Pulmonary RehabilitationContents: 0 Introduction 0 Goals and outcomes of PR 0 The pulmonary rehabilitation team 0 Components of PR 0 Patient assessment and goal setting 0 Management strategiesIntroduction 0 PR have been existed for more than 40 years, the American College of Chest Physicians defined PR (1974) and described aspects of care for patients with respiratory impairments. 0 Many successfull pulmonary rehabilitation programs exist and the need for early detection and treatment of respiratory dysfunction is widely accepted 0 Rehabilitation research emphasizes symptom improvement, functional and exercise gains and health related quality of life outcomes as measures of efficacy instead of changes in pulmonary physiologic parametersDefinition In 2006 ATC and ERS defined PR as; “Pulmonary rehabilitation is an evidence-based, multidisciplinary and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities, integrated into the individualized treatment of the patient to reduce symptoms, optimize functional status, increase participation and reduce health care costs through stabilizing or reversing systemic manifestations of the disease”0 Pulmonary rehabilitation principles can be generalized to many chronic disease patient populations. 0 The need for multidisciplinary programming is for individualized goals aimed at restoring optimal physical and psychological functioning by adding components of exercise, education and counseling 0 Disease specific aspects of rehabilitation include the following: o ooo0a0 Patient assessment and goal setting Exercise training Self-management education Nutritional intervention Psychological supportee Goals and Outcomes 0 Goals for an individual pulmonary patient must be very specific and pertinent to his or her lifestyle, needs and personal interests. 0 The rehabilitation personnel should assist the patient in identifying realistic goals that can be described in behavioral terms and measured as outcomes for rehabilitation. 0 Goals should be such that make the most impact on daily function as well as realistic and life enhancing.0 PR outcomes are measures that generally assess the success of set goals. 0 Outcome assessments are usually a combination of objective and subjective measures. 0 Three areas that require outcome measurements in pulmonary rehabilitation include the following: - Exercise capacity - Symptoms (dyspnea and fatigue) - Health related quality of lifeO Improvement on exercise capacity; - Gain sufficient strength, flexibility and endurance to accomplish identified ADLs - Learn to employ strategies to manipulate the environment to maximize physical functioning Outcome measures include: graded exercise tests, time distance walk tests, incremental shuttle walk test, timed ADL tests0 Improvement in clinical symptoms such as patient will be; - Able to effectively mobilize respiratory secretions, - Employ strategies to relieve symptoms of dyspnea and cough - Recognize early signs of the need for medical intervention - Decrease the frequency and severity of respiratory exacerbations - Obtain optimal oxygen saturation throughout the day and night Outcome measures: Borg’s scale, VAS to measure dyspnea or fatigue, dyspnea questionnaires, QOL etc..Re 0 Improvement in health related behaviors - Stop tobacco use and drug or alcohol misuse - Comply with medical and rehabilitation treatments - Improve coping skills - Improve psychosocial function 0 Outcome measure: behavioral surveys, patient diaries and other self reported tools 0 Other outcome assessments can be used such as: performance of home based activity, psychosocial outcomes (anxiety, depression), adherence (dropout or attendance rate), knowledge and self efficacy, smoking cessation, nutrition weight control, healthcare utilization, morbidity and mortality, patient satisfaction etc..Pulmonary Rehabilitation team o o o Patient and family The medical director/ Physiatrist/ Physician Physiotherapist Nurse Exercise physiologist Counselor Pharmacist nutritionistPatient Assessment 0 Patient interview 0 Medical history 0 Physical assessment 0 Review of diagnostic tests 0 Symptom assessment 0 Exercise testingTable 19-2 Practice Patterns for Patients with Pulmonary Diseases 6A 6B 6C 6E 6F Primary prevention/risk reduction for cardiovascular/pulmonary disorders Impaired aerobic capacity/endurance associated with deconditioning Impaired ventilation, respiration/gas exchange, and aerobic capacity/endurance associated with airway clearance dysfunction Impaired ventilation and respiration/gas exchange associated with ventilatory pump dysfunction or failure Impaired ventilation and respiration/gas exchange associated with respiratory failurePatients Goals 0 Reliving Dyspnea 0 Clearing excessive mucus secretions 0 Increasing functional capacity 0 Enhancing sustained activities and skills for specific tasks to maximize efficiencyTherapist’s Goals: a a gooao0qc0ooa BE To relive symptoms: Dyspnea and Cough with expectorations To increase functional status: - Environmental modification - Task modification/ simplification Reliving symptoms with activities Increase cardiopulmonary endurance Increase muscle strength Improve flexibility Improve respiratory muscle strength and endurance To improve psychological status Nutritional counseling Preventive measures and self managementRe To relive Symptoms: 0 Includes relief of dyspnea 0 Improving ventilation 0 Controlling (decrease) respiratory rate and 0 Facilitating appropriate breathing pattern 0 Relaxation: generalized relaxation of body with appropriate positioning followed by relaxation of upper chest Principle used : Jacobsen’s progressive relaxation “Maximal muscle contraction would yield a maximal muscle relaxation”Controlled breathing techniques: 0 Diaphragmatic breathing a Pursed lip breathing 0 Active expiration technique Uses: 0 To decrease the work of breathing 0 To improve alveolar ventilation 0 To assist in relaxation 0 To enable patients to feel self-control and confidence in managing disease or dysfunction 0 Also helps to teach airway clearance and strength training of respiratory musclesConsiderations for teaching breathing control in primary and secondary pulmonary dysfunction: 0 In primary pulmonary dysfunction such as COPD, asthma, bronchiectasis: CBTs used to relax the neck and chest accessory muscles and teach more use of diaphragmatic breathing in combination with pursed lip breathing to reduce WOB. 0 This focus on energy conservation and pacing activity with breath control.0 Teach all dyspnea reliving postures and give appropriate instructions about the use of DRPs Dr Shruti PanchalTo remove excessive mucus secretions: ee ec ACBT AD PD Clapping vibrations + shaking Acapella, flutter, RC cornet Use of nebulizers, bronchodilators and mucolytics or steam inhalation prior to ACTseee To increase functional status 0 Treatment goals should be:- 0 Adopting the environment to improve the ease of performing ADLs:- Environmental modifications 0 Altering the performance of tasks to decrease energy costs:- Energy conservation 0 Incorporating methods to relive symptoms associated with activities:- Work simulationBe Environmental modifications: 0 Providing work areas with supported seating of appropriate height for tasks done on a counter or table 0 Placing equipment that is used most often in convenient locations so that bending, reaching and lifting are minimized. 0 Locating a table at work situations on which one can slide heavy items instead of lifting & carrying them 0 Locating chairs at appropriate places when rests are needed, such as on the landing of stairs, on side of bathtub. 0 Place adaptive devices properly which simplify tasks and improve comfort 0 Improving ventilation for the bathroom, kitchen or other areas in which fumes, dust smoke or steam may cause respiratory symptomsTask Modifications: Modified by using energy conservation techniques: a Be Slow down pace Minimizing large body movements such as moving weight up and down Setting priorities and organizing activities to minimize waste of movements Planning appropriate amount of time to complete the task, including breaks for restRelief of Symptoms on Activity a Use of controlled breathing Altering postures to improve respiratory muscle function Use relaxation techniques Avoid breath-holding and Valsalva maneuver Avoid unnecessary talks while performing tasks Use of pursed lip breathing to slow down RR and to decrease minute ventilation during tasksProgression of functional training: 0 Decrease amount of physical assistance offered to the patient in performing task 0 Decrease time to complete tasks G Decrease time or frequency of rest periods 0 Decreasing the dependence on adaptive equipment 0 Standardized timed ADL tests or questionnaire that focus on functional abilities and QOL used as outcome measuresIncrease Cardio-respiratory endurance Based upon patient’s PFTs, symptoms and exercise tolerance physical conditioning should be decided. Mild Lung Moderate lung Severe Lung wo disease Clisease jisease - Mild symptoms - Pt. presents with acute - Pts. Restricted their - Seen in out patient exacerbations activities due to SOB settings - Worsening symptoms during ADLs |- PFTs within 70-85% - SOB with daily - PFTs < 55% of of predicted activities predicted - PFTs between 55-70% of predictedPatients with Mild lung disease Exercises prescribed to this patients would be similar to normal population based upon their exercise tolerance and other risk factors. F = 3-5 days/week *8-12 weeks I= Initiate with mild-moderate intensity and within few days progress to moderate to high intensity i.€., 60-70% VO2max / 65-75% of MHR / RPE on Borg’s scale > 13 (not >15) T = continuous or circuit training (such as walking, jogging, cycling, swimming etc.) T = 30-45 minutes CO Additional warm-up and cool-down should be added with above conditioning programPatients with Moderate lung disease Exercise tolerance is limited by ventilation so evaluation for that can be start at very low level of MET with close monitoring of vitals while measuring CV endurance using modified Bruce protocol, 12MWT or 6MWT. F = 5-7 days/week *8-10 weeks I = submaximal or moderate intensity; preferably initiate with very mild intensity and progress to moderate intensity. Le., 40 - 60% O 60-70% VO2max / 45-65% 0 70-85% MHR /<13 RPE on Borg’s T = Interval training progressed to continuous (walking, cycling etc..) T = Short bouts of training with intervals progress to continuous activity for 20-30 minPatients with Severe lung disease C Patient may require intermittent or continuous oxygen at rest and during activity 0 Exercise testing for such patient should be at low level using 6MWT or symptom limited walking tests. F = daily; twice /day *2-4 weeks I= low intensity < 40% of VO2max < 45% of MHR <11 RPE on Borg’s T interval training with frequent rest periods (walking along the corridor) T = short bouts of 10-20 min with rest times 0 In progression increase No. of bouts and length of bouts or decreasing rest periodsTo improve Muscle strength 0 Increasing muscle strength and local muscle endurance improves the patient's ability to perform functional activities, decrease local fatigue and enhance body image. 0 Strength training starts with low resistance progressed first by increasing number of repetitions first followed by load. 0 Use of wt. cuffs, therabands, tubes, etc. can be used. 0 Ensure that patient should not hold breath while performing loading exercises0 30-40 sec. bout of exercises with several minutes of rest given. 0 6-10 reps. For strengthening of both UL and LL muscles 0 Outcomes used:- 1 RM test, dynamometry and endurance test wit hl10 RMTo improve flexibility o Patients with chronic respiratory diseases have significant changes in posture and decreased mobility of chest wall Gentle stretching with full body movements Coordinate with breathing Full shoulder flexion and back extension coordinate with inspiration (0 increases trunk flexibility and facilitate breathing Forward bending/trunk flexion combined with expirationImprove respiratory muscle strength 0 Increased WOB & chest wall changes occurs with lung disease makes the respiratory muscle fatigue for that - Rest the muscles with a device to assist breathing at night such as CPAP - Increase performance of respiratory muscles through exercises.a Segmental breathing exercises 0 Manual resistance given to train inspiratory muscles 0 Resistive devices can be used to improve respiratory muscle strength F = daily/twice a day I= 25-35% of maximal —ve inspiratory pressure measured at FRC or start with low resistance T = interval type; rest time > exercise time T = 15 minutes session *2 bouts