Pulmonary Rehabilitation

1. A n Overview by Michele Andrew Pulmonary Rehabilitation Pulmonary rehabilitation is an integral part of the clinical management and health maintenance of those patients with chronic lung disease who remain symptomatic or continue to have decreased functional capacity despite standard medical treatment.Pulmonary rehabilitation is an integral part of the clinical management and health maintenance of those patients with chronic lung disease who remain symptomatic or continue to have decreased functional capacity despite standard medical treatment.

2. Consequences of Respiratory Disease Peripheral Muscle dysfunction Respiratory muscle dysfunction Nutritional abnormalities Cardiac impairment Skeletal disease Sensory defects Psychosocial dysfunction To understand how and why Pulmonary Rehabilitation is an optimal treatment for Chronic Lung disease you must understand the consequences of respiratory disease on the body as a whole. To understand how and why Pulmonary Rehabilitation is an optimal treatment for Chronic Lung disease you must understand the consequences of respiratory disease on the body as a whole.

3. Mechanisms for these morbidities Deconditioning Malnutrition Effects of hypoxemia Steroid myopathy or ICU neuropathy Hyperinflation Diaphragmatic fatigue Psychosocial dysfunction from anxiety, guilt, dependency and sleep disturbances. Pulmonary Rehabilitation tries to address these morbidities and their consequences through education and exercise. Patients are encouraged to become more actively involved in their own health care, more independent in ADLs and less dependent on health professionals and expensive medical resources. Rather than focusing solely on reversing disease processes, PR attempts to reduce symptoms and reduce the disability from the disease.Pulmonary Rehabilitation tries to address these morbidities and their consequences through education and exercise. Patients are encouraged to become more actively involved in their own health care, more independent in ADLs and less dependent on health professionals and expensive medical resources. Rather than focusing solely on reversing disease processes, PR attempts to reduce symptoms and reduce the disability from the disease.

4. Definition of Pulmonary Rehabilitation �A multidisciplinary continuum of services directed to persons with pulmonary diseases and their families, usually by an interdisciplinary team of specialists, with the goal of achieving and maintaining the individual�s maximum level of independence and functioning in the community� Sat Sharma, MD, FRCPC, Professor of Pulmonary Medicine, U. of Manitoba This is the shortest and most comprehensive definition I have found. Dr. John Hodgkin�s is two column's long! This one covers everything very concisely.This is the shortest and most comprehensive definition I have found. Dr. John Hodgkin�s is two column's long! This one covers everything very concisely.

5. Principle Goals of Pulmonary Rehabilitation Aims to reduce symptoms, decrease disability, increase participation in physical and social activities and improve overall quality of life. These goals are achieved through patient and family education, exercise training, psychosocial intervention and assessment of outcomes. The interventions are geared toward the individual problems of each patient and administered by the multidisciplinary team. Pulmonary programs vary in size and all allied health professionals may not be represented on each team, all services need to be available and provided by someone of the appropriate discipline. Smaller programs utilize other departments to supply the necessary disciplines rather than have all the disciplines a specific part of the program i.e.: Dietary to supply nutrition counseling; PT for ADLs, Social Services for psychosocial problems. Pulmonary programs vary in size and all allied health professionals may not be represented on each team, all services need to be available and provided by someone of the appropriate discipline. Smaller programs utilize other departments to supply the necessary disciplines rather than have all the disciplines a specific part of the program i.e.: Dietary to supply nutrition counseling; PT for ADLs, Social Services for psychosocial problems.

6. Benefits of Pulmonary Rehab. The benefits are seen in irreversible pulmonary disorders because much of the disability is not from the lung disease but from the secondary morbidities. Evidence from the 2008 Pulmonary Rehabilitation Guidelines shows great benefit in the following areas:

7. Benefits Improved Exercise Capacity Reduced perceived intensity of dyspnea Improve health-related QOL Reduced hospitalization and LOS Reduced anxiety and depression from COPD Improved upper limb function Benefits extend well beyond immediate period of training. Several impairments such as weakness, dysfunction of skeletal and respiratory muscles, anxiety and depression and abnormalities in nutrition have responded to treatment. Improvement in overall and exertional dyspnea and QOL have been demonstrated. Significant increases in maximum exercise capacity have been observed.. Trials have indicated a decrease in health resource use. No trials have documented a survival benefit.Several impairments such as weakness, dysfunction of skeletal and respiratory muscles, anxiety and depression and abnormalities in nutrition have responded to treatment. Improvement in overall and exertional dyspnea and QOL have been demonstrated. Significant increases in maximum exercise capacity have been observed.. Trials have indicated a decrease in health resource use. No trials have documented a survival benefit.

8. Patient Selection  Obstructive Diseases Restrictive Diseases Interstitial Chest Wall Neuromuscular Other Diseases Reference Pulmonary Rehabilitation; Guidelines To Success John E. Hodgkin,MD; Bartolome Celli, MD; GerilynConners, RRT 2009 Pulmonary Rehab should be considered for all patients with chronic respiratory disease who have persistent symptoms, reduced exercise capacity, limited activity or suboptimal adjustment to their illness despite standard medical management Obstructive: COPD, Bronchiectasis, Persistent Asthma, Bronchiolitis obliterans, cystic Fibrosis Restrictive : Interstitial diseases, Chest Wall Diseases, Neuromuscular diseases Other: Lung cancer, PPH, pre-post surgery on thorax, Obesity-related respiratory disease,Pulmonary Rehab should be considered for all patients with chronic respiratory disease who have persistent symptoms, reduced exercise capacity, limited activity or suboptimal adjustment to their illness despite standard medical management Obstructive: COPD, Bronchiectasis, Persistent Asthma, Bronchiolitis obliterans, cystic Fibrosis Restrictive : Interstitial diseases, Chest Wall Diseases, Neuromuscular diseases Other: Lung cancer, PPH, pre-post surgery on thorax, Obesity-related respiratory disease,

9. � Gains can be achieved from pulmonary rehabilitation regardless of age, gender, lung function or smoking status�. � Severe nutritional depletion and low fat-free mass may be associated with an unsatisfactory response to rehab. Exclusions: Conditions that may interfere with the disease process of that could cause risk during exercise training. Exclusions would be significant orthopedic , neurologic or psychiatric impairment; unstable cardiac disease; severe pulmonary hypertension. This must be based on the judgment of the medical director and Rehab. Team.Exclusions would be significant orthopedic , neurologic or psychiatric impairment; unstable cardiac disease; severe pulmonary hypertension. This must be based on the judgment of the medical director and Rehab. Team.

10. Objective Abnormalities FEV1 less than 80% predicted FEV1/FVC less than 70 % DLCO less than or equal to 65% of predicted Resting hypoxemia less than or equal to 90% Exercise Testing demonstrating hypoxemia less than 90% Enrolling active smokers is controversial but they may benefit significantly with a focus on smoking cessation. Patient Motivation is a necessary consideration. Traditionally Abnormal PFT results ( done within 6 moths to 1 year) have been used as primary selection criteria for patient eligibility. This is not significant since patients degree of dyspnea doesn�t always correlate with FEV1 or DLCO. A simple Dyspnea Index or Dyspnea Scale such as the Modified Medical Research Council Dyspnea Scale aids in assessing symptoms. In addition, reduction in physical activity, occupational performance, ADLs and increased use of medical resources should be used in selection process.Traditionally Abnormal PFT results ( done within 6 moths to 1 year) have been used as primary selection criteria for patient eligibility. This is not significant since patients degree of dyspnea doesn�t always correlate with FEV1 or DLCO. A simple Dyspnea Index or Dyspnea Scale such as the Modified Medical Research Council Dyspnea Scale aids in assessing symptoms. In addition, reduction in physical activity, occupational performance, ADLs and increased use of medical resources should be used in selection process.

11. Setting for Pulmonary Rehabilitation Outpatient Inpatient Home Community Based Choice varies depending on Distance to program Insurance payer coverage Patient preference Physical, functional, psychosocial status of patient Setting is irrelevant as long as all components are met.Setting is irrelevant as long as all components are met.

12. Components of a Comprehensive  Program Exercise Training Education Psychosocial/behavioral intervention Outcome Assessment These interventions are provided by a multidisciplinary team that often includes physicians, nurses, respiratory therapists, physical therapists, occupational therapists , dieticians and social workers.These interventions are provided by a multidisciplinary team that often includes physicians, nurses, respiratory therapists, physical therapists, occupational therapists , dieticians and social workers.

13. Exercise Training Does not alter underlying respiratory impairment Does improve dyspnea Targets endurance training of 60% max for 20-30 minutes, repeated 2-5 times a week Interval training of 2-3 minutes high intensity with equal periods of rest or low level exercise is tolerated well. Unsupported arm exercise aids ADLs and respiratory accessory muscle use. Respiratory muscle training benefits have not been well established. Because peripheral muscle weakness contributes to exercise limitation in patients with lung disease, strength training is a natural component of exercise training. Even low intensity leg and arm muscle conditioning leads to reduced ventilatory equivalent for oxygen and CO2. The reversibility of training effects is the same as for everyone. If you don�t adhere to a program log term, you lose the effects.Because peripheral muscle weakness contributes to exercise limitation in patients with lung disease, strength training is a natural component of exercise training. Even low intensity leg and arm muscle conditioning leads to reduced ventilatory equivalent for oxygen and CO2. The reversibility of training effects is the same as for everyone. If you don�t adhere to a program log term, you lose the effects.

14. Education Encourages active participation in health care Better understanding of disease Improved compliance

15. Energy Conservation Energy conservation and work simplification assist in maintaining ADLS Methods include Paced Breathing Body mechanics Advanced planning Prioritization of activities Use of assistance devices � grabbers, etc.

16. Medication and other therapies Types of medication, action, adverse effects, dose and proper us of inhaled medications . Instructions in inhaler technique. Appropriate use of oxygen

17. End of Life Education Poor prognosis and increased risks over time Decision to initiate life support brining in patient�s own values with physician�s prognosis Provides patients with understanding of life sustaining interventions and the importance of advanced planning

18. Psychosocial Intervention Anxiety, depression, difficulties coping with chronic disease Aided by regular patient education session or support groups Instruction in progressive muscle relaxation, stress reduction, panic control Morbid depression in COPD patients ranges from 20-69 Morbid depression in Copd ranges from 20-60% Morbid depression in COPD patients ranges from 20-69 Morbid depression in Copd ranges from 20-60%

19. Chest Physical Therapy Pursed Lip Breathing � shifts breathing pattern and inhibits dynamic airway collapse. 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 See benefits of PLB.See benefits of PLB.

20. Nutritional Assessment Diet history, BMI Over or Under weight. Classes in weight management and/or nutritional counseling to improve weight management

21. Outcome Assessment An important component of pulmonary rehabilitation, being used to determine individual patient responses and evaluate overall effectiveness of program. Dyspnea 10 pt scale, Borg scale, Visual Analog Scale Exercise Ability � Borg Scale, 6MDW/Progressive exercise testing pre and post rehab. Health Status � Respiratory-related QOL; CRDQ Activity Levels �Respiratory-Specific functional Status, Duke Functional Status Scale. Functional capacity is what the patient is capable of doing, whereas, functional performance is what the patient actually does on a day to day basis. Functional reserve is the difference between them. Pulmonary Rehab improves a patient�s functional reserve.Functional capacity is what the patient is capable of doing, whereas, functional performance is what the patient actually does on a day to day basis. Functional reserve is the difference between them. Pulmonary Rehab improves a patient�s functional reserve.

22. Future Directions of P.R. Impact of PR on Health Care Costs and survival Effectiveness of education, breathing strategies psychosocial support Best intensity, duration and optimum form of exercise training. Benefits of strength training and best UBE. Use of noninvasive positive pressure ventilation during exercise. Benefits of a maintenance program to slow progression.

23. Future Directions Optimal Frequency of a PR program leading to psychologic gains and decreased hospitalization rate. Simplifying or minimizing current assessment instruments without sacrificing their intent. Effectiveness of P.R. in diseases other than COPD.

24. Future of Pulmonary Rehabilitation Medicare Improvements for Patient and Provider Act of 2008 A specific benefit for Pulmonary Rehabilitation effective January 1, 2010 CMS must write regulations � who is eligible, duration, services, etc.