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Dr. ANIRBAN MALLICK
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Varying degrees ofairflow obstruction due
to inflammation andincreasedbronchomotor tone.After long periods ofirritation, excessive
mucous is producedconstantly, thebronchial tubes becomethickened
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A conditioncharacterized by
abnormalenlargement of thespaces distal to theterminal bronchiole,
accompanied by thedestruction of theirwalls and withoutobvious fibrosis.
EMPHYSEMA
Normal Lung Emphysematic Lung
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Characterised by a chronic cough and excessivesputum production.
There is an enlargement and an increased density
of mucous glands. The airway becomes thickened and undergo
squamous metaplasia
Reduced number of ciliated cells
Causes an increase in air flow resistance Plugged airways and decreased ciliary action
encourages stagnant bronchial secretions and anincreased risk of infection.
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Can be caused by smoking, air pollution andenvironmental and occupational hazards
Main characteristic is loss of lung elasticity andreduction of elastic recoil due to alveolardestruction
Destruction of elastic tissue leads to loss of elasticrecoil of lungs during expiration and forcedexpiration necessitated
Eventual destruction of airway / capillary
membranes
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Airflow obstruction Elastic recoil of lung promote,airway ressistance
limit
Reduced FEV1/FVC
Inspiratory phase
preserved
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Hyperinflation Increased RV , increased TLC causing
hyperinflation
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Become flat
+ve abdominal pressure not generated duringinspiration
Short fibres ,less contract
More radius, more tension
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Gas exchange Pao2 N even FEV1
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Even in the face of irreversible
abnormalities of lung architecturepulmonary rehabilitation can:
Reduce symptoms
Increase functional ability Improve quality of life
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These benefits occur not because of
Reduced airway obstruction
Decreased dynamic hyperinflation
But due to improvements in secondarymorbidities that are treatable
Reversal of muscle deconditioning Increased respiratory muscle strength
Desensitization to dyspnea
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Four major components
ExerciseTraining Education
Psychosocial/behavioral
interventions Outcome assessment
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Endurance training
Breathing exercise
Resistance training
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GRADE CAUSE OFDYSPNEA
FEV1 % VO2 MAX MAX V E BLOOD
GAS
1 Fast walkingStair
climbing
>60 >25 Not limiting N Paco2Sao2
2 Walking atnormal
space
90%
3 Slowwalking
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Assess cardiac risk Assess exercise capacity
(Vo2max)
Appropriate level to preventarrhythmia
Amount of o2, bronchodilator
needed
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Vo2 max = h.rate max x stroke volume max x
(a-v ) o2 difference max COPD > V/P mismatch > Pao2 reduced > a-v
o2 dif. reduced > reduce Vo2max > reduce CRF
Pt become more inactive
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AIR-FLOW OBSTRUCTION
PROLONGED EXPIRATION
PULMONARY HYPERINFLATION
DUE TO AIR-TRAPPING
INCREASED WORK OF BREATHING
DYSPNOEA
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ALVEOLAR DISTORTION
AND DESTRUCTION
LOSS OF HYPOXIA CAUSINGCAPILLARY BED PULMONARY
VASOCONSTRICTION
PULMONARY HYPERTENSION
SECONDARY VASCULAR CHANGES
COR-PULMONALE
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Hypoxia
H
ypercapnea Dynamic airway
compression
^ cardiac output
Reduced resting BP Increased peripheral
utilization of o2
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Compression of alveolar
capillary
Hypoxia induced pulmonaryvasoconstriction
Secondary pulmonaryhypertension
RV failure
^ Pao2
^a-v o2( o2 extraction)
Increased capillarization oftrained musclesa) new capillaries develop- o capillary to fiber ratio.b)Greater opening of
existing capillaries.c) More effective bloodredistribution (shunting
away from areas that dontneed high flow).
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HRR = MHR RHR
% ofH
RR = % of Vo2max Intensity threshold for deconditioned 50%
Vo2max
50%HRR + RHR = THR
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Start with 30% Vo2max
Proper warm-up,cooling down
Duration -15-20 mns
3 times wkly
Cont. for 4-6 wks
Increase by 10% Change speed & inclination
cautiously
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To improve jt motion
To improve support of chest wall
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To improve day to day activityTo prevent fall
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Exercise for both inspiratory & expiratory muscle
Improve value of breathing Decrease dyspnea
Increase exercise performance
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Diaphragmatic breathing
20 mins at a time,2-3 times daily To increase air in basal area
,more perfused
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Study published in American Journal ofRespiratory Medicine
Pi max measured by manometer
RMT done at 30% Pi max,for 8 wks, compared
with control group
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Pursed lip breathing
Increase intra-ductal pressure Decrease residual volume
Breath in through nose,
out through mouth Ins time -4 s ,
Exp. time 6-8 s
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Hypertrophy of muscleHypertrophy of muscle Cardiac hypertrophyCardiac hypertrophy Agility progressionAgility progression Flexibility progressionFlexibility progression
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Measure 1 RM for each important muscle group
Aim hypertrophy / endurance Target 70% of 1 RM
Start with low %
G
radual increment Target in 8 wks
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Determine 1RM (repetition max.)
Set -1 Repetition - 8-12
No. of ex 8-10
Frq. 2-3 d/ wk
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