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Pulmonary Rehabilitation

Lecture Objectives
Define pulmonary rehabilitation
List medical and surgical indications for
pulmonary rehabilitation services
Outline essential components of a
comprehensive pulmonary rehabilitation
program

Lecture Objectives
Discuss the recommended medical tests
and procedures required of patients
before starting pulmonary rehabilitation
Discuss the indications and
contraindications of exercise testing for
patients with pulmonary disease

Lecture Objectives
Describe common exercise tests used to
assess exercise capacity of patients with
pulmonary disease
Describe the measures used to monitor a
patient during exercise testing and training
Know the indicators for terminating an
exercise test

Lecture Objectives
Recommend an appropriate exercise
program (mode, intensity, frequency,
duration) for a patient in pulmonary
rehabilitation from case data
Calculate intensity of aerobic exercise
using measures of VO2, dyspnea, and
peak heart rate on 6MWT for patients in
pulmonary rehabilitation from case data

Lecture Objectives
Apply an appropriate PT diagnosis (Guide
to PT Practice 3.0) to a patient in
pulmonary rehabilitation using case data
Outline the expected outcomes of
participating in a comprehensive
pulmonary rehabilitation program

Pulmonary Disease
COPD is the 4th leading cause of death in
the US
Approximately 5% of residents of New
England have COPD or chronic bronchitis
Only 10-15% of eligible patients receive
pulmonary rehabilitation

Pulmonary Rehabilitation
Evidence based
Multidisciplinary
Designed for patients with chronic
respiratory diseases who are symptomatic
and have decreased daily life activities

Pulmonary Rehabilitation
Designed to reduce symptoms, optimize
functional status, increase participation,
and reduce health-care costs
Comprehensive programs include:
Patient assessment
Exercise training
Education
Psychosocial support

Eligibility Criteria
Inclusion
Diagnosis of COPD or restrictive lung disease
Significant limitations in social and family
activities, employment, and/or ADLs
Tobacco free or participating in a smoking
cessation program
Be motivated and willing to participate

Eligibility Criteria
Exclusion
Patients with musculoskeletal or neurological
disorders that prevent exercise
Patients with unstable cardiovascular disease

Primary Medical Diagnoses of


Patients in Pulmonary Rehabilitation

6C: Impaired Ventilation, Respiration/Gas


Exchange, and Aerobic Capacity/Endurance
With Airway Clearance Dysfunction
Inclusion:
Acute lung disorders
Acute or chronic oxygen dependency
Change in baseline breath sounds
Change in baseline chest radiograph
COPD
Frequent pulmonary infection

6C: Impaired Ventilation, Respiration/Gas


Exchange, and Aerobic Capacity/Endurance
With Airway Clearance Dysfunction
Impairments:
Dyspnea at rest or with activity
Impaired airway clearance
Impaired cough
Impaired gas exchange
Impaired ventilatory forces and flow
Impaired ventilatory volumes
Inability to perform ADLs due to dyspnea
Inability to work due to dyspnea

6E: Impaired Ventilation and


Respiration/Gas Exchange Associated With
Ventilatory Pump Dysfunction or Failure
Inclusion:
Elevated diaphragm and volume loss of CXR
Diaphragm paralysis
Neuromuscular disorders
Pulmonary disorders
Musculoskeletal disorders

6E: Impaired Ventilation and


Respiration/Gas Exchange Associated With
Ventilatory Pump Dysfunction or Failure
Impairments:
Abnormal/adventitious breath sounds
RR and TV at rest
Impaired strength and endurance of
ventilatory muscles
Dyspnea with ADLs and work tasks
Dyssynchronous or paradoxical breathing
in arterial O2 and in CO2 off ventilator
Ventilatory pump impairment requiring
ventilatory support to maintain gas exchange

Multidisciplinary Pulmonary
Rehabilitation Team
Patient and family
Physician
Nurse
Physical Therapist
Exercise Physiologist
Respiratory Therapist
Psychologist
Dietitian

Patient Assessment and Goal Setting


Medical history
Patient interview
Physical assessment
Review of diagnostic tests
Symptom assessment

Essential Components of Pulmonary


Rehabilitation
Pulmonary Function Testing (RT)
Exercise Training
Monitored exercise testing and training (PT, EP)
Breathing exercises and relief of dyspnea (PT,
RN)
Airway Clearance Techniques (PT, RN)

Essential Components of Pulmonary


Rehabilitation
Patient Education
Psychosocial and behavioral intervention
(Psych)
Smoking Cessation (Psych, RN)
Depression (Psych)
Nutrition (Dietitian)
Bronchial hygiene and aerosol medication (MD,
RT)

Patient Education Program


Multi-disciplinary presenters and topics
Lung anatomy and physiology
Pulmonary diseases
Breathing techniques
Support group
Bronchial hygiene and medications

Patient Education Program


Psychologist
Stress reduction
Pharmacist
Medications
Registered dietician
Nutrition
Advance care planning team
Advance directives
Hospice representative
Death and dying

Medical Director Assessment


Pulmonary rehab medical director evaluation
Pulmonary function tests (if not within 1 year)
Resting 12-lead ECG (if patient has diagnosed
CAD)
Recent chest x-ray
Blood tests

PT Physical Examination
Chart Review
Patient Interview
Systems Review
Inspection
Auscultation
Palpation

Patient Examination: Monitored


Activity
HR
BP
Sp02
ECG
Dyspnea
Clinical signs and symptoms
Exercise assessment

PT Examination
Exercise Capacity
Symptom limited graded exercise test
Submaximal exercise test
Field tests

Symptoms
Dyspnea
Fatigue
Health related quality of life

Exercise Testing to Assess Exercise


Capacity
Purposes
Not diagnostic for pulmonary disease
Determine the factors that limit exercise capacity
Determine the level of functional impairment and
activity limitation
Evaluate exercise-induced O2 desaturation via pulse
oximetry

Provide information that will guide exercise


prescription
Evaluate the effectiveness of rehabilitation in
altering exercise capacity and exertional dyspnea

Contraindications to Exercise Testing


Absolute
Recent MI or acute
cardiac event (2 days)
Unstable angina
Uncontrolled arrythmias
Symptomatic severe
aortic stenosis
Uncontrolled symptomatic
heart failure

Acute pulmonary
embolism
Acute myocarditis or
pericarditis
Suspected or known
dissecting aneurysm
Acute systemic infection
with fever

Contraindications to Exercise Testing


Relative
Left main coronary
stenosis
Moderate stenotic
valvular disease
Electrolyte abnormalities
Severe arterial HTN
(>200/110 @ rest)
Tachyarrythmia or
Bradyarrythmia
Hypertrophic
cardiomyopathy

Neuro, musculoskeletal,
or rheumatoid disorders
High degree AV block
Ventricular aneurysm
Uncontrolled metabolic
disease
Chronic infectious
disease (HIV)
Mental or physical
impairment

Supervision of Exercise Testing


Physician
Needed in vicinity for high risk patients; not for
moderate or low risk patients

Exercise Physiologist
Nurse
PA
PT
All personnel must have appropriate
training and ACLS certification

Exercise Protocols
Max vs. Sub-max
Treadmill
Cycle Ergometer
Field Tests

Assessing Exercise Capacity


Protocols
GXT usually modified for individual
patient
No standard protocol
Mode: treadmill vs. stationary cycling

Field-tests
Shuttle test
6 minute walk test

Indications for Terminating GXT


Absolute
Drop in SBP 10 mmHg
with an increase in work
rate with evidence of
ischemia
Angina (3/4 on scale)
Ataxia, dizziness, near
syncope

Signs of poor perfusion


Technical difficulties
Subjects desire to stop
Sustained ventricular
tachycardia
ST elevation 1mm

Indications for Terminating GXT


Relative
Drop in SBP 10 mmHg
with an increase in work
rate without evidence of
ischemia
Horizontal or downsloping
ST depression 2 mm
Arrhythmias other than
ventricular tachycardia

Fatigue, SOB, wheezing,


leg cramps, claudication
BBB that cant be
distinguished from
ventricular tachycardia
Increasing chest pain
Hypertensive response
(>250/115 mm Hg)

Indications for Terminating a GXT


Most patients exercise capacity is limited
by ventilation, not by myocardial ischemia
or abnormal hemodynamic responses (as
with CAD)

6 Minute Walk Test (6MWT)


Distance walked
Simple, functional
test used for patients
with:
COPD
Heart failure
severely ill children
chronic renal failure
older adults between
the ages of 65 and 89
years

6 Minute Walk Test


Walking track:
100 ft (recommended)
Circular track or
treadmill is not
recommended per ATS
Flat, with minimal blind
turns, traffic or
obstacles
Marked in increments
Comfortable ambient
temperature and
humidity

6 Minute Walk Test


Pre-test
Dress comfortably, wear appropriate footwear
Avoid eating for at least 2 hrs prior to test
Take prescribed bronchodilator medication within
1 hour of test, or when patient arrives for test
Rest 15 minutes before starting 6MWT
Record resting: HR, BP, O2 sat, dyspnea (Borg
scale)
Read standardized instructions to patient (see
lab handout)

6 Minute Walk Test


During test:
Patient may use prescribed O2 and usual
assistive device to walk
During the test, monitor for signs and
symptoms of exercise intolerance
Provide standard encouragement

6 Minute Walk Test


During test:
PT may walk close behind patients side BUT
do not set pace
Pulse oximeter may be attached to patient
IF the patient stops during the test
Allow the patient to sit if they wish
Immediately measure HR and Sp02
Ask patient why they stopped
Record time spent resting (but keep 6 min timer running)
Repeat the following every 15 seconds if necessary:
Begin walking as soon as you feel able

6 Minute Walk Test


Reasons to stop the test:
Angina
Evolving mental confusion or lack of
coordination
Light-headedness
Intolerable dyspnea
Leg cramps or extreme leg muscle fatigue
SpO2 > 4% from resting level AND/OR
in SpO2 < 88%

6 Minute Walk Test


End of test:
Mark the distance walked
Have patient sit (stand if preferred)
Immediately note HR, Sp02, dyspnea
Continue to observe patient in clinic for
15 minutes before release

6 Minute Walk Test


Ideally, a minimum of 3 trials is recommended
(to account for a learning effect)
The best of the 3 tests is recorded as the
patients score

6 Minute Walk Test Interpretation


580 m in health males
500 m in health females
630 m in older adults
If the tests are being used to compare pre
and post intervention status the minimum
clinically important difference has been
estimated as 54 meters (95% CI 37-71 m)
for patients with COPD

Estimating Aerobic Capacity from


Walk Test Data

Step 1: Determine walking speed


Distance (meters)/time (minutes)

Step 2: Calculate oxygen uptake


VO2 = 3.5 + (0.1 x walking speed )

Step 3: Convert VO2 to METs


METs = VO2/3.5

YMCA 3 Minute Step Test


Test of aerobic fitness based on how
quickly HR returns to normal after exercise
Requires little equipment or specialized
training
A functional test
Can require higher energy costs than
what some populations can handle

YMCA 3 Minute Step Test


Equipment
12 inch step (adults)
Metronome (96 beats per minute)
Stopwatch
Chair

YMCA 3 Minute Step Test


Pre-test
Determine HR and SP02 at rest

During test
During the test, monitor for signs and
symptoms of exercise intolerance
Patient must keep up with the metronome
otherwise the test is not valid

YMCA 3 Minute Step Test


Reasons to stop the test:
Patient chooses to stop
Sp02 falls below acceptable levels
3 minute stepping period is up

End of test:
Have patient sit
Immediately note HR during the 1 minute
period post exercise

YMCA 3 Minute Step Test


Interpretation
Results based on gender and age
Estimating VO2 max
Men: 111.33 (0.42 x HR during 1st minute of
recovery)
Women: 65.81 (0.1847 x HR during 1st minute
of recovery)

Convert VO2 to METs


METs = VO2/3.5

Components of PT Program
Breathing exercises
Stretching and flexibility exercises
Aerobic exercise
UE and LE resistance
Energy conservation techniques/pacing
Adaptive equipment

Aerobic Exercise Training: Type


Walking
Cycling
Stationary
Bicycling

Stair climbing
Swimming

Aerobic Exercise Training: Type


Cycle ergometer

Aerobic Exercise Training: Type


Walking laps or
treadmill walking

Aerobic Exercise Training: Intensity


Methods for setting training intensity:
Go at your own pace
~ 50% of VO2/METs achieved during GXT
Workload during GXT that elicits a target dyspnea
rating
Speed during 6MWT
Light: 30-40%
Moderate: 40-60%
Vigorous: 60-80%

Distance during 6MWT

Aerobic Exercise Training: Intensity

Aerobic Exercise Training: Intensity


Dyspnea on GXT
Maintain a similar level of dyspnea as
experienced during the GXT
Exercise at the same workload that caused a
Borg dyspnea score between 3 and 4 during
the GXT (moderate somewhat severe)

Aerobic Exercise Training: Intensity


6MWT speed
Treadmill speed for ex. = 80% average speed in 6MWT
Patient walked 720 ft in 6MWT
720 ft / 6 min =120 feet/min
120 ft/min 0.011 mph = 1.32mph

For Continuous training:


TM walking at ~ 1.05 mph (80% of speed during 6MWT) for
30 min

For Interval training:


TM walking at slightly faster than 1.05 mph for 2-3 min
intervals

Aerobic Exercise: Frequency and


Time
20 40 min of continuous or intermittent activity
Initially, may use intervals from 30s to 3 min followed by
equal length rest periods until patient can exercise
continuously
at least 3-5 days/week
Patients with lower exercise tolerance may benefit by more
frequent exercise at a lower intensity

6 8 weeks to achieve clinically important increases


in aerobic capacity
Patients should receive home exercise program to
continue after discharge from rehab

Resistance Exercises
Guidelines:
Start with low resistance and high repetitions
Increase repetitions (from 10 to 20) before
addition weight
Begin with 1 set with weight equal to 8 10 RM
In 3 4 weeks progress to 2 sets with weight
equal to 8 10 RM
2 to 3 rest intervals between sets
2 3x /week

Monitoring - Dyspnea

Monitoring - Sp02
SpO2 < 88% (on room air) is common criteria
for needing to introduce supplemental O 2
If SpO2 drops below minimum level, PT may:
Reduce intensity of activity OR STOP activity
Continue to monitor patient
Increase flow of O2 to keep saturation in the prescribed
range , but only in consultation with and prior approval of
physician
Recall: increasing O2 may reduce hypoxic drive to breathe
in patients with COPD and the PaCO 2 may increase

Use of Bronchodilators and


Supplemental Oxygen
Prescribed bronchodilators should be
taken before exercise training
May allow the patient to exercise:
At a greater intensity
For a longer duration
With less dyspnea

Prescribed O2 should be used during exercise

Patient Education Program


Physical Therapist
Energy conservation and pacing strategies
Home exercise program
Air Quality and Common Respiratory Irritants
Energy conservation and adaptive equipment in
daily activities

Energy Conservation Strategies &


Pacing
Seated work
Convenient equipment placement
Adaptive equipment
Tub seats
Wheeled carts
Wheeled walkers

Breathing techniques
Pacing
Prioritizing and planning

Common Airborne Allergens and


Respiratory Irritants
Cigarette smoke
Carbon monoxide
Dust mites
Molds
Animal dander
Pollen
Cockroaches

Common Airborne Allergens and


Respiratory Irritants - Ozone

Common Airborne Allergens and


Respiratory Irritants - Particles

Air Quality Measurement

Air Quality Index


AIR
QUALITY
INDEX

AIR QUALITY
DESCRIPTOR

OZONE
HEALTH
EFFECTS

PARTICULATE
MATTER
HEALTH
EFFECTS

COLOR
CODE

0-50

Good

No Health Notice

No Health Notice

GREEN

51-100

Moderate

Limited Health
Notice

Limited Health
Notice

YELLOW

101-150

Unhealthy for
Sensitive Groups

Health Notice

Health Notice

ORANGE

151-200

Unhealthy

Health Advisory

Health Advisory

RED

201-300

Very Unhealthy

Health Alert

Health Alert

PURPLE

Air Quality Index: Ozone/Particulate


Matter
Moderate air quality = Limited Health Notice - Extremely
sensitive children and adults should consider limiting prolonged
exertion outdoors
Unhealthy for Sensitive Groups = Health Notice Sensitive
children and adults and people with heart or lung disease
should limit prolonged exertion outdoors
Unhealthy = Health Advisory - Sensitive children and adults
and people with heart or lung disease should limit exertion
outdoors; everyone else, especially children, should limit
prolonged exertion outdoors
Very Unhealthy = Health Alert - Sensitive children and adults
and people with respiratory disease should avoid exertion
outdoors; everyone else, especially children, should limit
exertion outdoors

Heat Stress Index

Heat Index

Heat Stress
Risk of heat stress
65 years
Overweight
Heart disease or high blood pressure
Workers in hot environments
Firefighters,
Bakery workers
Farmers
Construction workers
Miners
Factory workers

Anticipated Goals & Expected


Outcomes for Pulmonary Rehabilitation
Individualized, patient-centered goals to maximize
functional independence
Reduce dyspnea during activity
Independent in use of DB in supine, sitting, or standing
Independent in use of PLB to slow RR
Independent in use of PB with PLB to control dyspnea and prevent
valsalva maneuver during activity
Knowledge of positions to relieve dyspnea

Independent in self-monitored aerobic activity program (20-60


min at least 3-5x/week)
Increase exercise capacity and endurance
Increase peak MET level/workload during GXT
Increase distance walked on 6MWT

Anticipated Goals & Expected


Outcomes for Pulmonary Rehabilitation
o Enhanced ability to perform activities of daily living
o Increased knowledge about respiratory disease and
management
o Understand and use the AQI and Heat Stress Index
to decide the safety of exercise outdoors
o Understand and employ strategies to reduce the effects
of air pollution on health
o Understand and employ strategies to reduce exposure
to common respiratory irritants (cigarette smoke, carbon
monoxide, dust mites, molds, animal dander, pollen,
cockroaches)

Evidence Based Practice Guidelines

Exercise training of the muscles of ambulation


A
Decreases dyspnea
A
Improve HRQOL
A
Reduces hospital days and health care utilization
B
Strength training improves muscle strength and mass
A
IMT not supported
B
Psychosocial benefits
B
Education component
B
Supplemental O2 should be used during ex.
C
Survival
no recommendation