INSIGHT OF

PULMONARY REHABILITATION
Dian Marta Sari
Cardiorespiration Division
Hasan Sadikin Hospital
Faculty of Medicine, University of Padjadjaran
Introduction

The respiratory tract provides passageways for

airflow between environmental air (rich in
oxygen) and the gas exchange region within the
pulmonary alveoli
 THE THORAX
■ A wide base, bounded by the diaphragm below
■ A narrow opening, bounded by the first rib and the upper portion of the sternum

The thorax is formed by the rib cage, the thoracic vertebrae, the sternum. They
serve as points of origin and insertion for the respiratory muscles.
It contains Esophagus, Trachea, Lungs, Heart, Great vessels, and Lungs.

This cage has 2 purposes:

1. Its bony structures protect the vital organs inside
2. The thoracic bones and muscles interact to vary its volume, so the gas can flow
into and out of the lungs.
Respiratory muscles

■ Primary muscles  active during both quiet breathing and exercise.

– Diaphragm and intercostal muscles
■ Accessory muscles  assist under conditions of increased ventilatory
demand.
– Scalenes, sternomastoids, pectoralis major, and abdominals muscles. Other
abdominal and chest wall muscles may also function as accessory muscles.
 The diaphragm

■ A thin musculotendinous dome-shaped

structure, separates the thoracic and
abdominal cavities.
■ Muscles fiber type: 55% slow oxidative
(type 1), 21% fast oxidative (type 2A)
and 24% fast glycolytic (type 2B).
■ Innervates by the phrenic nerves (C3-
C5)
 The diaphragm

■ About 75% of the change in thoracic

volume during quiet inspiration
■ Tidal breathing  moves ± 1,5 cm
■ 350 ml volume change in every cm of
vertical movement
■ May move 6-10 cm at high levels of
ventilation
 Mechanical action

1. Contraction draws the central tendon down

– Flattens the diaphragm
– Increasing the thoracic volume
– Lowering intrathoracic pressure
2. Contraction of its costal fibers
– Raises and everts the lateral costal margins
As a result, gas from the atmosphere flows into the lungs (inspiration)
Expiration  the diaphragm relaxes and moves upward into the thoracic cavity. It is
increases the intra alveolar and intrapleural pressures, causing gas to flow out of the
lungs.
 Upper airway muscles
■ Effective ventilation  depend on coordinated activity between the
primary muscles and upper airway muscles
■ Maintains patency and stability of the upper airway, reduces upper
airway resistance, and decreases work of breathing
■ Upper airway and respiratory muscles weakness  hypoventilation
and hypoxemia
■ It is also important for protection of the lower respiratory tract.
 Coordination of the respiratory muscles
Respiratory cycle sequence consists of:
■ Upper airway muscle contraction to maintain patency of the upper
airway
■ Intercostal muscle contraction to prevent rib cage distortion
■ Diaphragm contraction as the principal inspiratory muscle
■ Inspiratory muscle relaxation
■ Finally, passive expiration
When the ventilatory needs increase, the accessory inspiratory muscle
and the expiratory muscle are recruited.
■ Pulmonary Rehabilitation provides persons with the ability to
adapt to their chronic lung disease
■ Physical conditioning
■ Ongoing medical management
■ Training in coping skill
■ Psychosocial support
With the goal: achieving and maintaining the individual’s maximum
level of independence and functioning in community
PULMONARY REHABILITATION
Obstructive Restrictive
■ Intrinsic pulmonary diseases/Sick ■ Healthy lung
lung
■ Respiratory muscle dysfunction
■ Significant ventilation-perfusion
mismatching ■ Ventilatory impairment
■ Oxygenation impairment ■ Primarily hypercapnia (precede
significant hypoxia)
■ Eucapnic or hypocapnic
■ Therapy: NIV
Hypercapnia – only acute respiratory
failure or end-stage

■ Therapy: O2
Maximum Inspiratory Pressure &
Maximum Expiratory Pressure
Best correlated with inspiratory & expiratory
Muscle Strength
Vital Capacity
• Simple, easy to measure
• Objective, reproductive

Most important indicator of ventilator dysfunction

(hypoventilation is often worst during sleep, the supine rather than
sitting position)
CPF (Cough Peak Flow) :
• 270 L/min
• 160 L/min is the minimum needed to
eliminate airway secretion
• Assisted CPF: VCs < 1500 mL
Stable patients without intrinsic pulmonary disease
• ABGA is unnecessary
(25% hyperventilation during procedure: anxiety or pain)
 Noninvasive continuous blood gas monitoring
(capnography & oximetry)
: more useful information, particularly during sleep
Nocturnal noninvasive blood gas monitoring
 Any symptomatic pt with decreased VC
Multiple nocturnal oxyhemoglobin desaturation <95%,
↑nocturnal PaCO2
 Require Treatment for nocturnal hypoventilation
Oximetry feedback : important during management of upper
respiratory infection

Maintain SpO2 > 94%

If SpO2 < 95%

Underventilation or bronchial mucous plugging
If not quickly addressed  atelectasis or pneumonia
Treatment Options in Pulmonary Rehabilitation
(1) General Medical Management

Pharmacologic therapy in COPD

■ Vaccination (influenza, pneumococcal pneumonia)
■ Inhaled quaternary anticholinergic and/or β-adrenergic agonist bronchodilators
■ Inhaled corticosteroids
■ Oral theophylline

Exposure Prevention
(from environment & occupational pollution)

α – antitrypsin augmentation therapy

(in α – antitrypsin deficiency induced emphysema)

ETC
Smoking cessation, noninvasion mechanical ventilation, lung volume reduction surgery
(2) Oxygen Therapy
(3) Chest Physical Therapy
Breathing exercises begin with relaxation techniques!
(3) Chest Physical Therapy

Airway Clearance Strategy

• Postural drainage
• Manual/device-induced chest percussion
• Device-induced airway oscillation / vibration
• Autogenic drainage
• Cough assist mechanical in-exsufflator (MI-E) cough machine

Cough – VEST (high-

assist Positive expiratory frequency
pressure therapy chest wall
machine
oscillation)
Postural drainage
Maintaining Lung Compliance
• Noninvasive intermittent positive pressure ventilation (NIPPV), air
stacking / glossopharyngeal breathing
 Increase depth of inspiration
when inspiratory muscle are too weak
(4) Exercise Training: General Consideration
Stay out of
tobacco!
Aerobic Exercise Motivation! Consistent
• “backbone” of any pulmonary rehabilitation basis!
• Inclusion criteria:
• Decrease in functional exercise capacity d/t pulmonary dz.
• Able to participate safely in rigorous cardiorespiratory endurance training
program
• Cardiopulmonary Exercise Testing is necessary
• Pulmonary dz. should be relatively stable
• Medical comorbidities that contraindicate exercise should be absent
• Should not have orthopedic or cognitive disabilities that prevent exercise
 (4) Exercise Training: Exercise Prescription for
Pulmonary Rehabilitation Component Strength and Muscle Endurance Training
Table 34.2 Summary of ACSM Guidelines for Activity Resistance training: Low resistance, high
Exercise Prescription repetition
Component Cardiorespiratory Endurance Training Mode Variable resistance or hydraulic weight machines
Activity Dynamic exercise of large muscle Free weights
groups
Frequency 2-3 days/week
Mode Overground / treadmill walking
Duration One set of 3-20 repetition on 8-10 exercises that
Stationary leg cycling / outdoor include all of the major muscle groups
bicycling
Intensity Volitional exhaustion on each set, or
Stair climbing
Stop two or three reps before volitional
Frequency 3-5 days/week exhaustion
Duration 20-60 min/session Component Flexibility
50%-85% heart rate reserve Activity Static stretching of all muscle group
65-90% maximum heart rate Mode Minimum of 2-3 days/week
RPE = 12-16 (category scale) Ideally 5-7 days/week
RPE = 4-8 (category-rasio scale) Frequency 15-30 s/exercise 2-4 exercise stretching exercise
test
(5) Nutritional Issue
• Malnutrition can exacerbate muscle weakness and decrease lung and immunologic
function.
• Malnutrition and weight lost are independent and significant determinants of
morbidity and mortality from respiratory causes.
• Weight loss in COPD : Exercise capacity ↓ , health status ↓ , morbidity & mortality ↑
• In NMD require more proteins to help prevent muscle catabolism.

(6) Psychosocial Support