Pulmonary Rehabilitation

PULMONARY REHABILITATION

PULMONARY REHABILITATION

The National Institute of Health redefined pulmonary rehabilitation as

A multidimensonal continuum of services directed to persons with pulmonary disease and their families, usually by an interdisciplinary team of specialists, with the goal of achieving and maintaining the individuals maximum level of independence and functioning in the community

The lung volumesA. Volumes1. Tidal Volume (TV)2. Residual Volume (RV)3. Inspiratory Respiratory Volume (IRV)4. Expiratory Reserve Volume (ERV)B. Capacities1. Total Lung Capacity (TLC)2. Vital Capacity (VC)3. Functional Residual Capacity (FRC)4. Inspiratory Capacity (IC)

Pulmonary Rehabilitation

Applicable for

Obstructive and intrinsic pulmonary disease

Neuromuscular and restrictive condition

Rehabilitation of patient with chronic obstructive pulmonary disease (COPD) COPD affects 10-40% of population 5th leading cause of death 50% of patient have activity limitation 25% are bed disabled 4th largest cause of major activity limitation Most common causes:Chronic BronchitisEmphysemaAsthmatic BronchitisCystic fibrosis

CHRONIC BRONCHITIS

Inflammation of the bronchi that causes an irritating and productive cough that last at least 3 months and recurs over at least 3 consecutive years

Develop in heavy smoker

CHRONIC BRONCHITIS

PATHOLOGY

Increase in the number of mucus-producing goblet cells

Decrease in the number and action of ciliated epithelial cells

Narrowing of airways

CHRONIC BRONCHITIS

GENERAL APPEARANCE

Cyanotic because of hypoxemia

Shortness of breath

Bloated because of venous stasis

Often overweight

Blue Bloaters

EMPHYSEMA

A chronic inflammation, narrowing, thickening and destruction of the respiratory bronchioles and alveoli

A condition that develops secondary to chronic bronchitis

Can also be a primary disease that can occur in non-smokers

EMPHYSEMA

PATHOLOGY

Over inflation of the lungs and formation of pockets of air known as bullae

Destruction of lung tissue and loss of area where effective gas exchange can occur

Cigarette smoking

Most frequent cause of CB and Emphysema

Death by COPD: 3.5 to 25x for smoker than non-smoker

All one pack a day smokers would eventually develop emphysema

1 in 15 will succumb to lung Ca

For 30-35y.o.

10-20 sticks/day die 5 years sooner

1-2 packs/day die 6.5 years sooner

EMPHYSEMA

GENARAL APPEARANCE

Pink and thin

Abnormal posture- forward head, rounded and elevated shoulder

Use of accessory muscle

Pursed-lip breathing during expiration

Increased AP diameter of chest (Barrel Chested)

Pink Puffers

Cigarette smoking

Cessation of smoking has been associated with improvement in symptoms, pulmonary function, decrease risk of pulmonary infection and long term diseased reduction rate

ASTHMA

It is related to hypersensitivity of the trachea and brochi

Causes difficulties with respiration because of bronchospasm and increased mucus prodution

ASTHMA

PATHOLOGY

Severe spasm of smooth muscle of the bronchial tree

Narrowing of airways

Inflammation of mucosal lining and hyper secretion of mucus

ASTHMA

General Appearance

Chronically fatigue

Often thin

Poor posture- rounded shoulder, forward head

BROCHIECTASIS

Characterized by dilation of the medium-sized bronchioles, usually the fourth of the ninth generations

BROCHIECTASIS

PATHOLOGY

Repeated infection of the lobes of the lungs

Destruction of ciliated epithelial cells in infected areas

CYSTIC FIBROSIS

Generally based disease (autosomal recessive) that invloves malfunction of the exocrine glands, leading to abnormal secretions

Increase production of viscous mucus and periodic pulmonary infection

PATIENT EVALUATION

Patients history should be explore for presence of pulmonary disease

Medically history should focus on:

- Rate of progression of symptoms

- Impact on the patients functional activities

- Financial or psychological factors

PATIENT EVALUATION

Poor nutrition is characterized by low protein values

Serum albumin is a good indicator of visceral protein depletion. Correlates better with hypoxia than Spiro metric values and good predictor of rehabilitation outcome

Hypophosphatemia common in critically ill COPD patient

Hypomagnesemia, Hypocalcemia, and Hypoalkelemia may cause respiratory muscle weakness that is reversible after replacement

THERAPEUTIC INTERVENTION

MEDICATION Medical regimen is optimized before undertakin

the program Include METHYLXANTHINES, ADRENERGICS and

ANTICHOLINERGICS Administered orally/aerosolized THEOPHYLLINE can act as a bronchodilatorand

alleviates diaphragm fatigue, increase cardiac output, inhibit mast cell degranulation and enhances mucocillary clearance for COPD patient

Medication that can impair respiratory function includes non-selective beta blocker antihypertensive agents

Other medication such as expectorants, mucolytics and antibiotics are used along with humidification, ample fluid intake and facilitated airway secretion elimination

COUNSELING AND GENRAL MEDICAL CARE

DYSPNEA MAY CAUSE FEAR AND PANIC

Relaxation exercise and biofeedback may be used to decrease tension and anxiety.

Diaphragmatic and pursed-lip also aid in relaxation

Life quality is perceived to be impaired and depression has been reported in 50% of COPD patient. Psychosocial support optimizes intervention.


Smoking cessation strategies:

Nicotine impregnated gum and skin patches

Scare tactics

Acupuncture

Physician must play key political and educational roles for general public as well as abstinence from smoking necessary component of Pulmonary Rehabilitation


Yearly flu vaccination are recommended and pneumococcal vaccine are used one time or every 6 years of high risk cases

NUTRITIONAL

Significant weight loss in 19-71% of COPD

Significant under nutrition are more frequently colonized by PSEUDOMONAS SPECIES

Malnutrition may adversely affect lung repair, surfactant synthesis, respiratory muscle function

Increasing carbohydrate intake can exacerbate hypercapnea

Short term refeeding may lead to improved respiratory muscle endurance and strength

NUTRITIONAL

Patient are advised to take smaller mouthfuls of food, eat more slowly and take smaller and more frequent meals

BREATHING RETRAINING

Shallow rapid breathing is commonly seen in anxious and dyspenic patient

This increases dead space ventilation and airflow through narrowed airways, thus increasing the flow of work breathing

COPD patient have an altered pattern of ventilation. Ventilatory pressure is generated by the rib cage inspiratory muscle rather than the diaphragm.

BREATHING RETRAINING

Diaphragmatic breathing and pursed-lip exhalation can help to reverse these tendencies

Also decreases the respiratory rate and coordinates the breathing pattern and can improve blood gases

DIAPHRAGMATIC BREATHING EXERCISE

In supine or 15 to 25 deg head down position

Have the patient place one hand over the abdomen and the other on the thorax just below the clavicle

He/She should breath deeply through the nose while distending the abdomen

Movement of ribcage should be kept minimum

AIRWAY SECRETION ELIMINATION

Patients cough may be weak and frequent bouts are fatiguing

huffing or frequent short expulsive burst following a deep breath, is often an effective and more comfortable alternative to coughing

Chest percussion and postural drainage an be useful for patient with chronic bronchitis or >30% ml of sputum production per day


POSITIVE EXPIRATORY PRESSURE

MUCUS MORE EFFECTIVELY MOBILIZE

Applied by breathing through a face mask or mouth piece with an inspiratory tube containing a one-way valve and an expiratory tube containing a variable expiratory resistance

It increases functional residual capacity, reducing resistance to airflow collateral and small airway


MECHANICAL VIBRATION or OSCILLATION

Mechanically applied over the thorax to facilitate airway secretion

Vibration is possible at frequency up to 170 Hz

Effects of mechanical chest percussion and vibration appear to be frequency dependent

SUPPLEMENTAL OXYGEN THERAPY

Indicated for patients with PO2 continuously less than 55 to 60 mmHg

International consensus on the current status and indications for long term oxygen therapy

RECONDITIONING EXERCISE

Most patients cannot attain the 60-70% of predicted maximum heart rate nor the minute oxygen consumption needed for cardiac or aerobic thresholds

Exercise intensity can be guided

Walking, stair climbing, calisthenics, bicycling and pool activities may be effective

UE reconditioning is also part of any comprehensive program

RECONDITIONING EXERCISE

RECOMMENDATIONS:

Daily 12min walk

Daily 15min session of inspiratory muscle training

REHABILITATION OF PATIENT WITH RESTRICTIVE LUNG DISEASE

Characterized by the inability of the lungs to fully expand as the result of an extrapulmonary or pulmonary restrictions

Extrapulmonary

Pleural Disease (Pleural Effusion)

Chest wall injury/stiffness ( rib fracture, pectusexcavatum, scoliosis, AC )

Respiratory muscle weakness ( muscular dystrophy, high SCI )

REHABILITATION OF PATIENT WITH RESTRICTIVE LUNG DISEASE

Pulmonary restriction

Pneumonia

Tumor

Atelectasis

Heart disease

Characterized by:

Low VC

Reduced TLC

Tachypnea

Shallow breathing

Reduced pulmonary compliance

Increased elastic work of breathing

RESTRICTIVE LUNG DISEASE TREATMENT

COUNSELING

Patient is cautioned to avoid oxygen therapy, obesity, heavy meals, extremes of temperature, humidity, excessive fatigue, crowded areas, sedatives

Need for flu and bacterial vaccination

Abdominal binder may be useful to increase diaphragmatic excursion and VC


MAINTENANCE OF RESPIRATORY MUSCLE STRENGTH AND ENDURANCE

Short daily session of inspiratory resistive exercise alone did improve respiratory muscle endurance

No evidence that beginning an exercise program earlier would preserve more muscle function nor delay occurrence of pulmonary complications


GLOSSOPHRAYNGEAL BREATHING

Means of increasing a patients inspiratorycapacity when there is severe weakness of the muscle inspiration

Excellent back up in the event of ventilator equipment failure

Patient takes in several gulps of air. Then the mouth is closed and the tongue pushes the air back and traps in the pharynx. The air then forced into the lungs when the glottis is open


INTERMITTENT ABDOMINAL PRESSURE VENTILATOR

Ventilator preferred for daytime ventilatorysupport by the majority of wheelchair users with less than 1 hour of ventilator free breathing

It is convenient mode of assisted ventilation

GUIDELINES FOR THE SIX MINUTE WALK TEST

THIS OFFICIAL STATEMENT OF THE AMERICAN THORACIC SOCIETY WAS APPROVED BY THE ATS BOARD OF DIRECTORS MARCH 2002

Pulmonary Rehabilitation

Documents

Transcript of Pulmonary Rehabilitation