ESTABLISH A PULMONARY

REHABILITATION
PROGRAMME
“Respiratory physiotherapy”

Done by : Amina Issa

Sarah Yaqoob
Norhan Howary
Shahad Al_Hammad
INTRODUCTION :
 rehabilitation : is
the discrete process of improving an individual's adaptation
to disability by physical training and other techniques to increase
participation.

 We are here to set out what is required to establish a pulmonary rehabilitation programme
that can reliably produce positive outcomes.

Pulmonary Rehabilitation programme Definition :

“ Pulmonary rehabilitation is a comprehensive intervention based on a thorough patient
assessment followed by patient tailored therapies that include, but are not limited to,
exercise training, education, and behavior change, designed to improve the physical and
psychological condition of people with chronic respiratory disease and to promote the
longterm adherence to health-enhancing behaviors”
REHABILITATION PROGRAMME

Education

General exercise
Psycholoal
Psycholoal support
support training

Pulmonary
rehabilitation
component

Nutritional Breathing
advice retraining

Out come
assessment
CONSEQUENCE OF RESPIRATORY DISEASE :

• Peripheral Muscle dysfunction

• Respiratory muscle dysfunction
• Nutritional abnormalities
• Cardiac impairment
• Skeletal disease
• Sensory defects
• Psychosocial dysfunction
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
R E H A B I L I TAT I O N
 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.

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
SETTING FOR PULMONARY
R E H A B I L I TAT I O N
 Outpatient
 Inpatient

 Home

 Community Based

 Choice varies depending on

- Distance to program
- Insurance payer coverage
- Patient preference
- Physical, functional:
psychosocial status of patient
…
ASSESSMENT
 Necessary to determine severity of the respiratory impairment
 Clinical history
 Review of pertinent records
 Educational assessment
 Physical examination
 Other assessments:
 • Measurements of respiratory muscle strength
 • Measures of peripheral muscle strength
 • Assessments of ADL
 • Health status, cognitive function
 • Level of anxiety or depression
 • Nutritional status/ body composition
 • Stress testing:- physical performance test to measure activity limitation; e.g. 6minute walk test
 • Quality of Life
EXERCISE TRAINING
 Components of exercise training:

 A)Upper limb exercises

 B) respiratory muscle training

 Types of exercise:
 •Endurance or aerobic

 •Strength or resistance
ARM EXERCISE TRAINING
 Arm cycle ergometer
 Unsupported arm lifting

 Lifting weights

A) Upper extremity :
-Increase strength training with or without weights
-Without weights preferred
-Free weights like thera band etc.
Type: pulling/pushing
Upper extremity exercises along with the other benefits help in increasing thoracic cage mobility
• Cross training: • Both UL and LL ex. done together
POINTS TO BE CONSIDERED IN
EXERCISE PRESCRIPTION
 Frequency
 Intensity

 Time

 Type

Program duration and frequency

 • 20 sessions more effective than 10

 • 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

 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
 Training Specificity
 • Training effects have been found to be

 specific to trained muscles

 • Traditionally focused on lower extremity

 training

 • Many ADL involve UE. So UE training

 should be incorporated

 Strength and endurance

 • Traditionally endurance training is used in form of cycle/walking ex.

 • Relatively longer durations of higher intensity(>60% of max. work rate)

are
 adopted in endurance training Total effective training time should exceed

 30min.-but difficult to achieve in some patients

EX prescription in brief

 • Frequency : 3-4 times/wk

 • Intensity: high intensity training

– 60-80% max. work capacity for LE

– 60% of max. work cap. For UE
 • Duration: 25-30 minutes/ as tolerated

 • Mode: continuous/interval, combination of strength and

endurance
 • 20 sessions within 6-8 weeks

 • At least 2 supervised session

 • Monitor: HR, dyspnea, fatigue

 B) Respiratory Muscle training: decrease dyspnea, increase
Ventilatory efficiency , increase endurance.

 Self management education

 • Prevention of exacerbations

 • Breathing strategies

 • Bronchial hygiene

 • Medications

 • symptom management

 • Self-assessment

 • Exercise training and benefits

 • Activities of daily living and energy

 conservation
RESPIRATORY PHYSIOTHERAPY
 Chest Physical Therapy & Breathing Retraining:
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
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
NUTRITIONAL INTERVENTIONS
 Physiological intervention: Strength exercise Addition of
strength training lead to increase in strength and mid
thigh circumference (measured by CT)
 Pharmacological intervention : Anabolic steroids

 Growth hormone

 Testosterone.
OUTCOME ASSESSMENT
 Programme effectiveness is best documented by repeating the baseline measures upon graduation. More
widespread audits would allow comparison among centers and validate the effectiveness of individual
programmes against the pooled averages of many programmes.

 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