Pulmonary Rehabilitation

DR. SAJIN SUNNY MATHEW

RESIDENT
DEPT. OF PULMONARY MEDICINE
 INTRODUCTION – Historical Background
1. National Emphysema Treatment Trial (NETT): Compared it to Lung
Volume Reduction Surgery as the ‘best therapy’.
2. Cochrane Report: Effectiveness of Pulmonary Rehabilitation in a meta-
analysis.
3. GOLD: Part of Current treatment algorithm for COPD.
Considerable portion of dyspnoea & health status limitations can
respond to treatment; eg: Nutritional depletion, decrease in lower
extremity muscle mass, peripheral muscle weakness & fatigability ,
fear of dyspnoea producing activities.
Introduction- Spiral of Inactivity
 DEFINITION
•It is an evidence based, multi disciplinary & comprehensive intervention for patients with
chronic respiratory diseases who are symptomatic and often have decreased daily life
activities.
•Integrated into the individualised treatment of the patient, pulmonary rehabilitation is
designed to:
1. reduce symptoms,
2. optimize functional status,
3. increase participation and
4. reduce health care costs
through stabilizing or reversing the systemic manifestations of the disease.
 INDICATIONS
1. COPD
2. Pulmonary Fibrosis
3. Post tubercular lung disease
4. Thoracic Restriction
5. Bronchiectasis
6. Cystic Fibrosis
7. Asthma
8. Pulmonary Hypertension
9. Pre & Post Operatively for lung resection/volume reduction/ lung transplantation
 EXCLUSION CRITERIA
1. Myocardial Infarction sustained within 3 months
2. Unstable Angina
3. Moderate/ Severe Aortic Stenosis
4. Uncontrolled blood pressure
5. Severe Pulmonary Hypertension
6. Disabling Arthritis or Severe Neurologic/Cognitive/Psychiatric
Disease.
 Assessment
1. Assess inclusion & exclusion criteria
2. Assess Dyspnoea with MMRC Dyspnoea Scale
3. Assess Exercise Performance
Outcome Measures
1. Full Cardiopulmonary
Exercise Tests:
•Gold Standard measure of Exercise
Capacity: Peak Oxygen Consumption
•Equipment: Cycle Ergometer/Treadmill
•Maximal, Incremental, Symptom limited
CPT with expiratory gas analysis
•Provides precise limitation to exercise
Outcome Measures
2. Six Minute Walk Test:
•Most commonly used test
•Completed over a 30 metre flat course
•Self paces and standardised instructions
•Asked to walk as far as the patient can for
6 minutes till patient is dyspnoeic.
•Distance walked is a measure of
functional capacity
Outcome Measures
3. Incremental Shuttle Walk Test:
Symptom-limited, Externally paced test along a 10 meter course
Reflects maximal exercise capacity
Walking speed increases every minute until patient is too breathless
to continue/maintain required speed
Unlike 6MWT, ISWT has a graded physiological response
Result as total distance achieved
Outcome Measures
4. Endurance Shuttle Walk Test:
Test of submaximal exercise capacity
Symptom limited, externally paced over 10 meter course
2 minute warm up, patients walk at set speed until they are
too breathless to continue
Result as time walked after warm up
Outcome Measures
5. HEALTH STATUS:
To assess chronic disease interventions
Chronic Respiratory Questionnaire (CRQ)
St. George’s Respiratory Questionnaire (SGRQ)
EXERTIONAL DYSPNOEA BORG SCALE
VISUAL ANALOG SCALE
DYSPNOEA WITH DAILY MMRC
ACTIVITIES BASELINE & TRANSITIONAL DYSPNOE INDEXES (BDI/TDI)
SAN DIEGO SHORTNESS OF BREATH QUESTIONNAIRE (SOBQ)
FUNCTIONAL EXERCISE 6MWT
CAPACITY INCREMENTAL & ENDURANCE SHUTTLE WALK TESTS
EXERCISE PERFORMANCE INCREMENTAL CARDIO PULMONARY EXERCISE TESTING

HEALTH STATUS CHRONIC RESPIRATORY DIESEASE QUESTIONNAIRE (CRQ)

ST GEORGES RESPIRATORY QUESTIONNAIRE (SGRQ)
FUNCTIONAL PERFORMANCE PULMONARY FUNCTIONAL STATUS SCALE (PFSS

NUTRITIONAL STATUS BMI

DEXA SCAN
PSYCHOLOGICAL VARIABLE HOSPITAL ANXIETY & DEPRESSION QUESTIONNAIRE (HAD)
 CORE COMPONENTS
1. Exercise Training, Breathing Training, Chest Physical
Therapy
2. Multidisciplinary Education
3. Psychosocial support
4. Self Management
Exercise Training
1. LOWER LIMB ENDURANCE TRAINING
Improves exercise tolerance
Reduces Dyspnoea on exertion
High Intensity Training beneficial than lower intensity training
Training speed and load calculated from CPX test
Exercise session should last 20-30 minutes
Walking & Cycling effective
Exercise Training
2. LOWER LIMB & UPPER LIMB
RESISTANCE TRAINING
Also referred to as Strength
Training
Repetition maximum to be
achieved and progressed through
the program
Step ups/ Leg raises/ sit to stand/
Ankle weights
Breathing Training
1. PURSED LIP BREATHING
•Inhales through Nose
•Exhales over 4-6 secs through lips pursed in a
whistling/kissing position.
Recruitment of abdominal muscles during exhalation
Increases tidal volume
Reduces end expiratory lung volumes
Breathing Training
2. BREATHING WHILE BENDING FORWARD
•Decreases dyspnoea in some patients with severe COPD both
at rest and during exercise
•Increased Abdominal pressure while bending overstretches
the diaphragm, moving it into a contracting position and
leading to improved diaphragmatic function.
Chest Physical Therapy
•To remove bronchial secretions (Bronchial Hygiene)
1. Postural Drainage: Gravity to drain individual lung
segments
2. Chest Percussion & Vibration
3. Directed Cough
Multi Disciplinary Education
Education Topics:
1. Exercise
2. Nutrition Advise
3. Relaxation
4. Medication, Bronchial Hygiene, Devices & Oxygen Therapy
5. Benefits advise
6. Energy Conservation
7. Travel
8. Disease Education
Self Management
Increases patients’ involvement & control of disease
Improves sense of well being
Reduces resource utilisation
Early symptom recognition & Action plan
Learn to recognize exacerbations & avoid hospital admissions
Exercise, Nutrition and correct administration of medications.
Intensity & Duration of Programme

Minimum of 3 supervised sessions per week for six weeks

Additional home training required
Maintenance
Follow up & maintenance required to sustain the benefits
As adherence to exercise protocol decreases. The level of
exercise achieved is reduced
Repeat short term programs
Patients who benefitted little from the initial program
usually show poor adherence
Oxygen Therapy
Guidelines: (ATS/ERS 2004)
1. Resting PaO2: 55 mmHg or less
2. Resting Pao2 55-59 mmHg + cor pulmonale AND/OR
HCT > 55%
3. Nocturnal Hypoxemia (Pao2 < 55 mm Hg on multiple
occasions) OR HCT > 55 % OR clinical evidence of
Pulmonary Hypertension
Oxygen Therapy
Supplemental Oxygen during exercise
may be required in those who exhibit
profound desaturation.
Carrying the weight of the oxygen
cylinder may negate any additional
benefits
Liquid oxygen lighter to carry: but
expensive and not widely available
Vaccination
Influenza Vaccine
Once Annually in patients who are 65 years or older.

Pneumococcal Vaccine
≥65 years: Pneumococcal 23 once every 5 years.
<65 years: Pneumococcal 23 once.
Rehabilitation Team
1. Respiratory Physiotherapists
2. Occupational Therapists
3. Nurses
4. Assistants
5. Physicians
During Exacerbations
Dyspnoea, Exercise tolerance, Muscle Strength, health
related quality of life all decline following an exacerbation
Many patients do NOT reach back pre-exacerbation level of
function post exacerbation
Targeting exercise therapy immediately post exacerbation
may have benefits
THANK YOU