Pulmonary Rehabilitation

Imtiyaz Ali
Lecturer, UTAR
Objectives
 Define pulmonary rehab
 Discuss Pathophysiology of respiratory diseases
& its consequences
 List goals & benefits of pulmonary rehab
 Explain in detail about each component of
pulmonary rehab
 Briefly state additional strategies for improving
exercise performance
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 (2006)
 Education

General
exercise
Psychological training
support

Pulmonary
Rehabilitation
components
Breathing
Nutritional Retraining
advice

Outcome
Assessment
Pathophysiology
Consequences of Respiratory Disease
• Peripheral muscle dysfunction
• Respiratory muscle dysfunction
• Nutritional abnormalities
• Cardiac impairment
• Skeletal disease
• Sensory defects
• Psychosocial dysfunction
Mechanisms for these morbidities
• Deconditioning
• Malnutrition
• Effects of hypoxemia
• Steroid myopathy
• Hyperinflation
• Diaphragmatic fatigue
• Psychosocial dysfunction from anxiety, guilt,
dependency and sleep disturbances
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
Benefits of Pulmonary Rehabilitation
 Improved exercise capacity
 Reduced perceived intensity of dyspnea
 Improve health-related QOL
 Reduced hospitalization
 Reduced anxiety and depression from COPD
 Improved upper limb function
 Benefits extend well beyond immediate period of
training
 Patient Selection

 Obstructive Diseases
 Restrictive Diseases
 Interstitial
 Chest Wall
 Neuromuscular
 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)
Exclusion criteria
 Patients with severe orthopedic or neurological
disorders limiting their mobility
 Severe pulmonary arterial hypertension
 Exercise induced syncope
 Unstable angina or recent MI
 Inability to learn, psychiatric instability and disruptive
behavior
Setting for Pulmonary Rehabilitation
 Outpatient
 Inpatient
 Home
 Community based
 Choice varies depending on
- Distance to program
- Patient preference
- Physical, functional,
psychosocial status of patient
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
 Anxiety and panic control, including relaxation
techniques and stress management
Exercise Training
Exercise limitation due to:
 Alteration in pulmonary mechanics
 Dysfunction of the respiratory muscles
 Peripheral muscle dysfunction
 Abnormal gas exchange
 dyspnea
 Alterations in cardiac performance
 Nutritional imbalances
Exercise Training
Benefits of Exercise training:
Pathophysiological Benefits of exercise
abnormality training
Decreased lean body mass Increases fat free mass

Decreased type1 fibers Normalizes proportion

Decreased cross sectional area of muscle Increases

fibers
Decreased capillary contacts to muscle Increases
fibers
Decreased capacity of oxidative enzymes Increases

Increased inflammation No effect

Lower intracellular pH, increased lactate Normalization of decline in

levels and rapid fall in pH on exercise pH
Exercise Training
Components of exercise training:
 Lower extremity exercises
 Arm exercises
 Ventilatory muscle training

Types of exercise:
 Endurance or aerobic
 Strength or resistance
Exercise Training
Program Duration and Frequency:
 20 sessions more effective than 10 sessions
 Short term intensive programs- 20 sessions in 3-4
wk found to be more effective
 Outpatient rehabilitation 2-3 times/wk for 4 wks
less effect than 7 wks
 One supervised session is ineffective
(ATS 2006)
Exercise Training
Intensity of Exercise:
 Greater improvements can be obtained at
high (60% of maximal work rate, above the
anaerobic threshold) compared with low (30%
of maximal work rate) exercise levels
 Training respiratory patients at 60 to 75% of
maximal work rate results in substantial
increases in maximal exercise capacity and
reductions in ventilation and lactate levels at
identical exercise work rates
Exercise Training
 In clinical practice, RPE of 14 to 16 for dyspnea
or fatigue is usually a reasonable target
 So, High-intensity exercise 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
Exercise Training
Specificity of Exercise Training:
 Training effects have been found to be specific
to trained muscles
 Exercise programs traditionally focused on
lower extremity training
 Many ADL involve UE. So UE training should be
incorporated into the training program
Exercise Training
Endurance and strength training:
 Endurance training is used in form of cycle/walking
exercise
 Relatively longer durations of higher intensity(>60%
of max. work rate) are adopted in endurance
training
 Total effective training time should exceed 30min
 Interval training is preferred over continuous
 Interval training results in significantly lower
symptom scores despite high training loads, thus
maintaining the training effects
Exercise Training
 Strength training has greater potential to
improve muscle mass and strength
 Session includes: 2-4 sets of 6-12 reps with
intensity of 50 to 85% of 1 RM
 The combination of endurance and strength
training is probably the best strategy as it results
in combined improvements in muscle strength
and whole body endurance
Training method for LE Exercise
 Warm up for 5 - minutes - (L/L stretches, spot marching,
free ROM in all direction)
 Intensity: 60-80% of max. work capacity
 ↑ work every 5th session as tolerated
 ↑ work after 20-30min of submax
targeted work is achieved
 Aim for 20-24 sessions
 Monitor dyspnea (RPE12-13)
and HR
 Treadmill or cycle ergometry
 Cool down same as warm up
Training method for supported UE
Exercise
 Warm up for 5 minutes - (U/L stretches, free
ROM in all direction)
 Intensity: 60% of max. work capacity
 ↑ work every 5th session as tolerated
 Monitor dyspnea (RPE12-13) and HR
 Train for as long as tolerated up to 30 minutes
 Min. sessions: 20-24
 Arm Ergometry
 Cool down same as warm up
Training method for Unsupported UE
Exercise
 Warm up for 5 minutes - (U/L stretches, free ROM in all
direction)
 Use weight (750 gm)
 Lift to shoulder level for 2 minutes; rate equal to
breathing rate
 Rest 2 minutes
 Repeat sequence as tolerated for up 30 minutes
 Monitor Heart rate and dyspnoea (RPE12-13)
 Increase weight (250gm) every 5 sessions as tolerated
 Complete 20-24 sessions
 Cool down same as warm up
Additional Strategies to Improve
Exercise Performance
Maximizing pulmonary function before starting
exercise training:
 Respiratory muscle training
 Oxygen
 Noninvasive mechanical ventilation
 Neuromuscular electrical stimulation
Ventilatory Muscle Training

VMT in PR:
 Inspiratory muscle training
+
 standard exercise training in patients with poor initial
inspiratory muscle strength improves exercise capacity
mare than exercise alone
 Inspiratory muscle training could be considered as
adjunctive therapy in pulmonary rehabilitation, primarily
in patients with suspected or proven respiratory muscle
weakness

(ATS 2006)
Ventilatory Muscle Training
 Inspiratory muscle function may be compromised
in COPD, an impairment that may contribute to
dyspnea, exercise limitation, and hypercapnia
 Respiratory muscle strength is commonly
estimated by measuring maximal negative
inspiratory pressure (PImax), although this is a
highly effort-dependent test
 The minimal load required to achieve a training
effect is 30% of the PImax
 Generally initiated at low intensities then gradually
increased to achieve 60 to 70% of PImax
Ventilatory Muscle Training

Candidates:
 VMT may be considered in pts with COPD who
remain symptomatic despite optimal therapy
 Severe dyspnea
 Highly motivated
 Reduced respiratory muscle strength
 Moderate to severe respiratory impairment but
not “ end stage”, with severe hyperinflation and
flattening diaphragm
 Ventilatory Muscle Training
Resistive IMT:
Patient breaths through hand
held device with which resistance
to flow can be increased
gradually
• Difficult to standardize the load
• Patients may hypoventilate
• Leads to increased Pulmonary
Arterial Pressure and fall in
oxygen tension
Threshold IMT:
Patient breaths through a device
equipped with a valve which
opens at a given pressure
• Easily quantitated and
standardized
• Less changes in pulmonary
artery pressure
Ventilatory muscle training Devices
Ventilatory Muscle Training

Exercise prescription guidelines for VMT:

 Frequency: at least 5 times per week
 Intensity: >30% PImax
 Duration: 30 minutes per day (continuous or 15
minutes twice a day)
 Training device: a targeted (a % of individual’s
PImax) inspiratory resistance system
 A breathing frequency of 12-15 breaths per
minute is recommended
O2 Therapy
In general,
 Allows for higher training intensity and/or
reduced symptoms in the research setting
 Still inconclusive at clinical level

(ATS 2006)
Non invasive mechanical ventilation
 it should be used only in patients with
demonstrated benefit from this therapy
 Further studies are needed to further define its
role in pulmonary rehabilitation

(ATS 2006)
Neuromuscular electrical stimulation
(NMES)
 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 2006)
Nutritional Interventions
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
Body composition abnormalities
 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
Caloric supplementation
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
Nutritional 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
Why to give Small Frequent Meals
 High-calorie snacks- creamy, rich, 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 psychiatric disease should be
referred for appropriate professional care
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