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Pulmonary Rehabilitation
DR/RABAB HUSSEIN ALI
Pulmonary rehabilitation
‘Is an evidence based, comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities. Integrated into the individualised treatment of the patient
pulmonary rehabilitation is designed to reduce symptoms, optimise functional status, increase participation, and reduce health care costs through stabilising or reversing systemic manifestations of the disease’
ATS/ERS statement on pulmonary rehabilitation (2006) American journal of respiratory and critical care medicine, 173:1390-1413
PULMONARY REABILITATION
Goals
- General : Improve physical and psychological or emotional functioning of patients in interaction with theire environment
- Specific :
- Reduce symptoms
- Improve activity and daily function QOL
- Restore the highest level of independant function (in every day activities)
- Enhance knowledge of the disease
- Improve self-management
PULMONARY REABILITATION Components of the rehabilitation
program
1- Optimal medical treatment
2- Smoking cessation
3- Exercise training
4- Breathing retraining
5- Chest physiotherapy
6- Education
7- Psychological aspects and support
8- Nutritional therapy
9- Nursing care
BronchoPulmonary Hygiene is…A treatment intervention employed for improving pulmonary hygiene including
1. deep breathing and coughing exercises
2. Gravity-assisted Positioning
3. Manual techniques
4. Manual hyperinflation
5. Airway suctioning
6. Mobilization
to assist in mobilizing secretions in the lungs from the peripheral airways into the more central airways so that they can be expectorated or suctioned.
Indications
• Prophylactic - Pre-operative high risk surgical patient
- Post-operative patient who is unable to mobilize secretions
- Neurological patient who is unable to cough effectively
- Patient receiving mechanical ventilation who has a tendency to retain secretions
- Patients with pulmonary disease, who needs to improve bronchial hygiene
…contd
• Therapeutic - Atelectasis due to secretions
- Retained secretions
- Abnormal breathing pattern due to primary or
secondary pulmonary dysfunction
- COPD and resultant decreased exercise
tolerance
- Musculoskeletal deformity that makes breathing
pattern and cough ineffective
Assessment
Neurological system
Cardiovascular system
Respiratory system
Renal system
Hematological system
Gastrointestinal system
Respiratory system
• Auscultation• Percussion• Expansion• Chest X-ray • Mode of ventilation• Oxygen therapy• Airway pressures• Sputum
1. Ventilation – movement of air in & out of the lungs; facilitates respiration
2. Respiration – exchange of oxygen & carbon dioxide
3. Perfusion – relates the ability of the cardiovascular system to pump oxygenated blood to the tissues & return de-oxygenated blood to the lungs.
4. Diffusion – is responsible for the moving the molecules from one area to another
• Diffusion of respiratory gases occurs at the alveolocapillary membrane, & the rate of diffusion can be affected by the thickness of the membrane.
• Increased thickness of the membrane impedes diffusion because gases take longer to transfer across.
The elasticity of the lung tissue allows the lungs to stretch & fill with air during inspiration & return to a resting position after exhalation.
During inspiration => diaphragm contracts => moves downward in the thorax => intercostal muscles move the chest outward => elevating ribs & sternum => expands thoracic cavity
Expansion creates more chest space =>pressure within lungs
Air flows from area of higher pressure to lower pressure thus filling the air in the lungs
Accessory muscles of respiration = pectoralis minor & sternocleidomastoid
During expiration => respiratory muscles relax => thoracic cavity decreases => stretched elastic tissue recoils => intrathoracic pressure increases (d/t compressed pulmonary space & air moves out of the respiratory tract)
Abdominal muscles = rectus abdominis, transverse abdominis, & internal & external obliques
AssessmentGeneral Observation Patient Position
Respiration - Airway ET/Tracheostomy
Ventillator Mode
Vital Signs – Temperature, BP, RR, HR, ICP
Tubes - NG Tube, CV line, Peripheral line, Chest tubes, Catheters
Drugs
… contd
Examination
Auscultations
Respiratory pattern
Cyanosis
Clubbing
Radiograph
Skills: Self Monitoring
Early recognition
Early treatment
Less medication needed
Feel better faster
Skills: Self Monitoring
Difficulty breathing
Chest tightness
Cough interfering with activity or sleep
Inability to speak in sentences
Wheezing
Itchy, watery, glassy eyes
Sore, scratchy, itchy throat
Stroking of neck
Fever
Congestion
Sneezing
Runny nose
• Headache
• Dark circles under eyes
• Change in face color• Change in appetite• Change in activity level• Retractions
– suprasternal– supraclavicular– intercostal– substernal– subcostal
Goals Prevent accumulation of secretions
Improve mobilization and drainage of secretions
Promote relaxation to improve breathing patterns
Goals
Promote improved respiratory function
Improve cardio-pulmonary exercise tolerance
Teach bronchial hygiene programs to patients
with chronic respiratory dysfunction
Precautions
Untreated tension pneumothorax
Abnormal coagulation profile
Status epilepticus or status
asthamaticus
Immediately following intra cranial
surgery
Precautions
• Head injury with raised ICP
• Osteoporotic bones
• Recent acute myocardial infarction, unstable vitals
• Immediately after tube feedings
• Sutures
Physiotherapy Techniques
1. Deep breathing and coughing exercises
2. Gravity-assisted Positioning
3. Manual techniques
4. Manual hyperinflation
5. Airway suctioning
6. Mobilization
Deep Breathing and Coughing Exercises
Facilitates proper respiratory functioning.
Are frequently indicated for clients with restricted chest expansion like, COPD or post- chest surgery
(a) Pursed – lip breathing
(b) Diaphragmatic breathing
Abdominal and pursed-lip breathing
• Commonly employed breathing exercise
• Permits deep full breaths with little effort
• Pursed-lip creates a resistance to the air flowing out of the lungs, thereby prolonging exhalation and preventing airway pressure.
Abdominal and pursed-lip breathing
As if about to whistle and breaths out slowly and gently, tightening the abdominal muscles to exhale more effectively.
Inhales to a count of 3 and exhales to a count of 7
Diaphragmatic Breathing
• Is breathing that promotes the use of the diaphragm rather than the upper chest muscles
• Used to increase the volume of air exchange during inspiration & expiration
• Requires the client to relax intercostals and accessory respiratory muscles while taking deep inspirations
• With practice, it reduces respiratory effort & relieves rapid, ineffective breathing
• Useful for clients with pulmonary disease, post-operative clients & for women in labor to promote relaxation
Procedure:
Lie down with knees slightly bent. Place one hand on the abdomen and the other on the chest. Inhale slowly & deeply through the nose while letting the abdomen rise more than the chest. Purse the lips. Contract the abdominal muscles & begin to exhale. Press inward & upward with the hand on the abdomen while continuing to exhale. Repeat the exercise for 1 full minute; rest for at least 2 minutes. Practice the breathing exercises at least twice a day for a period of 5 to 10 minutes. Progress to doing diaphragmatic breathing while upright & active.
Coughing Exercises
Forceful coughing often is less effective than using controlled or huff coughing techniques.
Cough – is a sudden, audible expulsion of the air from the lungs
- is a protective reflex to clear the trachea, bronchi, & lungs of irritants and secretions
Carina – the point of bifurcation of the right & left main stem bronchus, is the most sensitive area for cough production
Coughing permits the client to remove secretions from both the upper & lower airways
The normal series of events in cough mechanism are deep inhalation, closure of the glottis, active contraction of the expiratory muscles, & glottis opening.
The effectiveness of coughing is evaluated by sputum expectoration, the client’s report of swallowed sputum, or clearing of adventitious sounds by auscultation.
1.Cascade cough – the client takes a slow, deep breath ad holds it for 2 seconds while contracting expiratory muscles.
The client opens the mouth & performs a series of coughs throughout exhalation; thereby coughing at progressively lowered lung volumes.
This promotes airway clearance & a patent airway in clients with large volumes of sputum.
2. Huff cough – stimulates a natural cough reflex & is generally effective only for clearing central airways
3. Quad cough – is used for clients without abdominal muscle control (SC injuries)
While the client breathes out with a maximal expiratory effort, the client or nurse pushes inward & upward on the abdominal muscles toward the diaphragm, causing the cough.
Procedure:
After using bronchodilators treatment (if prescribed), inhale deeply and hold your breath for a few seconds.
Cough twice. The first cough loosens the mucus; the second expels the secretions. For huff coughing, lean forward and exhale sharply with a “huff” sound. This technique helps
you keep your airways open while moving secretions up & out of the lungs. Inhale by taking rapid short breaths in succession (“sniffling”) to prevent mucus from moving
back into smaller airways. Rest. Try to avoid prolonged episodes of coughing because these may cause fatigue & hypoxia.
Gravity-assisted PositioningPhysiological effects of Positioning
1. Optimizes oxygen transport
2. Increases lung volumes
3. Reduces the work of breathing
4. Minimizes the work of heart
5. Enhances mucuciliary clearance (postural drainage)
Postural Drainage isn’t…
a separate technique. Its just an example of
positioning which has the particular aim of
clearing airway secretions with the assistance of
gravity.
Postural Drainage
Patients are positioned with the area to be
drained the upper most, but modifications should
be done wherever necessary.
Drainage times vary, but ideally each position
requires 10 minutes (gumery et al, 2001).
Positioning
• Positioning restores ventilation to dependent lung regions more effectively than PEEP or large tidal volumes (Froese & Bryan, 1974).
• Positioning has a marked influence on gas exchange because of unevenly damaged lungs (Tobin, 1994).
• Side lying reduces lung densities in the upper most lung (Brismar, 1985).
…contd
• Right side lying may be more beneficial for cardiac output than left side lying (Wong, 1998).
• Simply turning from supine to side lying can clear atelectasis from dependent regions (Brismar, 1985).
• Positioning affects lung volume• Lung volume is related to the
position of the diaphragm
…contd
• Positioning affects compliance (Wahba et al found that work of breathing is 40% higher in supine than in sitting)
• Positioning affects arterial oxygenation by improving V/Q mismatch (V/Q is usually mismatched if the affected lung is dependent- Gillespie et al)
“Bad lung up” position
Positioning…
Which position to choose…
?
Chest Maneuver
Chest Vibrations
Chest Percussion/Clapping
Clapping/Chest Percussion
Percussion consists of rhythmic clapping on the chest with loose wrist & cupped hand.
Effect : Dislodges & loosens secretions from the lung
Hand PositionHand Position
Chest Vibration
• Vibrations consists of a fine
oscillation of the hands directed
inwards against the chest, performed
on exhalation after deep inhalation.
• Effects: Helpful in moving loosened
mucous plugs towards larger airway
Manual Hyperinflation
Was originally defined as inflating the lungs with oxygen and manual
compression to a tidal volume of 1 liter requiring a peak inspiratory
pressure of between 20 and 40 cm H2O (Med j Aust, 1972).
More recent definitions include providing a larger tidal volume than
base line tidal volume to the patient (Aust j physiotherapy, 1996)
and using a tidal volume which is 50% greater than that delivered
by the ventilator (chest, 1994).
Indications
To aid removal of secretions
To aid reinflation of atelectatic segments
To assess lung compliance
To improve lung compliance
Techniques
Slow deep inspiration
Inspiratory hold (at full inspiration)
Fast expiratory release
Hand-held PEEP
Hazards of MHI
Reduction in blood pressure
Reduced saturation
Raised intracranial pressure
Reduced respiratory drive
Contraindications
• Undrained Pnuemothorax
• Potential bronchospasm
• Severe bronchospasm
• Gross cardiovascular instability inducing arrhythmias and hypovolaemia
• Unexplained Haemoptysis
• Patient on High PEEP
Advantages of MH
Reverses atelectasis (Lumb 2000)
Improves oxygen saturation and
lung compliance (Patman et
al.,1999)
Improves sputum clearance
(Hodgson et al., 2000)
Disadvantages of MH
Haemodynamic and metabolic
upset (Stone, 1991 & Singer et
al.,1994)
Risk of barotrauma
Discomfort and anxiety
Suctioning
• Suctioning is the mechanical aspiration of pulmonary secretions from a patient with an artificial airway in place.
• Indications• Inability to cough effectively• Sputum plugging• To assess tube patency
Contraindications
Frank haemoptysis
Severe brochospasm
Undrained pneumothorax
Compromised cardiovascular system
Guidelines:
The suction catheter used must be less than half the diameter of endotracheal tube.
The vacuum pressure should be as low as possible. (60-150mmHg)
Suction should never be routine, only when there is an indication
Hazards of suctioning
Mucosal trauma
Cardiac arrhythmias
Hypoxia
Raised intracranial pressure
What to suction?
Nasal and oral suction
Endotracheal suction
Tracheostomy suction
Closed-circuit suction
Mobilization
Critically Ill
(Frequent Position changes, Kinetic & Kinematic Therapy)
Stable
(Progressive tilting & Ambulation)
Mobilization
ICU rehabilitation has been shown to accelerate recovery (o’leary & coackley, 1996)
Early mobilization for unconscious patients starts right from turning the patient every two hours. ( Brooks- brunn, 1995).
Graded exercises can be started as soon as the patient regains consciousness.
Mobilization
• Activity is required to maintain sensory input, comfort, joint mobility and healing ability (Frank et al, 1994).
• Activity minimizes the weakness caused by loss of up to half the patients muscle mass (Griffiths & Jones, 1999).
• Graded ambulation can be started depending on patients condition
Thank you