Pulmonary Rehabilitation pptx

Dr Subin Ahmed MDAssistant Professor

AIMS

Art of medical practice wherein individually tailored multidisciplinary program is formulated, which through accurate diagnosis, therapy, emotional support and education; stabilizes or reverses both physio and psychopathology of pulmonary disease in attempts to 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 reduce symptoms, optimize functional status, increase participation, and reduce health care costs through stabilizing or reversing systemic manifestations of the disease

ATS – ERS definition (2005)

Charles Denison (1895): After recovery from PTB; Walking each day- Made him feel better; Increased exercise tolerance; Reduced respiratory and pulse rate

Albert Haas (1932): Carrying heavy books; Noticed weight gain & Feeling of well being

Haas and Cordon (1969): first showed benefits of pulmonary rehabilitation over conventional therapy in a cohort study

ACCP (1974): definition of pulmonary rehabilitation ACCP (1979): Detailed monograph on pulmonary rehabilitation

in JAMA

The Timeline………

Pulmonary Rehabilitation components

Psychological support

Nutritional advice

Breathing Retraining

Education

General exercise training

Outcome Assessmen

t

PATHOPHYSIOLOGY

• Peripheral Muscle dysfunction• Respiratory muscle dysfunction• Nutritional abnormalities• Cardiac impairment• Skeletal disease• Sensory defects• Psychosocial dysfunction

Consequences of Respiratory Disease

• Deconditioning• Malnutrition• Effects of hypoxemia• Steroid myopathy or ICU neuropathy• Hyperinflation• Diaphragmatic fatigue• Psychosocial dysfunction from anxiety, guilt, dependency and

sleep disturbances

Mechanisms for these morbidities

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.

Goals of Pulmonary Rehabilitation

Improved Exercise Capacity Reduced perceived intensity of dyspnea Improve health-related QOL Reduced hospitalization and LOS Reduced anxiety and depression from COPD Improved upper limb function Benefits extend well beyond immediate period of training

Benefits of Pulmonary Rehabilitation

Obstructive DiseasesRestrictive Diseases

InterstitialChest WallNeuromuscular

Other Diseases COPD patients at all stages of disease appear to benefit from

exercise training programs improving with respect to both exercise tolerance and symptoms of dyspnea and fatigue (GOLD)

Patient Selection

Patients with severe orthopedic or neurological disorders limiting their mobility

Severe pulmonary arterial hypertension Exercise induced syncope Unstable angina or recent MI Refractory fatigue Inability to learn, psychiatric instability and disruptive behavior

Exclusion criteria

Outpatient Inpatient Home Community Based Choice varies depending on

- Distance to program- Insurance payer coverage- Patient preference- Physical, functional,

psychosocial status of patient

Setting for Pulmonary Rehabilitation

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

Education……

Benefits of Exercise training

Exercise training

Pathophysiologicalabnormality

Benefits of exercisetraining

Decreased lean body mass Increases fat free mass

Decreased TY1 fibers Normalizes proportion

Decreased cross sectional area of muscle fibers

Increases

Decreased capillary contacts to muscle fibers

Increases

Decreased capacity of oxidative enzymes

Increases

Increased inflammation No effect

Increased apoptotic markers No effect

Reduced glutathione levels Increases

Lower intracellular pH, increased lactatelevels and rapid fall in pH on exercise

Normalization of decline inpH

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

Exercise training

Walking Treadmill Stationary bicycle Stair climbing Sit & Stand

Lower extremity exercise

Arm cycle ergometer Unsupported arm lifting Lifting weights

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

Arm exercise training

Resistive IMT:Patient breaths through hand held device with which resistance to flow can be increased gradually

Threshold IMT:Patient breaths through a device equipped with a valve which opens at a given pressure.

• Difficult to standardize the load• Patients may hypoventilate• Leads to increased Pulmonary

Arterial Pressure and fall in oxygen tension

• Easily quantitated and standardized

Ventilatory muscle training

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

Chest Physical Therapy & Breathing Retraining

Pursed Lip Flutter Device

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

Bronchial hygiene techniques

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 (ATS-ERS)

What does ATS-ERS & GOLD Say?

Both upper and lower extremity training should be utilized Lower extremity exercises like treadmill and stationary bicycle

ergometer & Arm exercises like lifting weights and arm cycle ergometer are recommended

The combination of endurance and strength training generally has multiple beneficial effects and is well tolerated; strength training would be particularly indicated for patients with significant muscle atrophy

Respiratory muscle training could be considered as adjunctive therapy, primarily in patients with suspected or proven respiratory muscle weakness

ATS-ERS

The minimum length of an effective rehabilitation program is 6 weeks. Daily to weekly sessions Duration of 10 minutes to 45 minutes per session Intensity of 50% of VO2 max to maximum tolerated Endurance training can be accomplished through continuous or

interval exercise programs. The latter involve the patient doing the same total work but divided into

briefer periods of high-intensity exercise, which is useful when performance is limited by other comorbidities

GOLD

Optimal bronchodilator therapy should be given prior to exercise training to enhance performance.

Patients who are receiving long-term oxygen therapy should have this continued during exercise training, but may need increased flow rates.

Oxygen supplementation during pulmonary rehabilitation, regardless of whether or not oxygen desaturation during exercise occurs, often allows for higher training intensity and/or reduced symptoms in the research setting. (ATS/ERS STATEMENT)

Additional considerations

NMES may be an adjunctive therapy for patients with severe chronic respiratory disease who are bed bound or suffering from extreme skeletal muscle weakness.

ATS/ERS Guidelines

Neuromuscular electrical stimulation (NMES)

Because NPPV is a very difficult and labor-intensive intervention, it should be used only in those with demonstrated benefit from this therapy

Further studies are needed to further define its role in pulmonary rehabilitation.

ATS/ERS guidelines

Non invasive mechanical ventilation

Why intervene? High prevalence and association with morbidity and mortality Higher caloric requirements from exercise training in pulmonary

rehabilitation, which may further aggravate these abnormalities (without supplementation)

Enhanced benefits, which will result from structured exercise training.

Nutritional Interventions

Increased activity related Energy expenditure Hyper metabolic state Decreased intake

Impairment of Energy balance Imbalance in Protein synthesis and breakdown

Loss of fat; Loss of weight : BMI < 21• 10% weight loss in 6 months• 5% weight loss in 1 month

Body composition abnormalities

Should be considered if :

BMI less than 21 kg/m2

Involuntary weight loss of >10% during the last 6 months or more than 5% in the past month

Depletion in FFM or lean body mass.

Caloric supplementation

Energy dense foods Well distributed during the day No evidence of advantage of high fat diet Patients experience less dyspnea after carbohydrate rich

supplement than fat rich supplement. (probably due to delayed gastric emptying)

Daily protein intake should be 1.5 gm/kg for positive balance

Nutritional supplementation

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

What to give……. Small Frequent Meals

Physiological intervention: Strength exercise Addition of strength training lead to increase in strength and mid

thigh circumference (measured by CT)Pharmacological intervention : Anabolic steroids Anabolic steroids Nandrolone decanoate - 50 mg for male; 25 mg for females; 2

Weekly for 4 doses Anabolic therapy alone increases muscle mass but not exercise

capacity


Growth hormone

rhGH 0.05 mg/kg for 3 weeks in addition to 35 Kcal/kg and 1gm protein/kg per day has shown to increase fat free mass

But does not improve muscle strength or exercise tolerance ( hand grip and maximal exercise ) and no change in well being of the patient.


Testosterone

Testosterone 100 mg weekly for ten weeks in men with low testosterone levels 320 ng/ml showed weight gain of 2.3 kg

Addition of exercise to testosterone has augmented weight gain to 3.3 kg

Physiological consequences and long term effects not studied


Increased calorie intake is best accompanied by exercise regimes that have a nonspecific anabolic action

Anabolic steroids in COPD patients with weight loss increase body weight and lean body mass; but have little or no effect on exercise capacity. (GOLD)

Pulmonary rehabilitation programs should address body composition abnormalities. Intervention may be in the form of caloric, physiologic, pharmacologic or combination therapy. (ATS/ERS STATEMENT)

What the Guidelines Say…..

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 psychiatric disease should be referred for appropriate professional care (ATS/ERS STATEMENT)

Psychological considerations

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

Current guidelines does not comment on maintenance & repeat rehabilitation

Yearly repeat rehabilitation program had shown: Short term benefits in the form of less frequent exacerbations

But no long term physiological effects on exercise tolerance, dyspnea & HRQL

Foglio K. Chest. 2001; 119:1696–1704

Maintenance rehabilitation &Repeat rehabilitation program

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

Pulmonary Rehab in Resource Poor Settings……..

THANK

YOU

What Does ACCP Say……..???

1. Recommendation: A program of exercise training of the muscles of ambulation is recommended as a mandatory component of pulmonary rehabilitation for patients with COPD. Grade of Recommendation: 1A

2. Recommendation: Pulmonary rehabilitation improves the symptom of dyspnea in patients with COPD. Grade of Recommendation: 1A

3. Recommendation: Pulmonary rehabilitation improves health related quality of life in patients with COPD. Grade of Recommendation: 1A

ACCP RECCOMENDATIONS (2007)

4. Recommendation: Pulmonary rehabilitation reduces the number of hospital days and other measures of health-care utilization in patients with COPD. Grade of Recommendation: 2B

5. Recommendation: Pulmonary rehabilitation is cost-effective in patients with COPD. Grade of Recommendation: 2C

6. Statement: There is insufficient evidence to determine if pulmonary rehabilitation improves survival in patients with COPD. No recommendation is provided.

7. Recommendation: There are psychosocial benefits from comprehensive pulmonary rehabilitation programs in patients with COPD. Grade of Recommendation: 2B


8. Recommendation: Six to 12 weeks of pulmonary rehabilitation produces benefits in several outcomes that decline gradually over 12 to 18 months. (Grade of Recommendation: 1A) Some benefits, such as health-related quality of life, remain above control at 12 to 18 months. (Grade of Recommendation: 1C)

9. Recommendation: Longer pulmonary rehabilitation programs (12 weeks) produce greater sustained benefits than shorter programs. Grade of Recommendation: 2C

10.Recommendation: Maintenance strategies following pulmonary rehabilitation have a modest effect on long-term outcomes. Grade of Recommendation: 2C


11.Recommendation: Lower-extremity exercise training at higher exercise intensity produces greater physiologic benefits than lower intensity training in patients with COPD. Grade of Recommendation: 1B

12.Recommendation: Both low- and high intensity exercise training produce clinical benefits for patients with COPD. Grade of Recommendation: 1A

13.Recommendation: Addition of a strength training component to a program of pulmonary rehabilitation increases muscle strength and muscle mass. Strength of evidence: 1A

14.Recommendation: Current scientific evidence does not support the routine use of anabolic agents in pulmonary rehabilitation for for patients with COPD. Grade of Recommendation: 2C


15.Recommendation: Unsupported endurance training of the upper extremities is beneficial in patients with COPD and should be included in pulmonary rehabilitation programs. Grade of Recommendation: 1A

16.Recommendation: The scientific evidence does not support the routine use of inspiratory muscle training as an essential component of pulmonary rehabilitation. Grade of Recommendation: 1B

17.Recommendation: Education should be an integral component of pulmonary rehabilitation. Education should include information on collaborative self-management and prevention and treatment of exacerbations. Grade of Recommendation: 1B

18.Recommendation: There is minimal evidence to support the benefits of psychosocial interventions as a single therapeutic modality. Grade of Recommendation: 2C


19.Statement: Although no recommendation is provided since scientific evidence is lacking, current practice and expert opinion support the inclusion of psychosocial interventions as a component of comprehensive pulmonary rehabilitation programs for patients with COPD

20.Recommendation: Supplemental oxygen should be used during rehabilitative exercise training in patients with severe exercise-induced hypoxemia. Grade of Recommendation: 1C

21.Recommendation: Administering supplemental oxygen during high-intensity exercise programs in patients without exercise-induced hypoxemia may improve gains in exercise endurance. Grade of Recommendation: 2C


22. Recommendation: As an adjunct to exercise training in selected patients with severe COPD, noninvasive ventilation produces modest additional improvements in exercise performance. Grade of Recommendation: 2B

23. Statement: There is insufficient evidence to support the routine use of nutritional supplementation in pulmonary rehabilitation of patients with COPD. No recommendation is provided.

24. Recommendations: Pulmonary rehabilitation is beneficial for some patients with chronic respiratory diseases other than COPD. Grade of Recommendation: 1B

25. Statement: Although no recommendation is provided since scientific evidence is lacking, current practice and expert opinion suggest that pulmonary rehabilitation for patients with chronic respiratory diseases other than COPD should be modified to include treatment strategies specific to individual diseases and patients in addition to treatment strategies common to both COPD and non-COPD patients.


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Pulmonary Rehabilitation pptx