CRC 432 Subacute Care
Pulmonary Rehabilitation
Pulmonary Rehabilitation
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Goals
– Maximize patient’s functional ability
– Minimize impact in
• Patient
• Family
• Community
– Improve quality of life
– Control & alleviate symptoms
Pulmonary Rehabilitation
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Historical Perspective
– 1951: Dr Barach recommended physical
reconditioning for COPD patients
• Walk without becoming dyspneic
– Barach was ignored; O2 therapy & bed rest
prescribed
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Skeletal muscle deterioration
Fatigue & weakness
Increased dyspnea
Homebound, room bound, bed bound
Pulmonary Rehabilitation
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Historical Perspective
– 1962: Pierce confirmed Barach
– Pierce found that exercising COPD patients
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Decreased pulse
Decreased respiratory rates
Decreased minute ventilation
Decreased CO2 production
Improved pulmonary function
Pulmonary Rehabilitation
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Historical Perspective
– Paez demonstrated
• Efficiency of motion
• Decreased O2 consumption
– Smoking cessation included
– Education added
• Pathophysiology
• Equipment
• Medications
Pulmonary Rehabilitation
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Scientific Basis
– Focus on patient
– Include clinical sciences
• Quantify degree of physiologic impairment
• Establish outcomes for reconditioning
– Include social sciences
• Psychological
• Social
• Vocational
Pulmonary Rehabilitation
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Physical Reconditioning
– Exercise increases energy demands
• Increased circulation
• Increased ventilation
• Increased O2 deliver
• Increase CO2 elimination
– If O2 demands NOT met
• Blood lactate level increase
• CO2 increases as lactic acid buffered
• Increased stimulus to breathe
Pulmonary Rehabilitation
Pulmonary Rehabilitation
This point is called the “onset of blood
lactate accumulation,” or OBLA
 Abrupt rise in PaCO2 & minute ventilation:
called “ventilatory threshold”
 Beyond VT, metabolism = anaerobic
respiration (decreased NRG production
efficiency, lactic acid rise, fatigue)
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Pulmonary Rehabilitation
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Physical Reconditioning
– MVV index of respiratory system’s ability to
handle increased physical activity
– MVV = FEV1 x 35
– Normal: 60%-70% of pred MVV during max
exercise
– Indicates adequate respiratory reserve
– Indicates ventilation NOT primary limiting
factor for ending exercise
Pulmonary Rehabilitation
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Physical Reconditioning
– MVV decreased with COPD
– COPDs have limited exercise ability
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Increased CO2 production
Respiratory acidosis
SOB
O2 consumption increases faster than normal
Pulmonary Rehabilitation
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Physical Reconditioning
– Rehab programs must:
• Physically recondition
• Increase exercise tolerance
Pulmonary Rehabilitation
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Psychosocial Support
– Indicators bettor predictors of frequency &
LOS for COPD patients compared to PFTs
– Psychosocial indicators better determine rehab
program completion than physical
reconditioning
– COPD negatively affects person’s outlook on
life
– Can reduce motivation
Pulmonary Rehabilitation
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Psychosocial Support
– Depression/hostility occur with acute & chronic
disease
– Economic loss & fear of death produce hostility
– Interaction among patients is beneficial
– Patient’s lacking social support at higher risk
for re-hospitalization
– Intolerance for physical exertion lessens social
activity
Pulmonary Rehabilitation
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Psychosocial Support
– Physical reconditioning & psychosocial support
linked
– Reducing exercise intolerance & improving
cardiovascular response to exercise =
independent, active lifestyle
– Improve social importance & self-worth
– Occupational training & job placement
important
Pulmonary Rehabilitation
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Program Goals
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Control respiratory infection
Basic airway management
Improve ventilation & cardiac status
Improve ambulation & other physical activities
Reduce medical costs
Reduce hospitalizations
Pulmonary Rehabilitation
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Program Goals
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Reduce LOS when hospitalized
Reduce # of MD office visits
Provide psychosocial support
Occupational training/job placement
Family education, counseling, support
Patient education, counseling, support
Pulmonary Rehabilitation
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PROGRAM OBJECTIVES
– Development of diaphragmatic breathing skills
– Development of stress management and relaxation techniques
– Involvement in a daily physical exercise regimen to condition both
skeletal and respiratory-related muscles
– Adherence to proper hygiene, diet, and nutrition
– Proper use of medications, oxygen, and breathing equipment (if
applicable)
– Application of airway clearance techniques (when indicated)
– Focus on group support
– Provisions for individual and family counseling
Pulmonary Rehabilitation
Chronic lung disease progressive &
irreversible
 Rehabilitation does NOT alter progressive
deterioration
 Rehabilitation improves utilization of O2
by:
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– Increasing muscle use effectiveness
– Promoting effective breathing techniques
Pulmonary Rehabilitation
O2 cost for given amount of ventilation is
excessive
 Training skeletal muscle groups alone NOT
beneficial
 Training respiratory related muscles
improves exercise tolerance
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Pulmonary Rehabilitation
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Evaluation of Rehabilitation Program Outcomes
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Changes in exercise tolerance
Before and after 6 minute walking distance
Review of patient home exercise logs
Strength measurement
Flexibility and posture
Performance on specific exercises (e.g., ventilatory muscle,
upper extremity)
Changes in symptoms
Dyspnea measurement comparison
Frequency of cough, sputum production, or wheezing
Weight loss or gain
Psychological test instruments
Pulmonary Rehabilitation
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Evaluation of Rehabilitation Program Outcomes
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Other changes
Activities of daily living (ADL) changes
Postprogram follow-up questionnaires
Preprogram and postprogram knowledge tests
Compliance improvement with pulmonary rehabilitation
medical regimen
Frequency and duration of respiratory exacerbations
Frequency and duration of hospitalizations
Frequency of emergency department visits
Return to productive employment
Pulmonary Rehabilitation
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Potential Hazards
– Cardiovascular abnormalities
• Cardiac arrhythmias (can be reduced with supplemental oxygen
during exercise)
• Systemic hypotension
– Blood gas abnormalities
• Arterial desaturation
• Hypercapnia
• Acidosis
– Muscular abnormalities
• Functional or structural injuries
• Diaphragmatic fatigue and failure
• Exercise-induced muscle contracture
Pulmonary Rehabilitation
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Potential Hazards
– Miscellaneous
• Exercise-induced asthma (more common in young
patient with asthma than in patients with COPD)
• Hypoglycemia
• Dehydration
Pulmonary Rehabilitation
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Patient Selection
– Evaluation
– Testing
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Patient Evaluation
– History (medical, psychological, vocational,
social)
– Questionnaire/interview form
– Physical exam
– CXR
Pulmonary Rehabilitation
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Patient Evaluation
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CBC
Electrolytes
Urinalysis
PFTs (spirometry, volumes, DLCO, pre/post)
Cardiopulmonary exercise evaluation
• Quantifies initial exercise capacity
• Provides basis for exercise prescription
• Renders baseline data for assessing progress
• Shows degree of hypoxemia/desat during exercise
Pulmonary Rehabilitation
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Common Physiological Parameters Measured During
Exercise Evaluation
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Blood pressure
Heart rate
ECG
Respiratory rate
Arterial blood gases (ABGs)/O2 saturation
Maximum ventilation (VEmax)
O2 consumption (either absolute VO2 or METS, the metabolic
equivalent of energey expenditure)
– CO2 production (VCO2)
– Respiratory quotient (RQ)
– O2 pulse
Pulmonary Rehabilitation
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Exercise Evaluation
– Graded levels (ergometer or treadmill)
– 3-min intervals allow steady state
– ABGs at rest & at peak exercise
Pulmonary Rehabilitation
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Relative Contraindications to Exercise Testing
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Patients who cannot or will not perform the test
Severe pulmonary hypertension/cor pulmonale
Known electrolyte disturbances (hypokalemia, hypomagnesemia)
Resting diastolic blood pressure > 110 mm Hg or resting systolic blood
pressure > 200 mm Hg
Neuromuscular, musculoskeletal, or rheumatoid disorders exacerbated
by exercise
Uncontrolled metabolic disease (e.g., diabetes)
SaO2 or SpO2 < 85% with the subject breathing room air
Untreated or unstable asthma
Pulmonary Rehabilitation
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Indications for Pulmonary Rehabilitation
– Symptomatic patients with COPD
– Patients with bronchial asthma and associated
bronchitis (asthmatic bronchitis)
– Patients with combined obstructive and restrictive
ventilatory defects
– Patients with chronic mucocilliary clearance problems
– Patients having exercise limitations due to severe
dyspnea
Pulmonary Rehabilitation
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Patient Selection
– Ex-smokers
– Smoking cessation program for smokers
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Patients Excluded
– Concurrent problems limit or preclude
exercising
– Condition complicated by malignant
neoplasms, e.g., bronchogenic carcinoma
Pulmonary Rehabilitation
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Program Design
– Open-ended format
• Participate until predetermined objectives
achieved
• No set timeframe
• Completed at patient’s pace
• Good format for self-directed patients
• Good format for schedule difficulties
• Good format for individual attention
• Lack group support/involvement
Pulmonary Rehabilitation
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Program Design
– Closed design
• Set timeframe (8 to 16 weeks; 1 to 3 sessions/wk)
• Insurance coverage may dictate length for which
person qualifies
• Sessions last 1 to 3 hours
• Presentations formal
• Offer group support/involvement
• Schedule determines program completion
Pulmonary Rehabilitation
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Content
Component
Education
Focus
Time Frame
Welcome (group interaction)
5 mins
Review of program diaries
(past week’s activities)
20 mins
Presentation of education topic
20 mins
Questions, answers, and group
discussion
15 mins
Physical
Physical activity and reconditioning 45 mins
Reconditioning
Individual goal-setting and session
summary
15 mins
Total: 120 minutes (2 hours)
Pulmonary Rehabilitation
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Physical Reconditioning
– Excise prescription with target HR based on
initial exercise evaluation
– Target HR set using Karvonen’s formula
– THR = [(MHR-RHR) x (50% to 70%)] + RHR
Pulmonary Rehabilitation
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Physical Reconditioning
MHR = 150 bpm
RHR = 90 bpm
THR = [(150 – 90) x (0.6)]+ 90 = 126 bpm
Pulmonary Rehabilitation
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Exercise Prescription
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Lower extremity aerobic exercises
Timed walking
Upper extremity aerobic exercises
Respiratory muscle training
Monitoring during Exercise
– Pulse oximetry
– Blood pressure
Pulmonary Rehabilitation
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Lower Extremity
– Walking (treadmill/flat surface)
• Goals for distance, time, grade on treadmill
• 6 minute flat surface/increase distance
– Bicycling (stationary)
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Upper Extremity
– Arm ergometers
– Rowing machines
Pulmonary Rehabilitation
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Inspiratory resistance breathing device
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Adjustable flow resistor
One-way valve
Inhale through restricted orifice (variable size)
Change inspiratory load
Exhalation through one-way valve
Pulmonary Rehabilitation
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Instruction
– Sit upright
– Breathe slowly through device (10 – 12 bpm)
– MIP < 30% of measured Pimax, use next smaller
orifice
– Repeat effort until 30% is consistently achieved
– 1 or 2 daily sessions for 10 – 15 minutes/session
– When 30% is consistently achieved, increase
resistance
– Increase session time to 30 minutes
Pulmonary Rehabilitation
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Introduction and welcome, program orientation
Respiratory structure, function, and pathology
Breathing control methods
Relaxation and stress management
Proper exercise techniques and personal routines
Methods to ad secretion clearance (bronchial hygiene)
Home oxygen and aerosol therapy
Medications: their use and abuse
Medications: use of MDIs and spacers
Dietary guidelines and good nutrition
Recreation and vocational counseling
Activities of daily living
Follow-up planning and program evaluation
Graduation
Pulmonary Rehabilitation
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Program Results
– Evaluate
• Patient
• Program outcomes
– Preprogram/current program status
– Data
• Physiological
• Psychological
• Sociological