATIONREHABILITATION

Presented by Presented by

Dr Shahid Dr Shahid PervaizPervaiz

Post Graduate TraineePost Graduate Trainee

Pulmonology Deptt.Pulmonology Deptt.

Nishtar Hospital MultanNishtar Hospital Multan

Pulmonary Pulmonary RehabilitationRehabilitation

Definition;Definition;

•“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”

Pulmonary Pulmonary RehabilitationRehabilitation

CandidatesCandidates

Any patient with impairment because of lung Any patient with impairment because of lung disease and who is motivated should be a disease and who is motivated should be a

candidate for pulmonary rehabilitation.candidate for pulmonary rehabilitation.

Pulmonary Rehabilitation Pulmonary Rehabilitation Common Indications for Common Indications for

Referral to Pulmonary RehabilitationReferral to Pulmonary Rehabilitation

• Anxiety engaging in activities• Breathlessness with activities• Limitations – Social, Leisure• Loss of Independence• Especially those whose dyspnea is out of

proportion to lung function or those with primarily fatigue limiting exercise

Pulmonary RehabilitationPulmonary Rehabilitation

Common conditions leading to referral to pulmonary rehabilitation

• COPD

• Bronchiectasis

• Chronic Asthma

• Post surgery

• ILD

• Neuromuscular Disease

• Cystic Fibrosis

• Exacerbations

Pulmonary Rehabilitation Pulmonary Rehabilitation ContraindicationsContraindications

• PSYCHIATRIC– Dementia

– Organic Brain Syndrome

• MEDICAL– Unstable cardiac

– Substance abuse

– Cancer (relative)

– Liver Failure

– Neurologic or Orthopedic condition preventing ambulation

Rehabilitation teamRehabilitation team

1. Physician Specialist Skilled In Evaluating The Neuromuscular, Musculoskeletal, Cognitive, And Cardiopulmonary Systems.

2.Physical Therapist

3.Occupational Therapist

4.Rehabilitation Nurse

Rehabilitation teamRehabilitation team

5. Social Worker

6. Respiratory Therapist

7. Vocational Counselor

8 .Psychologist

A successful team maintains coordination, cooperation, and open communication. Each member also needs to have knowledge of the general principles of other members' approaches

Components of Comprehensive Components of Comprehensive Pulmonary RehabilitationPulmonary Rehabilitation

Comprehensive pulmonary rehabilitation programs generally have the following 4 major components:

1.Exercise training2.Education3.Psychosocial/behavioral intervention4.Outcome assessment.


EducationEducation• Diagnosis

• Smoking Cessation

• Pharmacology

• Respiratory Therapy

• Physical Therapy

• Occupational Therapy

• Therapeutic Recreation

• Nutrition

• Psychosocial

Pulmonary Rehabilitation-Pulmonary Rehabilitation-EducationEducation

DiagnosisDiagnosis• Physician

• Pulmonary Function Tests–Spirometry

–ABG’s

–Diffusing Capacity

– Inhalation Challenge

–Exercise Testing

• Cardiac Tests

COPDCOPD


Smoking CessationSmoking Cessation

•

Smoking CessationSmoking CessationPhysician InterventionsPhysician Interventions

Ask about tobacco use at every visit

Advise all smokers to quit

Assess smokers readiness to quit

Assist the patient in quitting

Arrange follow up visit


PharmacologyPharmacology• OXYGEN

• BRONCHODILATORS

–Beta-agonists, LA and SA

–Anticholinergics, LA and SA

–Theophylline, other PDEI’s

• ANTI-INFLAMMATORY

–Corticosteroids

–Leukotriene Antagonists

Pulmonary Rehabilitation-Education & Pulmonary Rehabilitation-Education & ExerciseExercise

Respiratory TherapyRespiratory Therapy

• Breathing Techniques– Pursed lip– Diaphragmatic

• Medication Delivery Systems

• Peak Flow Measurement

• Self Management

Pursed lip breathing is taught to patients with severe chronic obstructive pulmonary disease (COPD). Pursed lip breathing may help to decrease dynamic hyperinflation, particularly during exercise.

A flutter device is sometimes used to aid in sputum expectoration in patients with bronchiectasis or chronic bronchitis who have a large amount of sputum production.

Pulmonary Rehabilitation-Pulmonary Rehabilitation-Education & ExerciseEducation & Exercise

Physical TherapyPhysical Therapy

• MAXIMIZE FUNCTIONAL INDEPENDENCE

–Exercise

–Energy conservation

–Oxygen

–Adaptive devices

A regular walking schedule is an important component of pulmonary rehabilitation. Walking distance is increased progressively, and oxygen supplementation often is used in a patient who de-saturates with exercise.

Exercise - HelioxExercise - Heliox

Heliox (79% He-21%O2) increases lower limb O2 delivery and utilization during dynamic exercise in patients with moderate-to-severe COPD. These effects contribute to enhance exercise tolerance in this patient population.

Lower extremity exercise by stationary bicycling improves strength and endurance.

Bilevel positive airway pressure is a noninvasive ventilatory support; it is prescribed for patients with chronic respiratory failure who develop nocturnal hypoventilation (eg, patients with neuromuscular disorders and obesity hypoventilation syndrome).

Pulmonary Rehabilitation-EducationPulmonary Rehabilitation-Education

NutritionNutrition

• WEIGHT MANAGEMENT

• DIETS– Supplements– Restrictions

• VITAMINS/ADDITIVES

09/200409/2004 Dr. Alastair JacksonDr. Alastair Jackson

Nutritional counsellingNutritional counselling• Both overweight and underweight can be a problem

• 25% of patients with moderate to severe COPD show a reduction in BMI which is an independent risk factor for mortality in COPD

• Reasons for difficulty eating should be explored: poor dentition, dyspnoea whilst eating

• Advise frequent small meals

Pulmonary Rehabilitation-EducationPulmonary Rehabilitation-Education

Psychosocial IssuesPsychosocial Issues

• INSURANCE/REIMBURSEMENT

• QUALITY OF LIFE CONCERNS

• SOCIAL SITUATION

• ETHICS ISSUES


INPATIENTINPATIENT• ADVANTAGES

– 24 hour nursing care

– Sicker patients

– No transportation problems

– Family participation

– Best for ventilator, tracheostomy patients

• DISADVANTAGES– Cost and insurance

difficulties

– Not suitable for less severe patients

– Family transportation problems


OUTPATIENTOUTPATIENT

• ADVANTAGES– Widely available

– Less costly

– Least intrusive to family

– Efficient use of staff

• DISADVANTAGES– Potential

transportation problems

– Cannot observe home activities


HOME - BASEDHOME - BASED• ADVANTAGES

– Convenience to patient

– Transportation no issue

– Exercise in familiar environment may lead to better adherence long term

• DISADVANTAGES– Cost/insurance issues

– Lack of group support

– Lack of full spectrum of multidisciplinary personnel

Outcome AssessmentOutcome Assessment

• Measurement of outcomes should be incorporated into every comprehensive pulmonary rehabilitation program. Minimal requirements include the assessment of the following measures of the patient's recovery before and after rehabilitation:

1.Dyspnea

1.Exercise ability

Outcome AssessmentOutcome Assessment

3.Health status

4.Activity levels

5.Consideration also should be given to follow-up measurements after longer periods of time, such as 6 and/or 12 months.

Pulmonary RehabilitationPulmonary RehabilitationAdverse EffectsAdverse Effects

• Musculoskeletal injury

• Exercise-induced bronchospasm

• Cardiovascular event (increased risk among COPD patients)

Effect of Effect of Therapy-Therapy- Does Not improve Does Not improve lung lung mechanicsmechanics or gas exchange, or gas exchange, but optimizes other body systemsbut optimizes other body systems

• Muscle biochemistry-higher work rates with less lactic acidosis leading to decreased carotid-body stimulation

• Reduced dynamic hyperinflation through reduced ventilatory demand

• Desensitization to dyspnea: antidepressant effect, social interaction, self management, and adaptive behaviors


Benefits in COPDBenefits in COPD• 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

• Benefits extend beyond training period – Evidence B

• Improves survival – Evidence B

Future Directions of Pulmonary Future Directions of Pulmonary RehabilitationRehabilitation

The following are several areas where further study or research is needed as the field of pulmonary rehabilitation continues to grow:

• Few data have been published on the impact of pulmonary rehabilitation on health care costs and survival; controlled studies in both areas are needed.

Future Directions of Future Directions of Pulmonary RehabilitationPulmonary Rehabilitation

• Exercise training is an important component of pulmonary rehabilitation. Little is known about the additional benefit of education, breathing strategies, psychosocial support, and group therapy. Knowledge of the effectiveness of these components would be beneficial for other patients who cannot exercise.


• More remains to be learned regarding the intensity, duration, and optimum form of exercise training. The benefits of strength training and the best exercises for upper extremity training are unknown


• The benefits of respiratory muscle rest with noninvasive, positive-pressure mechanical ventilation need to be further explored. Perhaps for selected patients with stable but advanced chronic obstructive pulmonary disease (COPD), noninvasive positive pressure ventilation could be used to help patients exercise more.

• The gains of pulmonary rehabilitation decline over time. It remains to be seen whether this progression can be slowed with a maintenance exercise program


• The optimal frequency of a pulmonary rehabilitation program is not well established. Whether more frequently repeated pulmonary rehabilitation in patients with COPD leads to physiological gains and decreases the hospitalization rate is not known. Data suggest that in severe and disabling COPD, frequently repeated inpatient pulmonary rehabilitation may lead to some additional physiological and clinical benefits over 1 year.

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Health & Medicine

Pulmonary rehablitation