Chapter 50 Cardiopulmonary Rehabilitation

Objectives State the definition and general goals of pulmonary rehabilitation programs. Describe the rationale for exercise conditioning and psychosocial support of patients with chronic pulmonary disease. Describe how to evaluate and select patients for pulmonary rehabilitation. Describe pulmonary rehabilitation program design including format and content.

Objectives (cont.) List the educational content to be addressed in a pulmonary rehabilitation program. Describe the implementation of a pulmonary rehabilitation program including staffing, facilities, scheduling, class size, equipment, and costs. Describe the outcome measures that can be used to evaluate pulmonary rehabilitation programs. Identify the potential hazards associated with pulmonary rehabilitation.

Definition and Goals Defined as the restoration of the individual to the fullest medical, mental, emotional, social, and vocational potential The overall goal is to maximize functional ability and minimize the impact of the disability. Other goals are to control symptoms and improve the overall quality of life.

Historical Perspective In 1951, Alvan Barach recommended reconditioning programs for chronic lung disease patients. In 1962, Pierce and associates published data that confirmed the value of reconditioning. Gradually the medical community came to appreciate the value of pulmonary rehab for patients with COPD and other disorders.

Scientific Basis Physical reconditioning Physical activity increases energy demands. Poor conditioning of muscles leads to inefficient use of oxygen and excess acid production. Pulmonary rehab aims to recondition the muscles and increase exercise tolerance.

Scientific Basis (cont.) Psychosocial support COPD can negatively affect the patient’s overall outlook and reduce motivation. Patients with COPD often have anxiety and stress. Psychosocial support in combination with physical reconditioning is needed to cause the best possible outcome.

Structure of a Pulmonary Rehab Program Program goals and objectives

Structure of a Pulmonary Rehab Program (cont.) Patient evaluation Patient evaluation begins with a complete patient history. Next, a complete physical examination is done. A chest radiograph, CBC, and ECG may be needed. Pulmonary function testing and exercise evaluation are often needed.

Structure of a Pulmonary Rehab Program (cont.) Patient evaluation (cont.) Contraindications include Patients who cannot perform the test Those with severe pulmonary hypertension Those with hypertension Those with neuromuscular disease Those with untreated or unstable asthma Those with angina with exercise

Structure of a Pulmonary Rehab Program (cont.) Patient selection

Structure of a Pulmonary Rehab Program (cont.) Program design Open-ended designs allow the patient to enter the program and progress through it until he or she achieves certain goals. Closed designs use a set time period to cover the program content. Classes meet 1 to 3 times per week for 6 to 16 weeks.

Structure of a Pulmonary Rehab Program (cont.) Format Long-term improvements are most likely to occur if planned follow-up is completed. Follow-up must be ongoing and available to all patients who complete the program.

Structure of a Pulmonary Rehab Program (cont.) Content

Structure of a Pulmonary Rehab Program (cont.) Physical reconditioning Consists of an exercise prescription with target heart rate based on the initial evaluation For most patients, an initial target heart rate is 20 beats/min above resting rate.

Structure of a Pulmonary Rehab Program (cont.) Physical reconditioning (cont.) The exercise prescription includes the following: Lower extremity aerobic exercises Timed walking (6- or 12-minute walk) Upper extremity aerobic exercises Ventilatory muscle training using progressive resistance

Structure of a Pulmonary Rehab Program (cont.)

Structure of a Pulmonary Rehab Program (cont.) Educational component Respiratory structure, function, and pathology Breathing control methods Methods of relaxation and stress management Exercise techniques and personal routines

Structure of a Pulmonary Rehab Program (cont.) Educational component (cont.) Bronchial hygiene techniques Home O2 and aerosol therapy Medications Dietary guidelines Recreation and vocational counseling

Structure of a Pulmonary Rehab Program (cont.) Psychosocial and behavioral component Emotional stress is a common problem for a patient with chronic lung disease. Experts can be brought in to help patients cope with their anxieties and sources of stress.

Structure of a Pulmonary Rehab Program (cont.) Staffing Pulmonary rehabilitation is a multidisciplinary endeavor. Staff conducting the program should be certified in basic and advanced life support.

Structure of a Pulmonary Rehab Program (cont.)

Structure of a Pulmonary Rehab Program (cont.) Facilities The facility must be easy to reach, be accessible to public transportation, and have available parking. Rooms should be spacious and comfortable with adequate lighting and ventilation. A room for counseling is helpful.

Structure of a Pulmonary Rehab Program (cont.) Scheduling Class times need to be scheduled at a time most convenient for the patients. Traffic patterns, bus schedules, and availability of rides are important factors to consider. Class size The ideal class size is 3 to 15 patients.

Structure of a Pulmonary Rehab Program (cont.) Equipment Class room equipment to facilitate teaching is needed. Blackboard or flipchart 35-mm projector or PowerPoint projector Formal learning packages

Structure of a Pulmonary Rehab Program (cont.) Equipment (cont.) Physical reconditioning equipment is needed. Stationary bicycles, treadmills, rowing machines Pulse oximeters Inspiratory resistance devices Emergency O2 should be in the room.

Structure of a Pulmonary Rehab Program (cont.)

Structure of a Pulmonary Rehab Program (cont.) Program results

Structure of a Pulmonary Rehab Program (cont.) Potential hazards Cardiovascular abnormalities Blood gas abnormalities Muscular abnormalities Miscellaneous Exercise-induced asthma Hypoglycemia Dehydration

Structure of a Pulmonary Rehab Program (cont.) Cardiac rehabilitation A comprehensive exercise and educational program designed for patients with cardiovascular diseases Goals are to improve heart health and work capacity, weight loss, and return to work.