Presented to: Group M1435

Dr.Chihai Victoria Hasan Mohannad

Hujeirat Sofian
Amara Fuad
 DEFINITION

Art of medical practice wherein individually tailored

multidisciplinary program is formulated, which
accurate diagnosis, therapy, emotional supportthrough and
education; stabilizes or reverses physio
psychopathologybothof pulmonary disease in attempts
andto return
the patient to highest possible functional capacity allowed by
pulmonary handicap and overall life situation
 Definition

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, pulmonary rehabilitation is designed to
symptoms, optimize functional status, reduce
increase
participation, and reduce health care costs through stabilizing
or reversing systemic manifestations of the disease
 Education

General
Psychological
support
exercise
training
Pulmonary
Rehabilitatio
n
components
Nutritional Breathing
advice
Outcome Retraining
Assessment
Consequences of Respiratory Disease

• Peripheral Muscle dysfunction

• Respiratory muscle dysfunction
• Nutritional abnormalities
• Cardiac impairment
• Skeletal disease
• Sensory defects
• Psychosocial dysfunction
Goals of Pulmonary Rehabilitation

Aims to reduce symptoms, decrease disability, increase

participation in physical and social activities and improve overall
quality of life.

These goals are achieved through patient and family education,

exercise training, psychosocial intervention and assessment of
outcomes.

The interventions are geared toward the individual problems of

each patient and administered by the multidisciplinary team.
Setting for Pulmonary Rehabilitation

Outpatient
Inpatient
Home
Communit
y Based
Choice
varies
dependin
g on
- Distance
to
 Education

EXAMPLES OF EDUCATIONAL TOPICS

Breathing Strategies
Normal Lung Function and Pathophysiology of Lung Disease
Proper Use of Medications, including Oxygen
Bronchial Hygiene Techniques
Benefits of Exercise and Maintaining Physical Activities
Energy Conservation and Work Simplification Techniques
Eating Right
 Education……

Irritant Avoidance, including Smoking Cessation

Prevention and Early Treatment of Respiratory Exacerbations
Indications for Calling the Health Care Provider
Leisure, Travel, and Sexuality
Coping with Chronic Lung Disease and End-of-Life Planning
Anxiety and Panic Control, including Relaxation
Techniques and Stress Management
 Exercise training

Components of exercise training:

•Lower extremity exercises
•Arm exercises
•Ventilatory muscle training
Types of exercise:
•Endurance or aerobic
•Strength or resistance
 Lower extremity exercise

Walking
Treadmill
Stationary bicycle
Stair climbing
Sit & Stand
 Arm exercise training

Arm cycle ergometer

Unsupported arm lifting
Lifting weights

Strength exercise
When strength exercise was added to
standard exercise protocol;
led to greater increase in
muscle strength and muscle mass
 Ventilatory muscle training

Resistive IMT: Threshold IMT:

Patient breaths through hand held Patient breaths through a device
device with which resistance to equipped with a valve which
flow can be increased gradually opens at a given pressure.

• Difficult to standardize the load

• Patients may hypoventilate • Easily quantitated
• Leads to increased Pulmonary and standardized
Arterial Pressure and fall in
oxygen tension
 Chest Physical Therapy &
Breathing Retraining

Pursed Lip Breathing – shifts breathing pattern and

inhibits dynamic airway collapse.
Posture techniques – forward leaning reduces respiratory
effort, elevating depressed diaphragm by shifting abdominal
contents.
Diaphragm Breathing – Some patients with extreme air trapping
and hyperinflation have increased WOB with this technique
Postural Draining – valuable in patients who produce more than
30cc/24 hours - Coughing techniques
Pursed Lip Flutter Device
Postural Drainage Diaphragmatic
Positions Breathing
 Bronchial hygiene techniques

Postural drainage
Percussion & vibration
Directed cough
Forced expiratory technique (huff cough)
Active cycle of breathing
Autogenic drainage
Positive expiratory pressure
Incentive Spirometry
 Vibratory PEP

Flutter device
Acapella
What does ATS-ERS & GOLD Say?

A minimum of 20 sessions should be given

At least three times per week
Twice weekly supervised plus one unsupervised home
session may also be acceptable.
Once weekly sessions seem to be insufficient
Each session to last 30 minutes
High-intensity exercise (>60% of maximal work rate) produces
greater physiologic benefit and should be encouraged; however,
low-intensity training is also effective for those patients who
cannot achieve this level of intensity
 Nutritional supplementation

Energy dense foods

Well distributed during the day
No evidence of advantage of high fat diet
Patients experience less dyspnea carbohydrate rich
supplement
after than fat rich supplement. (probably due to delayed
gastric emptying)
Daily protein intake should be 1.5 gm/kg for positive balance
 What to give…….
Small Frequent Meals

High-calorie snacks- creamy, rich puddings, crackers with

peanut butter, dried fruits and nuts.
Beverages- milk-shakes, regular milk and high-calorie fruit juices,
Breads and Cereals
Pep up Your Protein- milk or soy protein powder to mashed potatoes,
gravies, soups and hot cereal
Choose High-Calorie Fruits- bananas, mango, papaya, dates, dried
apples or apricots instead of apples, watermelon
Remember Your Vegetables potatoes, beets, corn, peas, carrots
Healthy, Unsaturated Fats
Soups and Salads
 Psychological considerations

Screening for anxiety and depression should be part of

the initial assessment.
Mild or moderate levels of anxiety or depression related to the
disease process may improve with pulmonary rehabilitation
Patients with significant disease should be
psychiatric for professional care.
referred appropriate
Outcome Assessment

Providing patients with an opportunity to give

feedback about the program is a useful
measure of quality control.

Patient feedback also allows coordinators to

evaluate the components of pulmonary
rehabilitation that patients find most useful.

The questionnaire should also provide

patients
with a variety of answering options

Exercise capacity measurement

 Pulmonary Rehab. in Resource Poor
Settings

Assess the patient with spirometry, saturation, 6MWT, weight/FFMI

by biometric impedance, and bone density by sonography, AQ 20
and PHQ questionnaire
Treatment of osteoporosis and dietary advice by the physician
Exercise training by the physician or a trained staff, or an assistant at
the time of enrolment for 30 minutes
The exercise should simulate the patient’s home environment
The endurance and strength training can be done by walking/
cycling, walking uphill/climbing stairs and straight leg raise,
respectively
Pulmonary Rehab in Resource Poor
Settings……..

The exercise should be guided by his ability to tolerate exercise and

6MWT with periods of rest if desired. The speed and distance
should be increased gradually
The patient can be educated about breathing techniques by the
physician/assistant
The patients should exercise twice in a day for 30 minutes for at
least 5 to 6 days in a week
The patient may be given a diary to maintain
The patient may follow up once in a week or 15 days for
reinforcement/increment/supervision of exercises