1. Pulmonary Rehabilitation In COPD
Dr. AKM Mosharraf Hossain
Internist & Pulmonologist
Mosharraf Hossain
06/11/2010

2. What is Pulmonary Rehabilitation?
Pulmonary rehabilitation is an essential component of the comprehensive management of COPD patients
“…a multidisciplinary programme of care for patients with chronic respiratory impairment that is individually tailored and designed to optimise each patient’s physical and social performance and autonomy.” (NICE)
Pulmonary rehabilitation can change outcomes that predict survival
Mosharraf Hossain
06/11/2010

3. Global impact of copd
The estimated prevalence of COPD varies from 7 to 19% in several well-conducted studies,
The total number of cases of COPD in the world approximates 280 million persons,
COPD was the 6th cause of death worldwide in 1990, by 2002 the ranking had risen to 5th,
by 2030, COPD would become the 4th leading cause of death worldwide (WHO),
The burden of COPD in Asia is currently greater than that in Western countries.
Mosharraf Hossain
06/11/2010

4. Percent Change in Age-Adjusted Death Rates, U.S., 1965-1998
Proportion of 1965 Rate
3.0
Coronary
Heart
Disease
Stroke
Other CVD
COPD
All Other
Causes
2.5
2.0
1.5
1.0
0.5
–59%
–64%
–35%
+163%
–7%
Source: NHLBI/NIH/DHHS

5. Copd is a treatable disease
Mosharraf Hossain
06/11/2010

6. GOLD Therapy at Each Stage of COPD
Gold Guidelines: COPD Treatment by Stage
All Stages
Active reduction of risk factor(s): influenza vaccination
Add short-acting bronchodilator (when needed)
Moderate through Very Severe
Add regular treatment with one or more long-acting bronchodilators (when needed):
Add pulmonary rehabilitation
Severe through Very Severe
Add inhaled glucocorticosteroids if repeated exacerbations
Add long term oxygen if chronic respiratory failure
C o n s i d e r s u r g i c a l t r e a t m e n t s
L u n g T r a n s p l a n t a t i o n
L u n g V o l u m e R e d u c t i o n S u r g e r y ( L V R S )
Key Communication Points:
B r o n c h o d i l a t o r s a r e c e n t r a l t o t h e s y m p t o m a t i c m a n a g e m e n t o f C O P D a c r o s s a l l s t a g e s .   T h e y c a n b e i n h a l e d a s a e r o s o l s p r a y s o r v i a n e b u l i z a t i o n
T h e e f f i c a c y o f i n h a l e d g l u c o c o r t i c o s t e r o i d s c o n t i n u e s t o b e u n d e r s t u d y , h o w e v e r s h o r t - t e r m b e n e f i t h a s b e e n d e m o n s t r a t e d .  
ALA COPD Fact Sheet, Global Initiative for Chronic Obstructive Pulmonary Disease.  Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease, 2003.
GOLD Therapy at Each Stage of COPD
FEV1/FVC <0.70
FEV1 <30% predicted or FEV1 <50% predicted plus chronic respiratory failure
FEV1/FVC <0.70
FEV1 ≥80% predicted
FEV1/FVC <0.70
30% ≤FEV1 <50% predicted
FEV1/FVC <0.70
50% ≤FEV1 <80% predicted
I: Mild
II: Moderate
III: Severe
IV: Very Severe
Active reduction of risk factor(s): influenza vaccination Add short-acting bronchodilator (when needed)
Add regular treatment with one or more long-acting bronchodilators Add pulmonary rehabilitation
Add inhaled glucocorticosteroids if repeated exacerbations
Add long-term oxygen if chronic respiratory failure
Consider surgical treatments
Global Initiative for Chronic Obstructive Lung Disease (GOLD). NHLBI/WHO Workshop report. 6

7. benefits Improved exercise capacity (Evidence A)
Improved health-related quality of life (Evidence A)
Reduced perceived intensity of breathlessness (Evidence A)
Reduced hospitalisations and length of stay (Evidence A)
Reduced anxiety and depression associated with COPD (Evidence A)
Increased survival (Evidence B)
Benefits probably extend well beyond the period of rehab, especially if exercise is maintained at home (Evidence B)
Improved psychological wellbeing (Evidence C)
Mosharraf Hossain
06/11/2010

8. Development of Disability in COPD
The decline in lung function may go unnoticed initially as people avoid exertion for dyspnoea
Up to 50% of FEV1 may be lost before a person develop significant symptoms
Significant disability develops late in the course of the disease when reversal of airway obstruction is not possible.
Dyspnoea , Limb muscle dysfunction, hypoxaemia, poor nutrition, steroid myopathy and loss of confidence may contribute to disability
Mosharraf Hossain
06/11/2010

9. Vicious cycle of Disability
Mosharraf Hossain
06/11/2010

10. Pulmonary rehabilitation components
General exercise training
Breathing retraining
Education
Nutritional advice
Psychological support
Mosharraf Hossain
06/11/2010

11. Exercise Training
Pulmonary rehabilitation general exercise training include:
a) Upper limb endurance training,
b) Upper limb strenthening training,
c) Lower limb endurance training,
d) Lower limb strenthening training,
e) Flexibility and stretching exercise
f) Balancing exercise
Usually 4-10 weeks, daily to weekly
Lower limb training improves exercise tolerance though no effect on measured lung function
Upper limb training improves arm strength and reduces ventilatory demand
Mosharraf Hossain
06/11/2010

12. Flexibility exercise
Flexibility of the joints in the spine (particularly the thoracic spine) is important for people with respiratory disorders to enable thoracic mobility when breathing.
Gently rotate the trunk side to side as far as possible
Mosharraf Hossain
06/11/2010

13. Stretching pectoral muscles
Stand in the corner or in a doorway with your hands at shoulder level and your feet away from the corner or doorway
Lean forward until a comfortable stretch is felt across the chest
Mosharraf Hossain
06/11/2010

14. Stretching hamstring muscles
Sit on the bed
■ Lean forward and slowly straighten your knee until you feel a stretch at the back of your thigh
Mosharraf Hossain
06/11/2010

15. Stretching triceps
Lift your arm so that your elbow is next to your ear.
Place your hand between your shoulder blades.
Gently push your elbow back with your other hand until you feel a stretch.
Mosharraf Hossain
06/11/2010

16. Upper limb endurance training
Hold a bar with hands at knee height.
Lift bar above head, then lower.
Breathe in while lifting bar up and out while lowering bar down.
Mosharraf Hossain
06/11/2010

17. Upper limb endurance training
Start with arms by your sides.
Lift your arms until they are at shoulder height (breathe in while you do this).
Move arms forwards to meet in the middle, keeping elbows straight (breathe out while you do this).
Reverse the movement until the arms are horizontal at shoulder height (breathe in while you do this).
Return arms to your side again (breathe out while you do this).
Mosharraf Hossain
06/11/2010

18. Upper limb strength exercise
Hold a weight in each hand at shoulder height.
With one arm, lift the weight straight up and down.
Breathe in while lifting the weight up, and breathe out while lowering the weight down.
Repeat the exercise with your other arm.
Fig 1: Arm exercise
Mosharraf Hossain
06/11/2010

19. Upper limb strength exercise
Start with your arms by your sides.
Bend your arm at the elbow to lift your hand towards your shoulder, then lower.
Repeat the exercise with your other arm.
Add hand weights as necessary.
This exercise can also be done in the sitting position.
Fig2: Biceps
Mosharraf Hossain
06/11/2010

20. Upper limb strength exercise
Start with holding a weight in each hand on your lap.
Lift both arms out to the side, but not above your shoulders (move your arms as if you were “spreading your wings”).
Keep your elbows slightly bent during the exercise.
Breathe in while you move your arms up, and breathe out as you lower your arms.
Fig3: Arm exercise
Mosharraf Hossain
06/11/2010

21. Lower limb endurance training
Mosharraf Hossain
06/11/2010

22. Lower limb strength training
Climbing stairs
Increase the number of steps.
Increase the height of the step (or walk up two steps at a time).
Carry a weight on your back.
Mosharraf Hossain
06/11/2010

23. Lower limb strength exercise
Knee extension sitting
Sit in a chair.
Straighten your knee.
Hold the knee straight for five seconds, and then relax.
Repeat for other leg.
Progression:
Add weights to legs.
Squats
Lean your back against a wall.
Squat down until your thighs are parallel with floor.
Slide up the wall to a standing position.
Start with only sliding down a short way.
Progression:
Increase depth of slide down.
Mosharraf Hossain
06/11/2010

24. Breathing retrainig
Retraining with breathing techniques which decrease breathing frequency, such as Yoga and pursed lip breathing, have in some studies led to increases in tidal volume and oxygen saturation, and a reduction in dyspnea.
Diaphragmatic breathing strenghthens diaphragm, reduces energy of breathimg; but conflicting evaluation shows increase work of breathing and dyspnoea
Mosharraf Hossain
06/11/2010

25. Purse lip breathing Sit down, straight but relaxed
Breathe in preferably through the nose
Purse lips slightly, as if whistle
Breathe out slowly through pursed lips
Do not force air out
Mosharraf Hossain
06/11/2010

26. Diaphragmatic breathing
Lie on your back in a bed with knees bent
Place one hand on abdomen, other hand upper chest
As you inhale through nose make your stomach move out
As you exhale through pursed lips let your stomach fall in
Your upper chest must remain as still as possible
Practice 3-4 times, 5-10 mins daily
Mosharraf Hossain
06/11/2010

27. yoga
The "complete breath" in yoga incorporates all three areas of your lungs, which helps 1)diaphragmatic breathing, 2) oxygenation of blood, 3) prevent air trapping in the lungs, and 4) relaxes the mind and body.
Mosharraf Hossain
06/11/2010

28. Location of training Hospital based Community based Home based
Mosharraf Hossain
06/11/2010

29. Hospital-based programs
Hospital based programs has the advantage of providing direct communication with respiratory physicians and other healthcare professionals.
This may be the most appropriate option for patients with very severe disease and/or complex comorbid conditions.
Sometimes provided for patients recovering from an acute exacerbation.
Mosharraf Hossain
06/11/2010

30. Community-based programs
Community-based programs are centre-based programs run in community settings (eg leisure centres; halls, health or rehabilitation centres; senior citizens centres or private practices). 
These programs may be run by hospital/community health staff, or
may use clinicians in community practices (eg GPs, practice nurses, private practice clinicians).
Mosharraf Hossain
06/11/2010

31. Home training
Started within 1-2 weeks after commencing the supervised training program to allow any difficulties undertaking the home program to be discussed and resolved during the supervised period.
Performed on 2 or 3 days per week (i.e. in addition to the 2 or 3 days that the patient is attending the supervised training program). In total, the patient should exercise 4 or 5 days per week
Walking for 30 minutes at the same pace as in the supervised program.
Mosharraf Hossain
06/11/2010

32. Importance of Education
Education to improve compliance in medication, oxygen therapy, smoking cessation, nutrition, exercise, and health preservation.
Education in an interactive session is more effective than didactic teaching.
Education helps patients to become active participants in their health care
Mosharraf Hossain
06/11/2010

33. Use of Supplemental Oxygen
Oxygen saturation should be regularly monitored using a pulse oximeter
Patients who desaturate below an oxygen saturation of 88% during exercise training, despite the use of interval training, should be assessed to determine the benefit of supplementary oxygen. 
Assessment for supplementary oxygen is done by providing oxygen via nasal prongs at a flow rate of 2-4 L/min. If the patient shows improved oxygen saturation or improved exercise tolerance or reduced dyspnoea when using oxygen, supplementary oxygen should then be given in future exercise training sessions.
Specific exercises that often cause desaturation include moderate to high intensity walking, climbing stairs, doing step-ups and sit-to-stand.
Patients receiving LTOT, increase the flow rate by 1-2 L/min, above the prescribed flow rate, when the patient is exercising.
Mosharraf Hossain
06/11/2010

34. Psychological components
COPD is associated with anxiety and depressive symptoms which may interfere with activities of daily living (ADL’s) and sexuality
Protracted psychological counselling is not necessary
About 15 to 20 rehabilitation sessions that include education, exercise breathing techniques, and relaxation techniques are more effective
Occasionally, it may be necessary to administer short courses of antidepressant medications
Mosharraf Hossain
06/11/2010

35. Nutritional counselling
Both overweight and underweight can be a problem
25% of patients with moderate to severe COPD show a reduction in BMI which is an independent risk factor for mortality in COPD
Reasons for difficulty eating should be explored: poor dentition, dyspnoea whilst eating
Frequent small meals with low carbohydrate are usually advised.
Mosharraf Hossain
06/11/2010

36. OUTcome Assessment Exercise capacity measurement
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
Mosharraf Hossain
06/11/2010

37. Pulmonary rehabilitation?
Comprehensive COPD care
Smoking cessation ?
Pulmonary rehabilitation?
Non-invasive ventilation?
Mosharraf Hossain
06/11/2010

38. All the best
Mosharraf Hossain
06/11/2010

39. Mosharraf Hossain
06/11/2010