Chapter 50

Cardiopulmonary Rehabilitation

Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 2

Objectives

State the definition and general goals of pulmonary rehabilitation programs.

Describe the rationale for exercise conditioning and psychosocial support of patients with chronic pulmonary disease.

Describe how to evaluate and select patients for pulmonary rehabilitation.

Describe pulmonary rehabilitation program design including format and content.

Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 3

Objectives (cont.)

List the educational content to be addressed in a pulmonary rehabilitation program.

Describe the implementation of a pulmonary rehabilitation program including staffing, facilities, scheduling, class size, equipment, and costs.

Describe the outcome measures that can be used to evaluate pulmonary rehabilitation programs.

Identify the potential hazards associated with pulmonary rehabilitation.

Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 4

Definition and Goals

Defined as the restoration of the individual to the fullest medical, mental, emotional, social, and vocational potential

The overall goal is to maximize functional ability and minimize the impact of the disability.

Other goals are to control symptoms and improve the overall quality of life.

Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 5

Historical Perspective

In 1951, Alvan Barach recommended reconditioning programs for chronic lung disease patients.

In 1962, Pierce and associates published data that confirmed the value of reconditioning.

Gradually the medical community came to appreciate the value of pulmonary rehab for patients with COPD and other disorders.

Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 6

Scientific Basis

Physical reconditioning Physical activity increases energy demands.

Poor conditioning of muscles leads to inefficient use of oxygen and excess acid production.

Pulmonary rehab aims to recondition the muscles and increase exercise tolerance.

Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 7

Scientific Basis (cont.)

Psychosocial support COPD can negatively affect the patient’s overall outlook and

reduce motivation.

Patients with COPD often have anxiety and stress.

Psychosocial support in combination with physical reconditioning is needed to cause the best possible outcome.

Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 8

Structure of a Pulmonary Rehab Program

Program goals and objectives

Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 9

Structure of a Pulmonary Rehab Program (cont.)

Patient evaluation Patient evaluation begins with a complete patient history.

Next, a complete physical examination is done.

A chest radiograph, CBC, and ECG may be needed.

Pulmonary function testing and exercise evaluation are often needed.

Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 10

Structure of a Pulmonary Rehab Program (cont.)

Patient evaluation (cont.) Contraindications include

Patients who cannot perform the test Those with severe pulmonary hypertension Those with hypertension Those with neuromuscular disease Those with untreated or unstable asthma Those with angina with exercise

Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 11

Structure of a Pulmonary Rehab Program (cont.)

Patient selection

Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 12

Structure of a Pulmonary Rehab Program (cont.)

Program design Open-ended designs allow the patient to enter the program and

progress through it until he or she achieves certain goals.

Closed designs use a set time period to cover the program content.

Classes meet 1 to 3 times per week for 6 to 16 weeks.

Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 13

Structure of a Pulmonary Rehab Program (cont.)

Format Long-term improvements are most likely to occur if planned

follow-up is completed.

Follow-up must be ongoing and available to all patients who complete the program.

Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 14

Structure of a Pulmonary Rehab Program (cont.)

Content

Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 15

Structure of a Pulmonary Rehab Program (cont.)

Physical reconditioning Consists of an exercise prescription with target heart rate based

on the initial evaluation

For most patients, an initial target heart rate is 20 beats/min above resting rate.

Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 16

Structure of a Pulmonary Rehab Program (cont.)

Physical reconditioning (cont.) The exercise prescription includes the following:

Lower extremity aerobic exercises Timed walking (6- or 12-minute walk) Upper extremity aerobic exercises Ventilatory muscle training using progressive resistance

Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 17

Structure of a Pulmonary Rehab Program (cont.)

Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 18

Structure of a Pulmonary Rehab Program (cont.)

Educational component1. Respiratory structure, function, and pathology

2. Breathing control methods

3. Methods of relaxation and stress management

4. Exercise techniques and personal routines

Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 19

Structure of a Pulmonary Rehab Program (cont.)

Educational component (cont.) Bronchial hygiene techniques

Home O2 and aerosol therapy

Medications

Dietary guidelines

Recreation and vocational counseling

Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 20

Structure of a Pulmonary Rehab Program (cont.)

Psychosocial and behavioral component Emotional stress is a common problem for a patient with chronic

lung disease.

Experts can be brought in to help patients cope with their anxieties and sources of stress.

Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 21

Structure of a Pulmonary Rehab Program (cont.)

Staffing Pulmonary rehabilitation is a multidisciplinary endeavor.

Staff conducting the program should be certified in basic and advanced life support.

Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 22

Structure of a Pulmonary Rehab Program (cont.)

Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 23

Structure of a Pulmonary Rehab Program (cont.)

Facilities The facility must be easy to reach, be accessible to public

transportation, and have available parking.

Rooms should be spacious and comfortable with adequate lighting and ventilation.

A room for counseling is helpful.

Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 24

Structure of a Pulmonary Rehab Program (cont.)

Scheduling Class times need to be scheduled at a time most convenient for

the patients.

Traffic patterns, bus schedules, and availability of rides are important factors to consider.

Class size The ideal class size is 3 to 15 patients.

Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 25

Structure of a Pulmonary Rehab Program (cont.)

Equipment Class room equipment to facilitate teaching is needed.

Blackboard or flipchart 35-mm projector or PowerPoint projector Formal learning packages

Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 26

Structure of a Pulmonary Rehab Program (cont.)

Equipment (cont.) Physical reconditioning equipment is needed.

Stationary bicycles, treadmills, rowing machines Pulse oximeters Inspiratory resistance devices Emergency O2 should be in the room.

Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 27

Structure of a Pulmonary Rehab Program (cont.)

Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 28

Structure of a Pulmonary Rehab Program (cont.)

Program results

Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 29

Structure of a Pulmonary Rehab Program (cont.)

Potential hazards Cardiovascular abnormalities Blood gas abnormalities Muscular abnormalities Miscellaneous

Exercise-induced asthma Hypoglycemia Dehydration

Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 30

Structure of a Pulmonary Rehab Program (cont.)

Cardiac rehabilitation A comprehensive exercise and educational program designed

for patients with cardiovascular diseases

Goals are to improve heart health and work capacity, weight loss, and return to work.