Pulmonary Rehabilitation Dr Nishtha

1. Dr Nishtha Singh Executive Director & Senior Pulmonary Consultant Asthma Bhawan, Jaipur

2. What does rehabilitation actually means? The process of returning to a healthy or good way of life, or the process of helping someone to do this after they have been not well..

4. When is Rehab advised? COPD/ILD patient Injury Physically handicapped patient

5. A new indication emerged 2 years back..

6. We faced a new challenge..

7. POST COVID COMPLICATIONS The Unknown Journey Ahead Variable long term outcomes of the patients who have recovered from COVID- 19

8. Long Covid Support

9. What works and what doesn’t ?

10. Where does PR comes in picture? Indications of PR

11. Pulmonary Clinic- Results: too good to be true?

12. Definition Background Outline Pulmonary Rehabilitation Program Indications and Contra-indications How team-work helps in PR and patient results 12

13. Definition- ATS-ERS statement 2013 Pulmonary rehabilitation (PR) 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 long-term adherence to health-enhancing behaviors” Spruit MA et al. Am J Respir Crit Care Med 2013.

14. Background • Amidst COVID-19 pandemic the need for pulmonary rehabilitation is reiterated • Patients suffering chronic respiratory conditions and COVID-19 survivors often report similar symptoms such as Decreased functional performance Hypoxemia Difficulty performing ADLs Muscle weakness Persisting symptoms • Pulmonary Rehabilitation is a comprehensive, multidisciplinary intervention designed to improve the physical condition of people with respiratory disease to support their recovery 14

15. Dysnoea management Dysnoea Aggravation of pulmonary disease Fear of activity Decreased CVS and muscular fitness Decreased activity

16. Need for Pulmonary Rehabilitation in COPD • Pulmonary Rehabilitation is identified as a non-pharmacological intervention for management in COPD due to Progressive dyspnea due to hyperinflammation and air trapping in lungs causing air flow limitation • Peripheral muscle dysfunction resulting from physical inactivity Exercise intolerance is the most common symptom in COPD patients leading to peripheral muscle deconditioning • Systemic inflammation and reduced exercise capacity (deconditioning) causing loss of muscle mass Corhay, J. L., et.al. (2014). Pulmonary rehabilitation and COPD: providing patients a good environment for optimizing therapy. International journal of chronic obstructive pulmonary disease, 9, 27–39. https://doi.org/10.2147/COPD.S52012 16

17. Need for Pulmonary Rehabilitation in COVID-19 Alteration in lung structure and function • 80% of patients progress to have ground-glass opacities, vascular thickening, bronchiectasis, pleural effusion and other manifestation. Post Intensive Care Syndrome (PICS) • ICU admission, oxygen support, intubation, and use of steroids and other medications cause physical deconditioning and muscle weakness. Impaired Quality of Life • Increasing evidence suggests post COVID-19 patients have persistent symptoms, dyspnea and difficulty in managing activities of daily living thereby affecting their Quality of Life(QOL) https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/what-coronavirus-does-to-the-lungs

18. Need for Pulmonary Rehabilitation in COVID-19 The purpose of pulmonary rehabilitation in COVID-19 patients is to improve symptoms of dyspnea, relieve anxiety, reduce complications, minimize disability, preserve function, and improve quality of life.

19. Out patient mild disease management • Mild disease is defined as mild symptoms without pneumonia manifestations on imaging. • Rehabilitation for mild disease can be managed in the outpatient setting using telemedicine.

20. Out patient mild disease management •About individual statistics based on comorbidities •Encourage habits like good sleep, hydration, nutrition, etc. Patient Education •Exercise intensity: Borg Dysnoea scale score ≤3 •Exercise frequency: 1-2 times per day, 3-4 times a week •Exercise duration: 10-15 mins for 1st3-4 sessions & later to 15-45mins each session •Exercise type: walking , biking •Progression: incrementally increase work load every 2-3 sessions to target Borg Dysnoea Scale score 4-6 and target duration to 30-45 mins Physical activity recommendations •Counsel about social support •Provide resources including psychiatric professionals Psychological intervention • • Expectorant hygiene into closed container Huff cough Airway clearing • Techniques: diaphragmatic breathing, pursed lip breathing, active abdominal contraction, yoga, pranayam, singing Frequency: 2-3 times/day, daily Duration: 10-15 mins for 1st3-4 sessions Progression: incrementally increase duration every 2-3 sessions toward a total goal duration of 30-60 mins Breathing exercises • • •

21. Diaphragmatic breathing

22. Airway Clearing • Autogenic drainage is a common technique that uses a combination of the maneuvers to mobilize and centralize secretions with -short breaths to collect secretions in peripheral airway -followed by normal breaths to collect secretions into the intermediate airway -deep breaths and huff cough to expel secretions. • Application of airway clearance techniques can significantly reduce the need for ventilatory support, days of mechanical ventilation, and hospitalization. • External vibration if available may be applied with oscillation frequencies less than 17 Hz to improve mucociliary clearance.

23. Pursed Lip Breathing

24. Moderate-severe disease management • Moderate to severe disease is defined as symptomatic patients with or approaching respiratory distress with RR>30/min, SpO2 at rest<93%, or PaO2/FiO2 <300 mm Hg. These patients require hospitalization and monitoring. • PR includes bed mobility, sit to stand, ambulation, breathing rehabilitation exercises.

25. Moderate-severe disease management • In acute exacerbation of chronic lung conditions, PR results in moderate to large effects on health-related quality of life and exercise capacity. • Exclusion criteria include the following: (1) body temperature of greater than 38.0°C (2) initial diagnosis time or symptom onset of 3 days or less (3) initial onset of dyspnea of 3 days or less (4) chest image progression within 24–48 hrs of more than 50% (5) SpO2 <90% (6) BP<90/60 mm Hg or >180/90 mm Hg (7) RR>40/min (8) HR<40 beats/min or >120 beats/min (9) new onset of arrhythmia and myocardial ischemia (10) altered level of consciousness.

26. Prone Ventilation • Anecdotal evidence in hospitals suggesting prone positioning during acute care of COVID-19 patient has been beneficial. • We recommend time in all positions including side lying, upright, supine, and prone and guided by imaging findings when possible. • Targeted positions may be determined by the location of consolidations seen on imaging or found on examination. • Prone positioning may aid in ventilation to dorsal lung through reduction in lung compression by the heart in the semi-prone position because of ventral displacement of the heart with increases in end-expiratory transpulmonary pressure and expiratory reserve volume, more homogenous lung inflation from dorsal to ventral and improvement in oxygenation. • Prone positioning has been used in the ICU to improve gas exchange in ARDS and improve Pa/FiO2 in patients on mechanical ventilation and reduces cardiovascular comorbidities.

27. Is Proning Use Is Proning Use

28. Cardiac problems Respiratory muscle dysfunction Lower limb dysfunction Exercise Limitations Ventilatory disturbance Gas exchange abnormalities Psychological disturbance

29. Program setting • Inpatient • Outpatient • Home based rehabilitation • Multidisciplinary team approach is necessary. • It requires a coordinated work of- 1. Pulmonologist 2. Physiotherapist 3. Dietician 4. Psychologist

30. Lower Limb, Upper Limb and Chest Exercise Training given at Asthma Bhawan

31. Patient experiences I feel my stamina has increased a lot. Earlier, I had difficulty in breathing on walking. I could walk for around 500m in a day. But now I walk around 3.5km without feeling breathless. Patient name: Jyoti, 38F Diagnosis: Post COVID-19/DM No. of sessions : 7 day sessions CTSS: 18/25 Before After FVC 58% 67% 6MWT SpO2 initial 92 97 SpO2 final 96 96 Distance 420m 562m I feel much more energetic and less fatigued after pulmonary therapy exercises. Patient name: Mr Pradeep Kumar, 64M Diagnosis: Post COVID-19 No. of sessions : 7 day sessions (Feb-April) Before After FVC 67% 71% 6MWT SpO2 initial 96 96 SpO2 final 91 94 Distance 420m 546m 32

32. My take on the PR story.. • In the months to years after this pandemic, the burden of disease may be large and PR will play a crucial role in the rehabilitation of patients with disability in relation to COVID-19. • PR includes nutrition, airway, posture, clearance technique, oxygen supplementation, breathing exercises, stretching, manual therapy, and physical activity. • Multidiscpinary team effort is needed for the successful completion of PR programme.

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