By

Riham Hazem RaafatLecturer of Chest Diseases

Ainshams University

Learning Objectives

• Definition of PR

• Benefits of PR

• Components of PR

• Selectivity of patients fit for PR

• Different programs of exercise in PR

• Nutritional plan in PR

• Different guidelines’ recommendations

DISEASE

IMPAIRMENT

DISABILITY

HANDICAP

TREATMENT

REHABILITATION

REHABILITATION

Spiral of Disability

• Evidence-based, multidisciplinary, and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities

• Integrated into the individualized treatment of the patient, pulmonary rehabilitation is designed to reduce symptoms, optimize functional status, increase participation, reduce health care costs through stabilizing or reversing systemic manifestations of the disease, and increase activities & QOL

ATS – ERS Definition

General exercise training

Pathophysiology

• Peripheral muscle dysfunction

• Respiratory muscle dysfunction

• Nutritional abnormalities

• Cardiac impairment

• Skeletal disease

• Sensory defects

• Psychosocial dysfunction

Consequences of Chronic Respiratory

Disease • Deconditioning

•Malnutrition

•Effects of hypoxemia

•Steroid myopathy or

ICU neuropathy

•Hyperinflation

•Diaphragmatic fatigue

•Psychosocial dysfunction from

anxiety, guilt, dependency and

sleep disturbances

Mechanisms of these

Morbidities

Benefits of Pulmonary Rehabilitation Pulmonary rehabilitation does not reverse nor have any direct effect on the primary respiratory pathophysiology, yet it has proven to improve the following:

Obstructive 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 ((GOLDGOLD))

Restrictive Diseases InterstitialChest WallNeuromuscular

Other Diseases

Patient Selection

• Patients with severe orthopedic or neurological disorders

limiting their mobility

• Severe pulmonary arterial hypertension

• Exercise induced syncope

• Unstable angina or recent MI

• Refractory fatigue

• Inability to learn, psychiatric instability and disruptive

behavior

Exclusion Criteria

Control of symptoms of cough and fatigue: Real time eval.: MRC breathlessness & Borg dyspnea scale Recall of symptoms

Performance evaluation: Ability to do ADL Directly observed or self reported + PFTs, ABG or Oximetry

Exercise tolerance: 6 minutes walking test Cardiopulmonary exercise testing

Quality of life: (specific or non-specific) Chronic respiratory disease questionnaire & SGRQs SF- 36

Assessment of respiratory and peripheral muscle strength Nutritional assessment

History, Laboratory, Anthropometric, Calorimetry (D&ID)

Baseline Evaluation

• Outpatient

• Inpatient

• Home

Choice varies depending on:

- Distance to program

- Insurance payer coverage

- Patient preference

- Physical, functional, psychosocial status of patient

Setting for Pulmonary Rehabilitation

•Breathing Strategies

•Normal Lung Function and

Pathophysiology of Lung Disease

•Proper Use of Medications, including Oxygen

•Bronchial Hygiene Techniques

•Benefits of Exercise and Maintaining Physical Activities

•Energy Conservation & Work Simplification Techniques

•Eating Right

1- Education

• Irritant Avoidance, including Smoking Cessation

• Prevention and Early Treatment of Respiratory

Exacerbations

• Indications for Calling the Health Care Provider

• Leisure, Travel, and Sexuality

• Coping with Chronic Lung Disease and End-of-Life

Planning

• Anxiety and Panic Control, including Relaxation

Techniques and Stress Management

2- Exercise trainingPathophysiological abnormality Benefits of exercise trainingDecreased lean body mass (N: 60-90%) Increases fat free mass

Decreased Type 1 fibers Normalizes proportion

Decreased cross sectional area of muscle fibers

Increases

Decreased capillary contacts to muscle fibers

Increases

Decreased capacity of oxidative enzymes

Increases

Increased inflammation No effect

Increased apoptotic markers No effect

Reduced glutathione levels Increases

Lower intracellular pH, increased lactate levels and rapid fall in pH on exercise

Normalization of decline inpH

Components of exercise training:

• Lower extremity exercises

• Arm exercises

• Ventilatory muscle training

Types of exercise:

• Endurance or aerobic

• Strength or resistance

• Walking

• Treadmill

• Stationary bicycle

• Stair climbing

• Sit & Stand

Lower extremity exercise

Benefits in COPD

• Increased work capability as assessed by pre & post PR

incremental treadmill protocol or 6 min walking distance

• 40 – 102% increase in endurance of maximal work rate

• Significant improvement in subjective assessment using

Borg dyspnea scale

• No changes in hemodynamics during exercise

• Arm cycle ergometer

• Unsupported arm lifting

• Lifting weights

Arm exercise training

Benefits in COPD • Has the potential to improve arm exercise performance &

capacity by decreasing ventilatory & metabolic demand

during arm work (measured by Vo2), and by improving

arm endurance.

• Arm training improves the ventilatory contribution of those

muscles by increasing shoulder girdle muscle strength.

• No significant effect on outcomes, such as functional status

and performance when arm training used alone.

Strength exercises:When strength exercise was added to standard exercise

protocol; led to:

greater increase in muscle strength and muscle mass (FFM) increased mid-thigh circumference

But NO additional benefit in: Exercise capacity as assessed by 6MWD or CPET HRQOL Physiological parameters of heart rate or blood lactate

levels

Resistive non-targeted IMT:Patient breaths through hand held

device with which resistance to

flow can be increased gradually.

Pressure Threshold IMT:Patient breaths through a device

equipped with a valve which opens

at a given pressure.

• Difficult to standardize the load

• Patients may hypoventilate

• Leads to increased Pulmonary

Arterial Pressure and fall in

oxygen tension

• Easily quantitated and

standardized

Ventilatory muscle training

*30 breath twice daily, intensity 50% of Pimax, inc. 5% load/wk. for 6wks

• Voluntary Isocapnic Hyperventilation (VIH):

Endurance technique; patients are asked to breathe at the highest

rate they can manage for 15 to 30 minutes. Hypocapnia and its

accompanying symptoms are prevented by adding CO2 to the

inspired air or by requiring partial rebreathing of expired air.

Can improve maximum voluntary ventilation (MVV) in COPD.

• Pursed Lip Breathing – shifts breathing pattern and inhibits dynamic airway collapse. (2s inh, 4s exh)

• 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

Chest Physical Therapy & Breathing Retraining

Pursed Lip Diaphragmatic Breathing

• Postural drainage

• Percussion

• Directed cough: as Forced expiratory technique (huffing: small long (LL) or big short huff (UL) in cycle; 10 mins twice /d)

• Active cycle of breathing (breathing control (hands on abd.), deep breathing exercises e’ breath hold (ribs) & huffing +/- manual technique)

• Autogenic drainage (self drainage: unstick, collect, evacuate)

• Positive expiratory pressure (behind mucus to push)

• Incentive Spirometry

Bronchial Hygiene Techniques

Can be associated with others

Vibratory PEP

Flutter deviceAcapella

• A minimum of 20 sessions should be given (6-12 wks)• At least three times per week • Twice weekly supervised plus one unsupervised home

session may also be acceptable.• Once weekly sessions seem to be insufficient• Each session to last 30 minutes (10-45)• High-intensity exercise (50-60% of maximal work rate

or peak Vo2) produces greater physiologic benefit and should be encouraged; however, low-intensity training is also effective for those patients who cannot achieve this level of intensity (ATS-ERS)

What do Guidelines Say?

• Both upper & lower extremity training should be utilized

• Lower extremity exercises like treadmill and stationary bicycle ergometer & Arm exercises like lifting weights and arm cycle ergometer are recommended

• The combination of endurance and strength training generally has multiple beneficial effects and is well tolerated; strength training would be particularly indicated for patients with significant muscle atrophy

• Respiratory muscle training could be considered as adjunctive therapy, primarily in patients with suspected or proven respiratory muscle weakness (ATS/ERS)

• The minimum length of an effective rehabilitation program is 6 weeks.

• Daily to weekly sessions

• Duration of 10 minutes to 45 minutes per session

• Intensity of 50% of VO2 max to maximum tolerated

• Endurance training can be accomplished through continuous or interval exercise programs.

• The latter involve the patient doing the same total work but divided into briefer periods of high-intensity exercise, which is useful when performance is limited by other comorbidities (GOLD)

• Optimal bronchodilator therapy should be given prior to exercise training to enhance performance.

• Patients who are receiving long-term oxygen therapy should have this continued during exercise training, but may need increased flow rates.

• Oxygen supplementation during pulmonary rehabilitation, regardless of whether or not oxygen desaturation during exercise occurs, often allows for higher training intensity and/or reduced symptoms in the research setting. (ATS/ERS)

Additional considerations:

may be an adjunctive therapy for patients with severe chronic respiratory

disease who are bed bound or suffering from extreme skeletal muscle

weakness.

• Non invasive mechanical ventilation: Because NPPV is a very difficult

and labor-intensive intervention, it should be used only in those with

demonstrated benefit from this therapy (ATS/ERS)

• Further studies are needed to further define its role in pulmonary rehabilitation.

• Neuromuscular electrical stimulation (NMES):

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.

3- Nutritional Interventions

Body composition abnormalities:

↑ ACTIVITY RELATED ENERGY EXPENDITURE

HYPERMETABOLIC STATE

DECREASED INTAKE

IMPAIRMENT OF ENERGY BALANCE

IMBALANCE IN PROTEIN SYNTHESIS AND BREAKDOWN

LOSS OF FAT

LOSS OF WEIGHT: BMI <2110% WEIGHT LOSS IN 6 MONTHS5% WEIGHT LOSS IN 1 MONTH

LOSS OF FFMANTHROPOMETRYBIOIMPEDANCE ANALYSISDEXALab. Investigations

CALORIC SUPPLEMENTS

PROTEIN SUPPLEMENT

STRENGTH

EXERCISE

ANABOLIC

STEROIDS

GROWTH

HORMONE

INTERVENTIONS

Should be considered if :

•BMI less than 21 kg/m2 (2/3 pts referred to PR, 1/3 outpatients

are underweight and have greater impairment in HRQoL, increased

mortality independent on degree of obstruction)

•Involuntary weight loss of >10% during the last 6 months

or more than 5% in the past month (can’t depend in edema)

•Depletion in FFM or lean body mass (make QoL worse and

less tolerant to exercise even when normal weight)

Nutritional Supplementation

• Energy dense foods, well distributed during the day

• No evidence of advantage of high fat diet (pulmocare:

high fat low CHO formula decrease Co2 retention)

• Patients experience less dyspnea after liquid

carbohydrate rich supplement than fat rich supplement.

(probably dt delayed gastric emptying distention)

• Daily protein intake should be 1.5 gm/kg for positive

balance

• Antioxidants like vitamin C, E .. Also Vitamin D

Nutritional supplementation

• High-calorie snacks- creamy, rich puddings, crackers with peanut butter, dried fruits and nuts.

• Beverages- milk-shakes, regular milk and high-calorie fruit juices

• Breads and Cereals• Pep up Your Protein- milk or soy protein powder to

mashed potatoes, gravies, soups and hot cereal• Choose High-Calorie Fruits- bananas, mango, dates,

dried apples or apricots instead of apples, watermelon • Remember Your Vegetables potatoes, beets, corn, peas,

carrots• Healthy, Unsaturated Fats • Soups and Salads

Small Frequent Meals (decrease metabolic & ventilatory effort, loss of appetite)

Physiological intervention: Strength exercise•Addition of strength training lead to increase in strength and mid thigh circumference (measured by CT)

Pharmacological intervention :

- Anabolic steroids•Anabolic steroids

•Nandrolone decanoate - 50 mg for male; 25 mg for females; 2 Weekly 4 doses

•Anabolic therapy alone increases muscle mass but not exercise capacity

Nutritional Interventions

- Growth hormone

•rhGH 0.05 mg/kg for 3 weeks in addition to 35 Kcal/kg &

1gm protein/kg per day has shown to increase fat free mass

•But does not improve muscle strength or exercise

tolerance (hand grip and maximal exercise) and no change

in well being of the patient.

- Testosterone

•Testosterone 100 mg weekly for ten weeks in men with

low testosterone levels 320 ng/ml showed weight gain of

2.3 kg

•Addition of exercise to testosterone has augmented weight

gain to 3.3 kg

•Physiological consequences and long term effects not

studied

INTERVENTION WEIGHT GAIN

FFM GAIN EXERCISE CAPACITY

CALORIC SUPP. + - -

CALORIC SUPPLEMENTATION +EXERCISE TRAINING

++ + +

STRENGTH EXERCISE - + -

ANABOLIC STEROIDS ++ ++ -

ANABOLIC STEROIDS + EXERCISE

++ +++ ?

• Increased calorie intake is best accompanied by exercise

regimes that have a nonspecific anabolic action

• Anabolic steroids in COPD patients with weight loss

increase body weight and lean body mass; but have little

or no effect on exercise capacity. (GOLD)

• Pulmonary rehabilitation programs should address body

composition abnormalities. Intervention may be in the

form of caloric, physiologic, pharmacologic or

combination therapy. (ATS/ERS STATEMENT)

What do Guidelines Say?

• Screening for anxiety and depression should be part of

the initial assessment.

• Mild or moderate levels of anxiety or depression

related to the disease process may improve with

pulmonary rehabilitation

• Patients with significant psychiatric disease should be

referred for appropriate professional care (ATS/ERS

STATEMENT)

4- Psychological considerations

5- Outcome Assessment

Control of symptoms of cough and fatigue: Real time eval.: MRC breathlessness & Borg dyspnea scale Recall of symptoms

Performance evaluation: Ability to do ADL Directly observed or self reported

Exercise tolerance: 6 minute walking test Cardiopulmonary exercise testing

Quality of life: Chronic respiratory disease questionnaire St Georges’s respiratory questionnaire SF- 36

Assessment of respiratory and peripheral muscle strength Nutritional assessment

Outcome Evaluation

• Current guidelines does not comment on maintenance &

repeat rehabilitation

• Yearly repeat rehabilitation program had shown: Short term

benefits in the form of less frequent exacerbations

• But no long term physiological effects on exercise tolerance,

dyspnea & HRQL but in 6Ms begin loss of benefits

6- Maintenance rehabilitation &Repeat rehabilitation program

• Assess the patient with spirometry, saturation, 6MWT, weight/FFMI by biometric impedance, and bone density by sonography, AQ 20 and PHQ questionnaire

• Treatment of osteoporosis & dietary advice by the physician

• Exercise training by the physician or a trained staff, or an assistant at the time of enrolment for 30 minutes

• Exercise should simulate the patient’s home environment• The endurance and strength training can be done by

walking/ cycling, walking uphill/climbing stairs and straight leg raise, respectively

Pulmonary Rehabilitation in Resource Poor Settings

• The exercise should be guided by his ability to tolerate exercise and 6MWT with periods of rest if desired. The speed and distance should be increased gradually

• The patient can be educated about breathing techniques by the physician/assistant

• The patients should exercise twice in a day for 30 minutes for at least 5 to 6 days in a week

• The patient may be given a diary to maintain

• The patient may follow up once in a week or 15 days for reinforcement/increment/supervision of exercises

1. Recommendation: A program of exercise training of

the muscles of ambulation is recommended as a

mandatory component of pulmonary rehabilitation for

patients with COPD. 1A

2. Recommendation: Pulmonary rehabilitation improves

the symptom of dyspnea in patients with COPD. 1A

3. Recommendation: Pulmonary rehabilitation improves

health related QOL in patients with COPD. 1A

ACCP RECOMENDATIONS

4. Recommendation: Pulmonary rehabilitation reduces the number of hospital days and other measures of health-care utilization in patients with COPD. 2B

5. Recommendation: Pulmonary rehabilitation is cost-effective in patients with COPD. 2C

6. Statement: There is insufficient evidence to determine if pulmonary rehabilitation improves survival in patients with COPD. No recommendation is provided.

7. Recommendation: There are psychosocial benefits from comprehensive pulmonary rehabilitation programs in patients with COPD. 2B

8. Recommendation: Six to 12 weeks of pulmonary rehabilitation produces benefits in several outcomes that decline gradually over 12 to 18 months. 1A.. Some benefits, such as health-related quality of life, remain above control at 12 to 18 months. 1C

9. Recommendation: Longer pulmonary rehabilitation programs (12 weeks) produce greater sustained benefits than shorter programs. 2C

10.Recommendation: Maintenance strategies following pulmonary rehabilitation have a modest effect on long-term outcomes. 2C

11.Recommendation: Lower-extremity exercise training at higher exercise intensity produces greater physiologic benefits than lower intensity training in patients with COPD. 1B

12.Recommendation: Both low- and high intensity exercise training produce clinical benefits for patients with COPD. 1A

13.Recommendation: Addition of a strength training component to a program of pulmonary rehabilitation increases muscle strength and muscle mass. 1A

14.Recommendation: Current scientific evidence does not support the routine use of anabolic agents in pulmonary rehabilitation for patients with COPD. 2C

15.Recommendation: Unsupported endurance training of the upper extremities is beneficial in patients with COPD and should be included in pulmonary rehabilitation programs. 1A

16.Recommendation: Scientific evidence does not support the routine use of inspiratory muscle training as an essential component of pulmonary rehabilitation. 1B

17.Recommendation: Education should be an integral component of pulmonary rehabilitation. Education should include information on collaborative self-management and prevention and treatment of exacerbations. 1B

18.Recommendation: There is minimal evidence to support the benefits of psychosocial interventions as a single therapeutic modality. 2C

19.Statement: Although no recommendation is provided since scientific evidence is lacking, current practice and expert opinion support the inclusion of psychosocial interventions as a component of comprehensive pulmonary rehabilitation programs for patients with COPD

20.Recommendation: Supplemental oxygen should be used during rehabilitative exercise training in patients with severe exercise-induced hypoxemia. 1C

21.Recommendation: Administering supplemental oxygen during high-intensity exercise programs in patients without exercise-induced hypoxemia may improve gains in exercise endurance. 2C

22.Recommendation: As an adjunct to exercise training in selected patients with severe COPD, noninvasive ventilation produces modest additional improvements in exercise performance. 2B

23.Statement: There is insufficient evidence to support the routine use of nutritional supplementation in pulmonary rehabilitation of patients with COPD. No recommendation is provided.

24.Recommendations: Pulmonary rehabilitation is beneficial for some patients with chronic respiratory diseases (CRD) other than COPD. 1B

25.Statement: Although no recommendation is provided expert opinion suggest that PR for pts with CRD other than COPD should be modified to include ttt strategies specific to individual diseases & pts in addition to ttt strategies common to both COPD & non-COPD pts.