PULMONARY REHABILITATION BY:- DR.HIMANI PARIKH (M.P.T.,CARDIO-PULMONARY)

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

FOCUS Multidisciplinary: Pulmonary rehabilitation programs utilize expertise from various healthcare disciplines that is integrated into a comprehensive, cohesive program tailored to the needs of each patient. Individual: Patients with disabling lung disease require individual assessment of needs, individual attention, and a program designed to meet realistic individual goals. Attention to physical and social function: To be successful, pulmonary rehabilitation pays attention to psychological, emotional, and social problems as well as physical disability, and helps to optimize medical therapy to improve lung function and exercise tolerance.

Interdisciplinary team of health-care professionals in PR Physician. Nurse. Respiratory therapist. Physical therapist. Occupational therapist. Psychologist.

Goals of pulmonary rehabilitation Reduce symptoms Decrease disability Increase participation in physical and social activities Improve overall quality of life Maintain long-term benefits through changes in life style Have some health economic advantages.

Selection Rehabilitation should be considered at all stages of disease progression when symptoms are present and not at a predetermined level of impairment. This would usually be Medical Research Council (MRC) dyspnoea scale grade 3 (the patient walks slower than contemporaries on the level because of breathlessness, or has to stop for breath when walking at own pace.

Common lung conditions COPD which includes chronic bronchitis and emphysema Asthma Bronchiectasis Cystic fibrosis Interstitial lung disease Restrictive chest wall disease Pulmonary hypertension Obesity-related respiratory disease Lung cancer

Setting Pulmonary rehabilitation is effective in all settings, including (1) hospital inpatient (2) outpatient (3) the community (4) patient's home

Programme content Outpatient programmes should include a minimum of 6 weeks of physical exercise, disease education, and psychological and social intervention. Physical aerobic training, particularly of the lower extremities (brisk walking or cycling), is essential. Upper limb and strength-building exercise can also be included. Exercise prescription should be individually assessed. Training intensity should usually be 60-70% of maximal walking speed achieved on a 6min. Walk test. Training frequency should involve three sessions (20-30 minutes) per week.

CONTRAINDICATION OSTEOPOROSIS UNSTABLE ANGINA MYOCARDIAL INFARCTION

GENERAL EXERCISE TRAINING Pulmonary rehab exercises involve your heart, lungs and respiratory functioning.  Emphasize Walking-Walking provides one of the most convenient ways to get cardiovascular exercise and has the lowest dropout rate of all physical activity, according to the American Heart Association. It provides an isotonic exercise that increases muscular strength, endurance, tone and cardiovascular health. Remember to walk only after rest periods, not when tired or after other exercises. While wearing properly-fitted walking shoes, start walking at a comfortable pace for two minutes down the hospital corridor, three times daily. When at home, walk indoors for five minutes, four times daily. Gradually increase your intensity and duration to walk once daily for 20 minutes.

Include Gentle Stretches-Pulmonary rehab exercises need to include gentle stretches as part of a warmup routine. Properly warming up for five minutes plays a key role in reducing injury by preparing your muscles for your exercise routine and gradually increasing your breathing and heart rate. Warm muscles improve flexibility. Start by doing some hamstring stretches. Sit with both legs extended in front of you, toes pointing upward. Gently lower your upper body forward until you feel a mild stretch along the backside of your knees. Hold this stretch for 10 seconds. Slowly return to the original position. Relax for 10 seconds. Repeat this exercise five times.

Stationary Bicycles-Stationary biking can provide continuous, rhythmic motion needed as a pulmonary rehab exercises. It provides one of the best ways to start a new exercise program whether you are recovering from pulmonary surgery or injury. Start biking at a slow, comfortable pace for three minutes, three times daily. After three minutes, start pedaling faster for two minutes. Pedal only until you become slightly breathless but can still carry on a conversation. Gradually increase to exercising one time daily for 20 minutes.

Lengthen Shortened Muscles-Many individuals with pulmonary difficulties, such as chronic obstructive pulmonary disease, resort to poor, leaning-forward posture to relieve symptoms. In this case, pulmonary rehab exercises need to work on strengthening the pectoral muscles, recommends the Australian Lung Association. Do some triceps stretches by either standing or sitting upright. Lift your right arm and place your hand on your lower neck area, between your shoulder blades. Place your elbow next to your ear. Place your left hand onto your right elbow and gently pull your elbow closer to your head to increase the stretch. Hold this stretch for 15 seconds. Remove your hand and return both arms to the original position. Relax for 10 seconds. Repeat this exercise 10 times. Do the exercise again by stretching your left triceps.

IN CASES OF COPD- Lower-body exercises: Most centres provide a regimen of exercises that centres on leg workouts. These exercises vary from simple walking on a treadmill or around a track to more intense stair climbing. Most of the proven benefits of pulmonary rehab come from studies in people doing leg exercises.

Upper-body exercises: The muscles in the upper body are important for breathing, as well as daily activities. Arm and chest exercises might include turning a crank against resistance, or simply repetitively lifting the arms against gravity.

Exercises for breathing muscles: Breathing through a mouthpiece against resistance during pulmonary rehab may increase the strength of the breathing muscles. These exercises are infrequently used, but may be helpful for people with very weak breathing muscles.

Education in Pulmonary Rehab for COPD Many pulmonary rehab centers offer group or one-on-one education sessions to help people learn to better manage their COPD. Teaching sessions generally focus on: Understanding your medication treatment plan. This includes using inhalers the right way and on a consistent schedule. How to understand and use oxygen therapy. Quitting smoking and staying away from cigarettes after quitting. Eating a healthy diet.

Psychological Support People with severe COPD are at risk for emotional disturbances, like depression and anxiety. Mood problems can interfere with normal life and relationships by making people less interested in pleasurable activities, including sex. Some pulmonary rehab centers offer relaxation training and other mood-modifying treatments, such as counseling. For many people, the regular exercise from pulmonary rehab alone is effective at reducing the negative mood symptoms of COPD.

Benefits Most people who complete a pulmonary rehab course feel better at the end. They are able to perform more activity without becoming short of breath, and they report their overall quality of life is better.

The BTS statement on pulmonary rehabilitation (BTS, 2001) recommends that pulmonary rehabilitation must contain aerobic exercise, and may contain upper and lower limb strength exercises. The BTS also recommend that exercise frequency should be three times a week for 30 minutes.

Endurance Training COPD patients participating in endurance training had lower peak work rates and oxygen uptake than normal subjects; however these variables improved with training. Subjects with COPD showed different physiological adaptations to endurance training than the normal subjects COPD subjects showed an increase in peak oxygen extraction but no significant change in heart rate, ventilation or oxygen delivery. This suggests changes from training take place at a skeletal muscle level rather than a change in ventilatory response to exercise. Sala et al., 1999.

ATS/ERS Statement on PR 2006

What do we do in Tower Hamlets? 8 week rolling programme 2 hours Twice a week Followed by 8 week programme of maintenance Once a week Exercise- individual programme aimed at meeting clients personal goal Strength Endurance Education Multi professional Coping strategies Improve knowledge of how lung disease affects you Cup of tea!

Pulmonary rehabilitation in 8 locations across the borough Classes in leisure centres, hospitals, GP practices, social clubs, community centres Bengali speaking rehab support workers Multi-disciplinary team Home programme for patients unable to attend local sites

So what do we actually do? Patients referred by GP’s, consultants/ hospital Dr’s, practice nurses, respiratory nurse specialists, physios. Initial assessment Suitable for PR medical history cardiovascular stability medical management optimised exercise capacity anxiety and depression quality of life

THEN……. Patient and physiotherapist discuss goals Exercises tailored to patient to help meet goal Exercise twice a week at PR Exercise at least three times/ week Home exercise booklet and diary Reassessed at eight weeks

BRONCHIAL HYGIENE THERAPY It includes- ACBT It is a flexible method for airway clearance, can be used with or without assistance. It is a cycle of Breathing control Thoracic expansion exercise Forced expiration techniques

Autogenic drainage: It is a breathing tech that uses expiratory air flow to mobilize the bronchial secretion. It’s a self drainage method. It consist of 3 phases: phase-1.Unsticking, phase-2.Collecting, phase-3.Evacuating.

Postural Drainage Postural Drainage consists of positioning the patient to allow gravity to assist the drainage of secretions from specific areas of the lungs. An adequate intake of fluid ( it allowed decreases the viscosity of the secretions). DURATION:- If PD is used, each position should be maintain for 15-20 mins. If PD is used in conjunction with another techniques the time of each position 3-5 mins is sufficient.

The most affected lobe should be addressed with the first treatment of the day, with the other affected area at a subsequent treatment. Secretions may not be mobilized immediately after the treatment but possibly half - one hour later (Frownfelter,1987).

Precautions PD should never be carried out immediately before or after a meal for the patient will feel either too tired to enjoy his meal or nauseated & perhaps vomit.

Manual Techniques Percussion-Percussion is performed with the aim of loosening retained secretion from the airway so they may be removed by the suctioning or expectoration. It is performed during both expiration – inspiration. The sound of percussion should be hollow which is produced by cupped hands.

If the size of infant does not allow to use of full hand, percussion may be done manually with 3-4 fingers, with middle finger ‘TENTED’ or thenar or hypothenar surfaces of hand [Crane-1990]. The rate of manual percussion is between 100-480 times/min [Imle -1989]. Electric or pneumatic percussor [Bauer et al-1994] are also available for adult & older pediatric population.

VIBRATION & SHAKING- Vibration involves a gentle, high-frequency force, where as shaking is more vigorous in nature. Vibration and shaking are performed with the aim of moving secretion from the lung periphery to the larger airways. They are performed only during expiration phase, starting with peak and continuing until the end of expiration. The compressive forces follow the movement of chest wall. The frequency of manual vibration is 12 -20 Hz. shaking is 2 Hz [Gormezano 1972 & Bateman,1981]

The mechanical devices (1) Small mechanical vibrator – which are cheaper & may help clearance from lung periphery (2) Mechanical vibrator [Bauer et al,1994] (adults) (3) Padded electric toothbrush (infant) [Crane,1990]

Manual hyperinflation The technique of manual hyperinflation is used in patient with artificial airway who are mechanically ventilated or who have a tracheotomy. This method of airway clearance promotes mobilization of secretion and reinflates collapsed area of lungs. Ideally three persons are required to treat a ventilated patient with treat a ventilated patient with manual hyperinflation, one to hyperinflate the patient, one to perform appropriate manual techniques and one to perform the suction – depending on the unit this will be anaesthetist,physiotherapist or nurse. Two persons can also perform this treatment. The co-ordination between these persons is necessary to achieving satisfactory results.

Treatment with MH One caregiver squeezes the manual ventilation bag slowly to inflate the lungs. a pause is maintained momentarily at peak of inflation to fill under expanded area of the lungs release of the bag should be required resulting in a high expiratory flow rate (Clement 1968). Second caregiver provides thoracic compression with shaking or vibration to assist with the mobilization of secretion. In a patient who is breathing spontaneously “bag squeezing “ with the manual ventilation bag should be timed to augment the patient inspiratory effort making vibration more effective (Imle 1989). After about 6 cycles of inspiration/expiration, the patient airway is suctioned using sterile techniques. The length of treatment depends on the amount of secretion present in the airways and area of lung affected. Manual hyperinflation may be performed with intubated infants or children using an appropriately sized ventilation bag.

Suction Suction may be indicated to remove these secretions. Suction should never be routine, only when there is an Indication. [Carroll,1994]. Indication -Intubated pt. -Inability to cough effectively. -Sputum plugging. -To assess tube patency. If the normal mechanism such as ciliary action are compromised, alveolar ventilation may be impaired. -Unconscious pt. or neurological impaired pt.

Contraindication: Nasal polyps Congenital deformity or old # of nose,csf leak or bleeding of the nose/ear [ Jenkin,1996] Unstable cardio-vascular system Undrained pneumothorax Hemoptysis of unknown origin Acute face, neck or head injury Severe bronchospasm

OTHER DEVICES USED ARE- HFCWO Common Conditions/Situations for HFCWO Patient with evidence of retained secretions Independent patient without access to a caregiver Patient with reduced mobility Patient who cannot tolerate Trendelenburg positioning Fragile patient who cannot tolerate the force of CPT

PEP valve Positive Expiratory Pressure Action: splints airways during exhalation Can be used with aerosolized medications Technique dependent Portable Time required: 10 - 15 minutes

Positive Expiratory Pressure (PEP) Active expiration against a variable flow resistance Helps move secretions into larger airways Filling underaerated or nonaerated segments via collateral ventilation Preventing airway collapse during expiration Subsequent huff or FET maneuver allows patient to generate the flows needed to expel mucus Aerosol drug therapy may be added to a PEP session to improve the efficacy of bronchodilator

PEP (Flutter Valve) Oscillating PEP Combines the techniques of EPAP with high- frequency oscillations at the airway opening Actively exhaling into the pipe creates a positive expiratory pressure between 10 – 25 cm H2O Changing the angle of the device alters the oscillations

FLUTTER

Action: loosens mucus through expiratory oscillation; positive expiratory pressure splints airway Portable May not be effective at low airflows Time required: 10 - 15 minutes

PEP Oscillating PEP acapella® Combines the techniques of EPAP with high- frequency oscillations at the airway opening

In-Exsufflator Action: creates mechanical “cough” through the use of high flows at positive and negative pressures Positive/negative pressures up to 60 cm of water Used independently or with caregiver assistance Technique independent Portable

Intrapulmonary Percussive Ventilation (IPV) Action: “percussion” on inspiration, passive expiration; dense, small particle aerosol Used independently or with caregiver supervision Used with aerosolized meds Technique dependent May not be well tolerated by patient Time required: 20 minutes

REFRENCES Textbook of medical Physiology - By Guyton & Hall Chest, Heart & Vascular Disorder for Physiotherapists- By Cash Physiotherapy for Respiratory & Cardiac problems- By Jennifer Pryor & S Ammani Prasad Physiotherapy in Respiratory Care- By Alexandra Hough Principles & Practice of Cardiopulmonary Physical Therapy- By Donna Frownfelter Cardiopulmonary Physical Therapy- By Scot Irwin & Jan Stephen Tecklin

Lacasse Y, Goldstein R, Lasserson TJ, et al; Pulmonary rehabilitation for chronic obstructive pulmonary disease. CochranKillian, KJ et al. (1992). Exercise capacity and ventilatory, circulatory, and symptom limitation in patients with chronic airflow limitation. The American Review of Respiratory Disease, 146(4), 935-940. Jobin et al. (1998). COPD: cappilarity and fiber-type characteristics of skeletal muscle. Journal of Cardiopulmonary Rehabilitation, 18(6), 432-427.

NICE CG101 Chronic obstructive pulmonary disease (update) 2010. Sala (1999). Effects of endurance training on skeletal muscle bioenergetics in COPD. American Journal of Respiratory and Critical Care Medicine, 159(6), 1726-34. e Database Syst Rev. 2006 Oct 18;(4)

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