Respiratory Rehabilitation

Lecture 2
 The respiratory diseases
• Restrictive versus Obstructive

• Mechanical versus Intrinsic

• Ventilatory impairement – retention of CO2 

secondarily hypoxia

• Oxygenation impairement – eucapnic or

hypocapnic, despite hypoxia
 Restrictive Lung Disorders (RLD)
Lung parenchimal disease Ventilatory pump
Pleural abnormalities - 
causing  compliance dysfunction  thoracic
thoracic expansion
and  lung compliance expansion

 IC, VC,  Lung expansion

TLC, nl or
 RV

 Tidal volume
 or uneven alveolar
 Inspiratory effort
ventilation
 Use of accessory
V/Q mismatching
respiratory muscles
Impaired gas exchange
 Work of breathing
Hypoxic vasoconstriction
 Restrictive Lung Disorders (RLD)
Lung parenchimal disease Ventilatory pump
Pleural abnormalities - 
causing  compliance dysfunction  thoracic
thoracic expansion
and  lung compliance expansion

 IC, VC,  Lung expansion

TLC, nl or
 RV

 Tidal volume
 Respiratory
 on
rate especially or uneven alveolar
 Inspiratory effort
exertion ventilation
 Use of accessory
V/Q mismatching
respiratory muscles
Impaired gas exchange
 Work of breathing
Hypoxic vasoconstriction
 Restrictive Lung Disorders (RLD)
Lung parenchimal disease Ventilatory pump
Pleural abnormalities - 
causing  compliance dysfunction  thoracic
thoracic expansion
and  lung compliance expansion

 IC, VC,  Lung expansion

TLC, nl or
 RV

 Tidal volume
 or uneven alveolar
 Inspiratory effort
ventilation
 Use of accessory
V/Q mismatching
respiratory muscles
Impaired gas exchange
 Work of breathing
Hypoxic vasoconstriction
 Restrictive Lung Disorders (RLD)
Lung parenchimal disease Ventilatory pump
Pleural abnormalities - 
causing  compliance dysfunction  thoracic
thoracic expansion
and  lung compliance expansion

 IC, VC,  Lung expansion

TLC, nl or
 RV

 Tidal volume
 or uneven alveolar
 Inspiratory effort
ventilation
Arterial  Use of accessory
V/Q mismatching
hypoxemia respiratory muscles
Impaired gas exchange
 Work of breathing
Hypoxic vasoconstriction
 Restrictive Lung Disorders (RLD)
Lung parenchimal disease Ventilatory pump
Pleural abnormalities - 
causing  compliance dysfunction  thoracic
thoracic expansion
and  lung compliance expansion

 IC, VC,  Lung expansion

TLC, nl or
 RV

 Tidal volume
 or uneven alveolar
 Inspiratory effort
ventilation
Arterial  PA  Use of accessory
V/Q mismatching
hypoxemia pressure respiratory muscles
Impaired gas exchange
 Work of breathing
Hypoxic vasoconstriction
 Restrictive Lung Disorders (RLD)
Lung parenchimal disease Ventilatory pump
Pleural abnormalities - 
causing  compliance dysfunction  thoracic
thoracic expansion
and  lung compliance expansion

 IC, VC,  Lung expansion

TLC, nl or
 RV

 Tidal volume
 or uneven alveolar Potential for
 Inspiratory effort
ventilation
Arterial  PA  Use ofrespiratory
accessory
V/Q mismatching
hypoxemia pressure respiratorymuscle
muscles
Impaired gas exchange fatigue
 Work of breathing
Hypoxic vasoconstriction

Disease affecting the lung
parenchyma
Atelectasis
Pneumonia
Interstitial lung
disease/pulmonary fibrosis
Acute respiratory distress
syndrome
Pulmonary edema
Neonatal respiratory
distress syndrome
Bronchopulmonary
dysplasia
Occupational lung disease
Collagen vascular and
connective tissue disorders
RLD
Disease affecting the Disorders affecting
pleurae ventilatory pump function
Pleural effusion Impaired respiratory drive
Pleural fibrosis (e.g. CNS depression due to
Pneumothorax disease or drugs, head injury)
Hemothorax Neurologic and
neuromuscular disease (e.g.
spinal cord injury,
amyotrophic lateral sclerosis,
myasthenia gravis etc.)
Muscle weakness (e.g.
myopathy, muscular
dystrophy)
Lung hyperinflation (e.g.
COPD)
Collagen vascular and
connective tissue disorders
affecting the thoracic joints
Extrathoracic conditions (e.g.
pregnancy, obesity, ascites,
abdominal incision)
 Obstructive Lung Disorders (OLD)
Airway narrowing (e.g. Peribronchical Abnormalities
Airway impediments (e.g. bronchoconstriction, (e.g. destruction of lung
edema fluid, excessive mucous gland parenchima, compression by
mucus, foreign material) hypertrophy, tumor or enlarged lymph
inflammation, fibrosis) nodes)

 Airway resistance +  flow rates

Cough,
sputum Expiratory airflow Prolonged
production, limitation expiration
wheezes

Early airway closure + incomplete alveolar emptying

 Residual volume + possible air trapping

 Obstructive Lung Disorders (OLD)
Airway narrowing (e.g.
Airway impediments (e.g. bronchoconstriction,
edema fluid, excessive mucous gland
mucus, foreign material) hypertrophy,
inflammation, fibrosis)
Peribronchical Abnormalities
(e.g. destruction of lung
parenchima, compression by
tumor or enlarged lymph
nodes)

 Airway resistance +  flow rates

Cough,
sputum Expiratory airflow Prolonged
production, limitation expiration
wheezes

Early airway closure + incomplete alveolar of

Hyperinflation emtying
lungs
Uneven ventilation Efficiency of breathing
V/Q mismatching mechanics
Impaired gasexchange Work
Residual volume + possible airoftrapping
breathing
Hypoxic vasoconstruction Use of respiratory
accesory muscles
 Obstructive Lung Disorders (OLD)
Airway narrowing (e.g.
Airway impediments (e.g. bronchoconstriction,
edema fluid, excessive mucous gland
mucus, foreign material) hypertrophy,
inflammation, fibrosis)
Peribronchical Abnormalities
(e.g. destruction of lung
parenchima, compression by
tumor or enlarged lymph
nodes)

 Airway resistance +  flow rates

Cough,
sputum Expiratory airflow Prolonged
production, limitation expiration
wheezes

Early airway closure + incomplete alveolar of

Hyperinflation emtying
lungs
Uneven ventilation Efficiency of breathing
V/Q mismatching mechanics
Impaired gasexchange Work
Residual volume + possible airoftrapping
breathing
Hypoxic vasoconstruction Use of respiratory
accesory muscles
 Obstructive Lung Disorders (OLD)
Airway narrowing (e.g.
Airway impediments (e.g. bronchoconstriction,
edema fluid, excessive mucous gland
mucus, foreign material) hypertrophy,
inflammation, fibrosis)
Peribronchical Abnormalities
(e.g. destruction of lung
parenchima, compression by
tumor or enlarged lymph
nodes)

 Airway resistance +  flow rates

Cough,
sputum Expiratory airflow Prolonged
production, limitation expiration
wheezes

Early airway closure + incomplete alveolar of

Hyperinflation emtying
lungs
Uneven ventilation Efficiency of breathing
mechanics Potential for
V/Q mismatching
Arterial hypoxemia  PA +pressure respiratory muscle
Impaired gas Residual volume
exchange Work
possible airoftrapping
breathing
Hypoxic vasoconstruction Use of respiratory fatigue
accesory muscles
 OLD
• Chronic bronchitis
• Emphysema
• Asthma
• Bronchiectasis
• Cystic fibrosis
• Bronchiolitis Obliterans
 Physiological changes in PD
Measure OLD RLD Mixed disorders
FEV1/FEV Decreased Normal or Decreased
increased
FEV1 Decreased Decreased, normal Decreased
or increased
FVC Decreased or Decreased Decreased or
normal normal
TLC Normal or Decreased Normal or
increased increased

RV Normal or Decreased Normal or

increased increased
 Who would benefit?
• Pts. able to cope and learn

• Preservation of adequate bulbar – innervated muscle

functions to use equipment and techniques that can
optimize general physical functioning, inspiratory and
expiratory aids, oxymetry feedback that can optimise
pulmonary function.

• Tracheostomy (for survival) – advanced, averbal bulbar

amyotrophic lateral sclerosis and spinal muscle atrophy
type 1, without adequate parental involvement
 Errors in management of pts. with
ventilatory impairement
• Misinterpretations of symptoms caused by hypercapnia and
inspiratory muscle weakness
• Failure to do spirometry with the pts. supine and to
monitor maximum insufflation capacity
• Use of arterial blood gas analyses instead of oximetry and
noninvasive CO2 monitoring
• Administration of O2, periodic intermittent positive-
pressure breathing (PPB), continuous positive airway
pressure (CPAP), or inadequate bi level positive airway
pressure (BiPAP) when noninvasive respiratory muscle aids
are indicated
• Failure to prevent acute respiratory failure and
hospitalization
 Errors in management of pts. with
ventilatory impairement
• Administration of O2, periodic intermittent positive-
pressure breathing (PPB), continnous positive airway
pressure (CPAP), or inadequate bi level positive airway
pressure (BiPAP) when noninvasive respiratory muscle
aids are indicated
• Use of methylxanthines and any other respiratory
medications on an ongoing basis without evidence of
bronchospasm
• Failure to prevent acute respiratory failure and
hospitalization
• Resort to tracheostomy when peak cough expiratory
flows exceeds 3 L/sec
Parameters to be monitor in pts. with
neuromuscular diseases
• Vital capacity (VC)
• Maximum insufflation capacity (MIC)
• Peak cough flows (PCF) assisted and
unassisted
• Oxyhemoglobin saturation (SpO2) via
oximetry
• End-tidal carbon dioxide (EtCO2) via
capnography
 Symptoms/signs – hypoventilation
(hypercapnia)
• Fatigue • Decreased libido
• Shortness of breath • Irritability
• Headaches • Anxiety
• Sleep awakenings with • Depression
shortness of breath • Memory impairment
• Poor concentration • Frequent arousal from
• Nightmares sleep to urinate
• Signs of heart failure – • Muscle ache
lower limb swelling • Excessive weight loss
  Blood oxyhemoglobin saturation
(SpO2)
• Hypoventilation • Oximetry – vital sign
• Hypercapnia • SpO2 > 94%
• Airway obstruction
(mucus)
• Intrinsic lung disease
(atelectasis or
pneumonia)
 When non-invasive ventilation
(nocturnal)?
• Ventilatory insufficiency
• Hypercapnia during sleep (EtVCO2 > 50mmHg)
and VC < 50%
• Mean SpO2 < 95% for longer than 5 minutes
of sleep
• Multiple episodes of oxygen desaturation
during sleep
• PaCO2 > 45mmHg when awake
 Respiratory muscle aids
• Manual or mechanical forces to the body
• Intermittent pressure changes to the air
• Negative - pressure body ventilators (NPVBs)
• Body ventilators
• Forced exsufflation devices
Iron lung/Negative - pressure body
ventilators (NPVBs)
Positive pressure ventilators – long day
time use
• Mouthpiece
intermittent positive
pressure ventilation
(IPPV)
 Positive pressure ventilators – long day
time use

Intermittent abdominal
pressure ventilator (IAPV)
Nocturnal aids for inspirratory muscles
• Nasal IPPV delivered via
CPAP masks (nasal
interfaces)
Nocturnal aids for inspirratory muscles
• Mouthpiece IPPV with
Lip seal retention

• Speaking clearly is
difficult
Cough machine/mechanical
insufflator- exsufflator
Cough machine/mechanical
insufflator- exsufflator
• Positive pressure to the
airways and then
shifting (rapidly) to
negative pressure
• High expiratory flow
• PCF (peak cough flow) >
4L/sec
• Cycle – 4-8 seconds
• Pressures: 40 to -40
cmH2O
Cough machine/mechanical
insufflator- exsufflator
• Cycle – 4-8 seconds
• Pressures: 40 to -40
cmH2O
• Abdominal thrust –
exsufflator phase
• Pressure via mask,
endotracheal tube or
tracheostomy tube
 Cough machine/mechanical
insufflator- exsufflator – Benefits
• Neuromuscular
disorders
• High spinal cord injury
• Traumatic brain injury
• Cerebral palsy
• Severe fatigue
• PCF< 5L/sec
Cough machine/mechanical
insufflator- exsufflator –
Contraindications
• Bullous emphysema
• Pneumothorax
• Pneumomediastinum
• Recent barotrauma
• Impaired consciouness
• Inability to
communicate
Frog breathing/ Glossopharyngeal
breathing
Frog breathing/ Glossopharyngeal
breathing
• Maximal insufflations
• Noninvasive method of
emergent support of
ventilation
• Backup for ventilatory
failure
• Prevents micro
atelectasis
• Normalize the volume
and rhythm of speech
 Indication for tracheotomy
• SpO2 less 95% (persistently) despite CNV and
aggressive mechanically assisted cough
• A mentally incompetent or uncooperative patient,
who requires ongoing heavy sedation and
narcotics
• Severe intrinsic lung disease
• Substance abuse
• Uncontrollable seizures
• Conditions interfering with the use of IPPV
interfaces
Key points for non invasive pulmonary
ventilation
1. First step – normalize oxyhemoglobin saturation
(SpO2) by providing adequate ventilation and assisted
coughing before considering O2 therapy and
intubation.
2. Signs of successful noninvasive pulmonary rehab are:
• Decreased respiratory rate
• Decreased accessory respiratory muscle use
• Increase chest expansion
• Normalization of end tidal carbon dioxide and SaO2
• Relief of dyspnea
• Decreased of hospitalization rates
Key points for non invasive pulmonary
ventilation
3. Ventilatory impairment and oxygenation
impairment need to be evaluated and
managed differently.

4. Respiratory muscle aids can substitutes for

inspiratory and expiratory muscle function,
but not for the function of bulbar-innervated
muscles.
Key points for non invasive pulmonary
ventilation
5. Nasal ventilation is introduced to treat symptoms
of nocturnal hypoventilation. It is use on needed
basis and continuously for full ventilatory
support without ever being hospitalized.

6. Do not blame the brain for what diaphragm can’t

do. Polysomnograms diagnose central and
obstructive apneas, not symptoms caused by
muscle weakness.
 Tracheotomy indications
• SpO2 persistently less than 95% in ambient air,
despite up to continuous noninvasive ventilation
and aggressive mechanically assisted coughing
• Uncooperating patient or one who requires
ongoing heavy sedation or narcotics
• Severe intrinsic lung disease
• Substance abuse or uncontrollable seizures
• Conditions interfering with the use of IPPV
interfaces
 OLD – Oxygenation impairment
• Chronic bronchitis
• Emphysema
• Asthma (asthmatic
bronchitis) • Common causes of OLD
• Bronchiectasis
• Cystic fibrosis
• Bronchiolitis Obliterans
 OLD/COPD
Emphysema
• Distention of air spaces
distal to the terminal
nonrespiratory bronchiole
with destruction of alveolar
walls
• Loss of lung recoil
• Excessive airways colapse
on exalation
• Chronic airflow obstruction
Chronic bronchitis/ Cystic
fibrosis
• Enlargement of
tracheobronchial mucus
glands
• Chronic mucus
hypersecretion
• Chest infections
 COPD - prognosis
• Pulmonary functions

• FEV1 (forced expiratory volume in 1 second) <

750ml (30%) – 1 year survival

• FEV1 (forced expiratory volume in 1 second) <

750ml (50%) – 3 years survival
Pulmonary rehabilitation - candidates
• Nonsmokers

• Former smokers

• Active participants
 PR programme
• Evaluating the • Airway secretion
nutritional state techniques
• Optimizing the • Exercise programme
pharmacologic • Supplemental O2 use
management: • Controled breathing
 Anticholinergics methods – pursed lip
 Bronchodilators breathing (for dyspnea)
 Steroid inhalers
 Expectorants
 Exercises in COPD
• Lower limb exercise • Strength training
• Ambulation • Endurance training
programmes • Relaxation therapy (yet
• High and low intensity to be proved)
programmes
 Exercises in pts. with marked
hypercapnia
• Improvement in walking
distance

• ADLs (activities of daily

livings)

• Pulmonary parameters
 Methods to assist in airway secretion
elimination
Inexpensive methods
• Huffing
• Chest percussion
• Postural drainage
• Autogenic breathing
• Positive expiratory pressure
masks
• Flutter valves that create
positive back pressure
Expensive methods
• Vibrating tests
• Vibrating air under chest
shells
• High frequency oscillation
40-200 times/minute of the
air column delivered via
mouthpiece or airway tube
 Surgical options
Lung volume reduction surgery
1. Advanced emphysema
2. 20 to 30% of one or both
lungs removed
3. Reduce hyperinflation
4. Improve FEV1
5. Improve forced vital
capacity (FVC)
6. Improve quality of life
Lung transplant
• cystic fibrosis - children
• Primary pulmonary
hypertension – children
• COPD - adults
• Pulmonary HTN - adults
• Pulmonary fibrosis – adults
• Absolute CI – smoking
• Relative CI – cancer, psychiatric
dg., obesity, correctable
coronary artery disease
 Benefits of pulmonary rehabilitation
• Reduction in dyspnea and respiratory rate
• Improvement in ADLs
• Decrease anxiety and depresion
• Increase cognitive function and sense of well
beeing
• Decrease frequency of hospitalizations for
respiratory impairement
• Increase exercise tolerance, symptom limited
oxygen consumption, work output, mechanical
efficiency