PULMONARY REHABILITATION

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

- One of the most common pulmonary disorders
- Characterized by airflow obstruction
- Decreased expiratory flow rate, airway narrowing, destruction of lung disease:

Chronic Bronchitis

- Hallmark: excessive mucus production in the bronchial tree with a chronic or recurrent
productive cough that lasts at least 3 months and recurs over the last 2 consecutive
years
- Epidemiology:
- M>F
- > 50 y.o
- Etiology:
- Cigarette smoking
- Air pollution
- Secondhand smoke
- Occupational exposure
- Pathophysiology:
- Hypertrophy and hyperplasia of goblet cells → chronic inflammation and
obstruction of bronchial tree → narrowing of airways
- Clinical Manifestations:
- Mild to moderate dyspnea
- Prominent cough
- Copious and purulent sputum
- Frequent bronchial infection
- Cyanotic
- Rhonchi and wheezing
- Obesity and edema
Emphysema

- Destruction of alveolar walls, loss of elastic fibers of alveoli

- Hallmark: excessively large and ineffective air spaces
- Blebs (<1 cm)
- Bullae (>1 cm)
- Epidemiology:
- M>F
- > 60 y.o
- Pathophysiology:
- Overinflation of lungs and formation of pockets of air between alveolar spaces
(blebs) and within parenchyma → loss of lung tissue elasticity
- Clinical Manifestations:
- More severe dyspnea, less prominent cough
- Scanty and mucoid sputum
- (+) barrel chest
- Less frequent bronchial infection
- Hypertrophied accessory muscles
- Increased physiologic dead space
Asthma

- Episodic periods of reversible airway narrowing in the presence of aeroallergens,

irritants, or exercise
- Epidemiology:
- M>F
- <10 y.o, though symptoms may appear at any age
- Etiology:
- Allergens (pollen, dust, food, animal hair, irritant inhalants)
- Climate change, exercise, genetic predisposition
- Pathophysiology:
- Widespread narrowing of airways → increased airway resistance →
abnormal distribution of ventilation to the alveoli
- Clinical Manifestation
- Accessory muscles for ventilation are used
- May be barrel chested
- Triad:
- Non-productive cough
- Wheezing
- Dyspnea

Bronchiectasis

- Permanent, abnormal dilation and distortion of one or more bronchi caused by

destruction of elastic and muscular components of bronchial walls
 - Epidemiology:
- Estimated 110.000 individuals
- F>M
- Pathophysiology:
- Prolonged bronchial obstruction → destruction of bronchial walls → reparative
laying down of fibrous tissue → infection causes accumulation of copious and
purulent secretions
- Clinical Manifestations:
- Recurrent pulmonary infections
- Productive cough with putrid sputum

Cystic Fibrosis

- Multisystem disorder involving the exocrine glands

- Etiology:
- Genetic (autosomal recessive trait) caused by mutations in the long arm of
chromosome 7
- Pathophysiology:
- Gene defect causes secretions of the exocrine glands to be thick and viscous

- Clinical Manifestations:
-
- Productive cough
- Bronchial infections
- Weight loss
- Increased NaCl in sweat
- (+) honeycomb lungs in radiograph
- Crackles and wheezes
- Cyanosis

RESTRICTIVE LUNG DISEASES (RLD)

- Characterized by decreased chest expansion
- Decreased inspiratory flow rate, decreased lung compliance, difficulty in lung expansion
- Restriction may be parenchymal or extraparenchymal
- Parenchymal - affecting the lung itself
 - Post-thoracotomy, pneumonia, atelectasis, sarcoidosis, idiopathic pulmonary
fibrosis, pneumoconiosis, drug or radiation-induced interstitial lung disease
- Extraparenchymal - outside the respiratory system that restricts lung compliance
- MG, GBS, MD, musculoskeletal conditions, cervical spine injury, kyphoscoliosis,
obesity, AS

Pulmonary Tuberculosis

- Caused by mycobacterium tuberculosis

- Maximally infectious for the first 2 weeks
- Incubation period: 2-10 weeks
- Treatment may last for 3-12 weeks
- Patient must be isolated in a negative pressure room
- Observe proper standard precautions when treating TB patients

Pneumonia

- Intra-alveolar lung infection

- Types:
- Bacterial pneumonia
- Viral pneumonia
- Aspiration pneumonia
- Clinical manifestations:
- Chills
- Fever
 - Productive cough
- Dyspnea

Pleural Effusion

- Excessive fluid accumulation on the pleural space

- Limited lung expansion
- Clinical Presentation:
- (+) pleural friction rub
- Dyspnea
- Dull or sharp pain

Pneumothorax

- Air or gas leaking into the pleural space

- Clinical manifestations:
- Sudden sharp pain
- Dyspnea
Pulmonary Embolism

- Lodging of small or large particles into the pulmonary venous circulation

- MC cause: DVT
- Clinical manifestations:
- Sudden acute pain
- Sudden onset of dyspnea
- Coughing
- Fever and chills

Pulmonary Edema

- Water enters the alveoli due to unequal capillary pressure

- Associated with left-sided heart failure and MVD
- Clinical manifestations:
- Cough
- Crackles
- Dyspnea
- Fever
Atelectasis

- Complete or partial collapse of a lung or lobe of a lung

- Develops when alveoli becomes deflated
- Usually a complication after surgery
Differential Diagnosis:

PT Assessment:
- Subjective examination and history taking
- Ocular inspection, general appearance
- Barrel chest
- Pectus excavatum (funnel chest)
- Pectus carinatum (pigeon chest)
- Vital signs
- Chest expansion
- Upper lobe expansion
- Middle lobe expansion
- Lower expansion
- Breathing pattern
- Dyspnea - distressed, labored breathing
- Tachypnea - rapid, shallow breathing
- Hyperventilation - rapid, deep breathing
- Orthopnea - dyspnea in supine
- Tropopnea - dyspnea in sidelying
- Platypnea - dyspnea in upright position
- Apnea - cessation of breathing in expiratory phase
- Apneusis - cessation of breathing in inspiratory phase
 - Palpation
- Tactile fremitus
- Chest wall pain
- Mediastinal shift
- Mediate percussion
- Auscultation of breath sounds

NORMAL Breath Sounds: ABNORMAL breath sounds:

Vesicular - soft, low-pitched, breezy but faint Crackles/Rales - fine, discontinuous sounds
sounds similar to the sound of bubbles popping

Bronchial - loud, hollow, or tubular high Wheezes/Rhonchi - continuous, high or low

pitched sounds pitched sounds or sometimes musical notes

Bronchovesicular - softer than bronchial

- Cough and sputum evaluation

- Endurance testing
- Rating of perceived exertion
- ROM assessment
- MMT of primary and accessory muscles of ventilation
- Limb girth measurement
- Graded exercise test
- Functional assessment
GOLD CLASSIFICATION OF COPD:

PT Management:
- Airway clearance/secretion removal techniques
- Breathing exercises
- Preventing and relieving episodes of dyspnea
- Energy conservation techniques, activity pacing
- Chest wall mobility exercises
- Aerobic exercises
- Strength training and resistive exercises
- Chest splinting in presence of pain
- Patient/family education

CHRONIC OBSTRUCTIVE PULMONARY RESTRICTIVE LUNG DISEASE (RLD)

DISEASE (COPD)

Chronic Bronchitis Pulmonary Tuberculosis

Emphysema Pneumonia

Asthma Pleural Effusion

Bronchiectasis Pneumothorax

Cystic fibrosis Pulmonary Embolism

Pulmonary Edema

Atelectasis