Scenario: A 27 year old male presents

complaining of chest pain and shortness of

breath. Hyper resonant percussion noted
over the right side of chest, vocal fremitus
absent on right side; breath sounds absent
on right side. He is diagnosed with
pneumothorax.
Scenario: A 20 year old geologist who
raises carrier pigeons as a hobby presents
with 10 day duration of non-productive
cough, fever, fatigue, body aches, malaise
and headache. There are sparse rales over
lower 1/3 of right lung; no pleural rubs. A
sputum culture reveals fungus
Scenario: A 23 year old Hispanic woman who now works
as a secretary presents at the office with month old
symptoms of evening fever (approximately 102), night
sweats, fatigue, increasing shortness of breath on exertion,
anterior chest pain and a 5 pound weight loss. In the last
few weeks she has also developed a cough productive of
yellow sputum. The patient had worked as a migrant field
worker until 3 years ago. Tests are done and she is
diagnosed with mycobacterium tuberculosis. She is treated
with Isoniazid, Ethambutol, Rifampicin and Pyridoxine.
Her husband and child are given Isoniazid prophylaxis
Pulmonary Rehabilitation
Juanito C. Lim III, PTRP
General Medical
Background: Definition
Pulmonary Conditions
are any disorder affecting the function of the
respiratory system.
General Medical
Background: Definition
Pulmonary Rehabilitation
According to the American College of Chest
Physicians, pulmonary rehabilitation is the art
of medical practice wherein an individually
tailored, multi-disciplinary program is
formulated which, through accurate diagnosis,
therapy, emotional support, and education,
stabilizes or reverses both the physical and
psychopathological aspects of pulmonary
diseases.
General Medical
Background: Definition
Pulmonary Rehabilitation
In current practice, pulmonary rehabilitation
includes post-surgical management of lung and
heart-lung transplants.
General Medical
Background: Classification
Physiologic Classification
Anatomic Classification
General Medical
Background: Classification
Physiologic Classification
Obstructive
Restrictive
General Medical
Background: Classification
Physiologic Classification
Obstructive
aka intrinsic disorder, oxygenation impairment
Conditions which impede the rate of flow into and
out of the lungs.
Any conditions that obstruct airflow in the
respiratory tract and affects VENTILATION and
RESPIRATION
Characterized by an increase in airway resistance
that is measured as a decrease in peak expiratory
flow rates.
General Medical
Background: Classification
Physiologic Classification
Obstructive
Common examples:
Asthma
Chronic obstructive pulmonary disease (COPD)
Emphysema
Chronic bronchitis
Bronchiectasis
Cystic fibrosis
Bronchopulmunary dysplasia (BPD)
General Medical
Background: Classification
Physiologic Classification
Obstructive
Other examples:
Byssinosis
Bronchiolitis
Asbestosis
General Medical
Background: Classification
Physiologic Classification
Restrictive
aka mechanical disorder, ventilatory impairment
Conditions which cause a reduction in the functional
volume of the lungs.
Characterized by an increase of the force trying to
collapse the lung (recoil) and a decrease in lung
compliance, measured as a decrease in all lung
volumes.
General Medical
Background: Classification
Physiologic Classification
Restrictive
These can be subdivided into:
Parenchymal
Extraparenchymal
General Medical
Background: Classification
Physiologic Classification
Restrictive
These can be subdivided into:
Parenchymal
Restrictive disorders affecting the lung tissue itself.
Common examples:
Post-thoracotomy
Pneumonia
Atelectasis
General Medical
Background: Classification
Physiologic Classification
Restrictive
These can be subdivided into:
Parenchymal
Other examples:
Sarcoidosis
Idiopathic pulmonary fibrosis
Pneumoconiosis
Drug- or radiation-induced interstitial lung
disease
General Medical
Background: Classification
Physiologic Classification
Restrictive
These can be subdivided into:
Extraparenchymal
Disorders outside of the respiratory system that
restrict lung compliance indirectly.
Examples:
Neuromuscular conditions
Diaphragmatic weakness/paralysis
Myasthenia gravis
General Medical
Background: Classification
Physiologic Classification
Restrictive
These can be subdivided into:
Extraparenchymal
Examples:
Guillain-Barre syndrome
Muscular dystrophies
Musculoskeletal conditions
Cervical spine injury
Chest wall injury
General Medical
Background: Classification
Physiologic Classification
Restrictive
These can be subdivided into:
Extraparenchymal
Examples:
Kyphoscoliosis
Obesity
Ankylosing spondylitis
General Medical
Background: Classification
Anatomic Classification
Upper respiratory tract
Commonly used in the context of infectious
respiratory disease.
Examples:
Rhinosinusitis (common cold)
Sinusitis
Pharyngitis/tonsillitis
Laryngitis
Acute bronchitis
General Medical
Background: Classification
Anatomic Classification
Lower respiratory tract
Commonly used in the context of infectious
respiratory disease.
Examples:
Pneumonia
Tuberculosis
Parenchymal
Disorders affecting the lung tissue directly.
General Medical
Background: Classification
Anatomic Classification
Extraparenchymal
Disorders outside of the respiratory system that
affect the lung tissue indirectly.
Vascular
Disorders affecting the vascular system of the lungs.
Examples:
Pulmonary edema
Pulmonary embolism
Pulmonary hypertension
General Medical
Background: Epidemiology
Chronic respiratory diseases are a leading
cause of major limitation of activity, loss of
work days, and premature retirement due to
disability.
COPD is the 5
th
leading cause of death in
the United States, and its incidence has
doubled since 1970.
General Medical
Background: Epidemiology
Worldwide, respiratory diseases are the 4
th

leading cause of death.
Respiratory disease is the most common
cause of early death in traumatic
quadriplegia and neuromuscular disorders.
COPD and asthma most common lung
diseases for which pulmonary rehabilitation
is rendered.
General Medical
Background: Etiology
Each pulmonary disorder has its own
etiologic factor(s).
However, these can be generally classified
into:
Hereditary/Genetic causes
Exposure to environmental agents
General Medical
Background: Etiology
However, these can be generally classified
into:
Hereditary/Genetic causes
less common
Examples:
Alpha 1 antitrypsin deficiency
Mutation of the cystic fibrosis transmembrane
conductance regulator (CFTR).
General Medical
Background: Etiology
However, these can be generally classified
into:
Exposure to environmental agents
more common
Examples:
Smoking most common environmental agent
Exposure to infectious organisms
Occupational exposure
General Medical Background:
Pathophysiology /
Pathomechanics
In obstructive lung conditions:
Airway obstruction is the primary
pathophysiologic mechanism which can be
caused by:
Reversible factors:
Irreversible factors:
Localized lesions
General Medical Background:
Pathophysiology /
Pathomechanics
In obstructive lung conditions:
Airway obstruction is the primary
pathophysiologic mechanism which can be
caused by:
Reversible factors:
Inflammation
Bronchospasm
Mucus plugging
General Medical Background:
Pathophysiology /
Pathomechanics
In obstructive lung conditions:
Airway obstruction is the primary
pathophysiologic mechanism which can be
caused by:
Irreversible factors:
Fibrotic airway
Damaged alveoli
Localized lesions
General Medical Background:
Pathophysiology /
Pathomechanics
In obstructive lung conditions:
All of these conditions decrease the size of the
air passages.
Due to airway obstruction, both expiratory and
inspiratory flow rates are decreased, which
decreases gas exchange between the alveoli and
capillaries.
General Medical Background:
Pathophysiology /
Pathomechanics
In obstructive lung conditions:
Because of decreased gas exchange, respiratory
volumes must be increased to compensate for
this, thus, more energy expenditure is necessary
for breathing.
Patients become hypoxic despite being
normally eucapneic or hypocapneic.
General Medical Background:
Pathophysiology /
Pathomechanics
In restrictive lung conditions:
Decreased mechanical compliance is the
primary pathophysiologic mechanism which
can either be caused by poor mechanical
compliance of:
The lung tissue itself (parenchymal)
Structures surrounding the lung (extraparenchymal)
General Medical Background:
Pathophysiology /
Pathomechanics
In restrictive lung conditions:
Because of poor mechanical compliance, the
lung cannot normally expand nor return to its
resting size.
Hypoxia only occurs secondarily.
General Medical Background:
Clinical Manifestation(s)
4 common clinical manifestations of
pulmonary disease:
Dyspnea or shortness of breath
Cough
Hemoptysis
Chest pain with a pleuritic quality
General Medical Background:
Clinical Manifestation(s)
Other clinical manifestations of pulmonary
disease are:
Abnormal or adventitious breath sounds
Cyanosis
Digital clubbing
Changes in lung volumes
General Medical Background:
Clinical Manifestation(s)
Other clinical manifestations of pulmonary
disease are:
Abnormal or adventitious breath sounds, such
as:
Crackles (rales)
Wheezes (rhonchi)
Pleural friction rub
Stridor
Death rattle worst, as this is usually heard in a
patient dying of pulmonary arrest only
General Medical Background:
Clinical Manifestation(s)
Other clinical manifestations of pulmonary
disease are:
Cyanosis, either:
Peripheral usually
Central
Digital clubbing
Changes in lung volumes
General Medical Background:
Clinical Manifestation(s)

General Medical Background:
Clinical Manifestation(s)

General Medical Background:
Clinical Manifestation(s)
General Medical Background:
Clinical Manifestation(s)

General Medical Background:
Complication(s)
Complications may arise if lung disease is
not managed as early as possible, such as:
Decreased cardiovascular and pulmonary
endurance
Increased risk of contracting infectious
pulmonary conditions
Death due to pulmonary arrest
General Medical Background:
Diagnosis
History
Physical examination
Laboratory examination
General Medical Background:
Diagnosis
The patients history must be taken to
determine:
Family history of lung conditions
Exposure to environmental agents
Smoking history or secondary exposure to smoking
Occupational environmental agents (dusts)
Presence of coexisting disease
General Medical Background:
Diagnosis
In the physical examination, the general
principles of inspection, palpation,
percussion, and auscultation apply to the
examination of the respiratory system.
However, the physical examination should be
directed not only toward ascertaining
abnormalities of the lungs and thorax but also
toward recognizing other findings that may
reflect underlying lung disease.
General Medical Background:
Diagnosis
Physical examination
Inspection
Rate and pattern of breathing
Depth and symmetry of lung expansion
Visible abnormalities of thoracic cage
Palpation
Symmetry of lung expansion (to confirm findings
during inspection)
Vibrations (tactile fremitus)
General Medical Background:
Diagnosis
Physical examination
Percussion
Resonance of lungs
Auscultation
Quality and intensity of breath sounds
Presence of abnormal or adventitious breath sounds

General Medical Background:
Diagnosis

General Medical Background:
Diagnosis
Physical examination
meticulous general physical examination is
mandatory in patients with disorders of the
respiratory system.
Enlarged lymph nodes in the cervical and
supraclavicular regions should be sought.
Disturbances of mentation or even coma can occur
in patients with acute carbon dioxide retention and
hypoxemia.
General Medical Background:
Diagnosis
Physical examination
meticulous general physical examination is
mandatory in patients with disorders of the
respiratory system.
Telltale stains on the fingers point to heavy cigarette
smoking; infected teeth and gums may occur in
patients with aspiration pneumonitis and lung
abscess.
General Medical Background:
Diagnosis
Physical examination
meticulous general physical examination is
mandatory in patients with disorders of the
respiratory system.
Clubbing of the digits can be found in lung cancer,
interstitial lung disease, and chronic infections in the
thorax, such as bronchiectasis, lung abscess, and
empyema.
General Medical Background:
Diagnosis
Laboratory examination is always included
in the diagnosis of pulmonary conditions,
such as:
Imaging studies
Examination of biologic specimens
Viewing techniques
Gas analysis techniques
General Medical Background:
Diagnosis
Laboratory examination is always included
in the diagnosis of pulmonary conditions,
such as:
Imaging studies
Chest x-rays
CT scans
MRI
Scintigraphic imaging
Pulmonary angiography
Chest ultrasound
General Medical Background:
Diagnosis
Laboratory examination is always included
in the diagnosis of pulmonary conditions,
such as:
Examination of biologic specimens
Sputum collection
Percutaneous needle aspiration
Thoracentesis
General Medical Background:
Diagnosis
Laboratory examination is always included
in the diagnosis of pulmonary conditions,
such as:
Viewing techniques
Thoracotomy
Video-assisted viewing techniques
Bronchoscopy
Thoracoscopy
Mediastinoscopy
General Medical Background:
Diagnosis
Laboratory examination is always included
in the diagnosis of pulmonary conditions,
such as:
Gas analysis techniques
Pulmonary function testing
Arterial blood gas (ABG) analysis
Pulse oximetry
General Medical Background:
Differential Diagnosis
Lung conditions are differentiated using the
following bases:
Physiologic basis
Anatomic basis
Etiologic basis
General Medical Background:
Prognosis
Although a comprehensive rehabilitation
program may have little effect on the rate of
progress of the underlying disease, a
number of beneficial effects have been
documented, including:
Reduction in the average number of
hospitalization days per year
Subjective improvement in symptoms and
quality of life
Other Healthcare Management:
Pharmacologic
obstructive lung conditions
enlarging the respiratory passages and
decreasing or expectoration of mucus
restrictive lung conditions
directed toward the particular cause of the
restriction
Other Healthcare Management:
Medical/Surgical
Pulmonary patients do not usually undergo
surgery because of the disease itself but if
the patient must undergo surgery for other
conditions, the lung condition may affect
the persons response to anesthetic and
ability to cope with respiratory problems
after surgery.
Other Healthcare Management:
Medical/Surgical
In preparation for surgery the pulmonary
status of persons with lung disease will be
carefully evaluated and measures will be
instituted to improve ventilation and
perfusion.
Persons with chronic pulmonary problems
must be monitored very carefully during
surgery and in the early post-op period.
Other Healthcare Management:
Medical/Surgical
Tracheostomy may be indicated if a patient
will be using positive-pressure ventilators
often.
Other Healthcare Management:
Other Rehabilitative
Respiratory therapists will instruct the
patient and caregivers on the use of the
following, as needed:
Metered dose inhalers
Nebulizers
Supplemental oxygen
Home ventilators
Other Healthcare Management:
Other Rehabilitative
Occupational therapists
Assessment and provision of exercise programs
for upper extremity ROM and strengthening
Assessment and provision of training for self-
care activities
Recommend adaptive equipment to increase
independence and minimize energy expenditure
Other Healthcare Management:
Other Rehabilitative
Occupational therapists
Evaluate home and work environments for any
possible modification
Give suggestions to increase independence and
energy conservation
PT Examination, Evaluation &
Diagnosis:
Points of Emphasis in Examination
Aside from the components stated above in
the history taking and physical examination,
PTs perform additional examination
techniques of the following:
Cardiovascular and pulmonary systems
Neurologic system
Musculoskeletal system
Posture
Functional assessment

PT Examination, Evaluation &
Diagnosis:
Points of Emphasis in Examination
Cardiovascular and pulmonary systems
Regular vital signs assessment
Endurance testing using either of the following:
Walk test ambulate as far as possible in 12 minutes.
Cycle test begin with 100 kpm , increase 100 kpm
Treadmill test - constant 0 grade.
Rate of Perceived Exertion Scale (Borg)
Shortness of Breath Scale
Chest expansion measurements
PT Examination, Evaluation &
Diagnosis:
Points of Emphasis in Examination
Neurologic system
Check for any signs of neuromuscular involvement
Musculoskeletal system
Joint play of chest wall articulations
ROM
MMT
Limb girth measurements
PT Examination, Evaluation &
Diagnosis:
Points of Emphasis in Examination
Posture
Note particularly for;
Scoliosis
Kyphosis
Lordosis
Other trunk deformities
Functional assessment
Check both basic and instrumental ADL
Moser Classification of Functional Pulmonary
Disability

PT Examination, Evaluation &
Diagnosis:
Problem List
Problems addressable by physical therapy in
this population are the following:
Impaired airway clearance secondary to
difficulty in expectoration (coughing) of mucus
PT Examination, Evaluation &
Diagnosis:
Problem List
Problems addressable by physical therapy in
this population are the following:
Impaired ventilatory function leading to poor
gas exchange secondary to either:
Parenchymal dysfunction due to:
Impaired mechanical compliance of lung tissue
Extraparenchymal dysfunction due to either:
Impaired chest wall articulation joint play
Pain on chest wall motions
PT Examination, Evaluation &
Diagnosis:
Problem List
Problems addressable by physical therapy in
this population are the following:
Impaired aerobic capacity/endurance
Easy fatigability
PT Examination, Evaluation &
Diagnosis:
Physical Therapy Diagnosis
The physical therapy diagnostic label for
patients with pulmonary conditions could
encompass any of the following, as
applicable:
Primary prevention/risk reduction for
cardiovascular/pulmonary disorders
Usually for at-risk patients
Impaired aerobic capacity/endurance associated
with deconditioning
For severely debilitated patients
PT Examination, Evaluation &
Diagnosis:
Physical Therapy Diagnosis
The physical therapy diagnostic label for
patients with pulmonary conditions could
encompass any of the following, as
applicable:
Impaired ventilation, respiration/gas exchange
and aerobic capacity/endurance associated with
airway clearance dysfunction
For obstructive conditions
PT Examination, Evaluation &
Diagnosis:
Physical Therapy Diagnosis
The physical therapy diagnostic label for
patients with pulmonary conditions could
encompass any of the following, as
applicable:
Impaired ventilation and respiration/gas
exchange associated with ventilatory pump
dysfunction or failure
For restrictive conditions
PT Examination, Evaluation &
Diagnosis:
Physical Therapy Diagnosis
The physical therapy diagnostic label for
patients with pulmonary conditions could
encompass any of the following, as
applicable:
Impaired ventilation and respiration/gas
exchange associated with respiratory failure
For severe cases undergoing respiratory failure and
patients with acute respiratory distress syndrome
(ARDS)
PT Examination, Evaluation &
Diagnosis:
Physical Therapy Diagnosis
The physical therapy diagnostic label for
patients with pulmonary conditions could
encompass any of the following, as
applicable:
Impaired ventilation, respiration/gas exchange
and aerobic capacity/endurance associated with
respiratory failure in the neonate
For severe cases undergoing respiratory failure in
patients with infantile respiratory distress syndrome
(IRDS)
PT Prognosis (including Plan of
Care) & I ntervention:
Plan of Care
Appropriate PT goals for patients with
pulmonary disorders are the following, as
applicable:
Improve airway clearance through:
Efficient expectoration of mucus
Involvement of patients caregivers in airway
clearance techniques
Improve ventilation through:
Increasing chest wall articulation joint play
Decreasing pain during chest wall motions
PT Prognosis (including Plan of
Care) & I ntervention:
Plan of Care
Appropriate PT goals for patients with
pulmonary disorders are the following, as
applicable:
Improve aerobic capacity/endurance
Prevent fatigability
PT Prognosis (including Plan of
Care) & I ntervention:
Interventions
Airway clearance techniques
PJM of chest wall articulations
Splinting
Breathing exercises
Aerobic/endurance exercises
PT Prognosis (including Plan of
Care) & I ntervention:
Interventions
Airway clearance techniques
Postural drainage
Manual chest percussion
Mechanical chest vibration
Coughing techniques
PT Prognosis (including Plan of
Care) & I ntervention:
Interventions
PJM of chest wall articulations
If presence of impaired chest wall articulation
joint play is found
Splinting
If pain with chest motions are noted
Could be through:
Applying elastic bandages around chest area
Manual chest splinting
PT Prognosis (including Plan of
Care) & I ntervention:
Interventions
Breathing exercises
Diaphragmatic breathing
Pursed-lip breathing
Glossopharyngeal breathing
PT Prognosis (including Plan of
Care) & I ntervention:
Interventions
Aerobic/endurance exercises
Patient is encouraged to apply breathing
techniques during these exercises
Precautions are taken to prevent fatigue
Do not exercise to point of fatigue
Graded Exercise Test Termination Criteria may
also be used during these exercises to decide if
immediate termination of exercise is necessary
Thank You!