CRC 432 Subacute Care Pulmonary Rehabilitation. Pulmonary Rehabilitation Goals –Maximize...

CRC 432 Subacute CarePulmonary Rehabilitation

Pulmonary Rehabilitation

Goals– Maximize patient’s functional ability– Minimize impact in

• Patient

• Family

• Community

– Improve quality of life– Control & alleviate symptoms


Historical Perspective– 1951: Dr Barach recommended physical

reconditioning for COPD patients• Walk without becoming dyspneic

– Barach was ignored; O2 therapy & bed rest prescribed

• Skeletal muscle deterioration• Fatigue & weakness• Increased dyspnea• Homebound, room bound, bed bound


Historical Perspective– 1962: Pierce confirmed Barach– Pierce found that exercising COPD patients

• Decreased pulse

• Decreased respiratory rates

• Decreased minute ventilation

• Decreased CO2 production

• Improved pulmonary function


Historical Perspective– Paez demonstrated

• Efficiency of motion• Decreased O2 consumption

– Smoking cessation included– Education added

• Pathophysiology• Equipment• Medications


Scientific Basis– Focus on patient– Include clinical sciences

• Quantify degree of physiologic impairment• Establish outcomes for reconditioning

– Include social sciences• Psychological • Social• Vocational


Physical Reconditioning– Exercise increases energy demands

• Increased circulation• Increased ventilation• Increased O2 deliver• Increase CO2 elimination

– If O2 demands NOT met• Blood lactate level increase• CO2 increases as lactic acid buffered• Increased stimulus to breathe



This point is called the “onset of blood lactate accumulation,” or OBLA

Abrupt rise in PaCO2 & minute ventilation: called “ventilatory threshold”

Beyond VT, metabolism = anaerobic respiration (decreased NRG production efficiency, lactic acid rise, fatigue)


Physical Reconditioning– MVV index of respiratory system’s ability to

handle increased physical activity– MVV = FEV1 x 35– Normal: 60%-70% of pred MVV during max

exercise– Indicates adequate respiratory reserve– Indicates ventilation NOT primary limiting

factor for ending exercise


Physical Reconditioning– MVV decreased with COPD– COPDs have limited exercise ability

• Increased CO2 production

• Respiratory acidosis

• SOB

• O2 consumption increases faster than normal


Physical Reconditioning– Rehab programs must:

• Physically recondition

• Increase exercise tolerance


Psychosocial Support– Indicators bettor predictors of frequency &

LOS for COPD patients compared to PFTs– Psychosocial indicators better determine rehab

program completion than physical reconditioning

– COPD negatively affects person’s outlook on life

– Can reduce motivation


Psychosocial Support– Depression/hostility occur with acute & chronic

disease– Economic loss & fear of death produce hostility – Interaction among patients is beneficial– Patient’s lacking social support at higher risk

for re-hospitalization– Intolerance for physical exertion lessens social

activity


Psychosocial Support– Physical reconditioning & psychosocial support

linked– Reducing exercise intolerance & improving

cardiovascular response to exercise = independent, active lifestyle

– Improve social importance & self-worth– Occupational training & job placement

important


Program Goals– Control respiratory infection– Basic airway management– Improve ventilation & cardiac status– Improve ambulation & other physical activities– Reduce medical costs– Reduce hospitalizations


Program Goals– Reduce LOS when hospitalized– Reduce # of MD office visits– Provide psychosocial support– Occupational training/job placement– Family education, counseling, support– Patient education, counseling, support


PROGRAM OBJECTIVES– Development of diaphragmatic breathing skills– Development of stress management and relaxation techniques– Involvement in a daily physical exercise regimen to condition both

skeletal and respiratory-related muscles– Adherence to proper hygiene, diet, and nutrition– Proper use of medications, oxygen, and breathing equipment (if

applicable)– Application of airway clearance techniques (when indicated)– Focus on group support– Provisions for individual and family counseling


Chronic lung disease progressive & irreversible

Rehabilitation does NOT alter progressive deterioration

Rehabilitation improves utilization of O2 by:– Increasing muscle use effectiveness– Promoting effective breathing techniques


O2 cost for given amount of ventilation is excessive

Training skeletal muscle groups alone NOT beneficial

Training respiratory related muscles improves exercise tolerance


Evaluation of Rehabilitation Program Outcomes– Changes in exercise tolerance– Before and after 6 minute walking distance– Review of patient home exercise logs– Strength measurement– Flexibility and posture– Performance on specific exercises (e.g., ventilatory muscle,

upper extremity)– Changes in symptoms– Dyspnea measurement comparison– Frequency of cough, sputum production, or wheezing– Weight loss or gain– Psychological test instruments


Evaluation of Rehabilitation Program Outcomes– Other changes– Activities of daily living (ADL) changes– Postprogram follow-up questionnaires– Preprogram and postprogram knowledge tests– Compliance improvement with pulmonary rehabilitation

medical regimen– Frequency and duration of respiratory exacerbations– Frequency and duration of hospitalizations– Frequency of emergency department visits– Return to productive employment


Potential Hazards– Cardiovascular abnormalities

• Cardiac arrhythmias (can be reduced with supplemental oxygen during exercise)

• Systemic hypotension

– Blood gas abnormalities• Arterial desaturation• Hypercapnia• Acidosis

– Muscular abnormalities• Functional or structural injuries• Diaphragmatic fatigue and failure• Exercise-induced muscle contracture


Potential Hazards– Miscellaneous

• Exercise-induced asthma (more common in young patient with asthma than in patients with COPD)

• Hypoglycemia

• Dehydration


Patient Selection– Evaluation– Testing

Patient Evaluation– History (medical, psychological, vocational,

social)– Questionnaire/interview form– Physical exam– CXR

Pulmonary Rehabilitation Patient Evaluation

– CBC

– Electrolytes

– Urinalysis

– PFTs (spirometry, volumes, DLCO, pre/post)

– Cardiopulmonary exercise evaluation

• Quantifies initial exercise capacity

• Provides basis for exercise prescription

• Renders baseline data for assessing progress

• Shows degree of hypoxemia/desat during exercise


Common Physiological Parameters Measured During Exercise Evaluation– Blood pressure– Heart rate– ECG– Respiratory rate– Arterial blood gases (ABGs)/O2 saturation– Maximum ventilation (VEmax)– O2 consumption (either absolute VO2 or METS, the metabolic

equivalent of energey expenditure)– CO2 production (VCO2)– Respiratory quotient (RQ)– O2 pulse


Exercise Evaluation– Graded levels (ergometer or treadmill)– 3-min intervals allow steady state– ABGs at rest & at peak exercise


Relative Contraindications to Exercise Testing– Patients who cannot or will not perform the test– Severe pulmonary hypertension/cor pulmonale– Known electrolyte disturbances (hypokalemia, hypomagnesemia)– Resting diastolic blood pressure > 110 mm Hg or resting systolic blood

pressure > 200 mm Hg– Neuromuscular, musculoskeletal, or rheumatoid disorders exacerbated

by exercise– Uncontrolled metabolic disease (e.g., diabetes)– SaO2 or SpO2 < 85% with the subject breathing room air– Untreated or unstable asthma


Indications for Pulmonary Rehabilitation– Symptomatic patients with COPD

– Patients with bronchial asthma and associated bronchitis (asthmatic bronchitis)

– Patients with combined obstructive and restrictive ventilatory defects

– Patients with chronic mucocilliary clearance problems

– Patients having exercise limitations due to severe dyspnea


Patient Selection– Ex-smokers– Smoking cessation program for smokers

Patients Excluded– Concurrent problems limit or preclude

exercising– Condition complicated by malignant

neoplasms, e.g., bronchogenic carcinoma


Program Design– Open-ended format

• Participate until predetermined objectives achieved

• No set timeframe

• Completed at patient’s pace

• Good format for self-directed patients

• Good format for schedule difficulties

• Good format for individual attention

• Lack group support/involvement

Pulmonary Rehabilitation Program Design

– Closed design• Set timeframe (8 to 16 weeks; 1 to 3 sessions/wk)• Insurance coverage may dictate length for which

person qualifies• Sessions last 1 to 3 hours• Presentations formal• Offer group support/involvement• Schedule determines program completion


ContentComponent Focus Time Frame

Education Welcome (group interaction) 5 mins

Review of program diaries

(past week’s activities) 20 mins

Presentation of education topic 20 mins

Questions, answers, and group

discussion 15 mins

Physical Physical activity and reconditioning 45 mins

Reconditioning Individual goal-setting and session

summary 15 mins

Total: 120 minutes (2 hours)


Physical Reconditioning– Excise prescription with target HR based on

initial exercise evaluation– Target HR set using Karvonen’s formula– THR = [(MHR-RHR) x (50% to 70%)] + RHR


Physical Reconditioning

MHR = 150 bpm

RHR = 90 bpm

THR = [(150 – 90) x (0.6)]+ 90 = 126 bpm


Exercise Prescription– Lower extremity aerobic exercises– Timed walking– Upper extremity aerobic exercises– Respiratory muscle training

Monitoring during Exercise– Pulse oximetry– Blood pressure


Lower Extremity– Walking (treadmill/flat surface)

• Goals for distance, time, grade on treadmill

• 6 minute flat surface/increase distance

– Bicycling (stationary) Upper Extremity

– Arm ergometers– Rowing machines


Inspiratory resistance breathing device– Adjustable flow resistor– One-way valve– Inhale through restricted orifice (variable size)– Change inspiratory load– Exhalation through one-way valve

Pulmonary Rehabilitation Instruction

– Sit upright– Breathe slowly through device (10 – 12 bpm)– MIP < 30% of measured Pimax, use next smaller

orifice– Repeat effort until 30% is consistently achieved– 1 or 2 daily sessions for 10 – 15 minutes/session– When 30% is consistently achieved, increase

resistance– Increase session time to 30 minutes

Pulmonary Rehabilitation Introduction and welcome, program orientation Respiratory structure, function, and pathology Breathing control methods Relaxation and stress management Proper exercise techniques and personal routines Methods to ad secretion clearance (bronchial hygiene) Home oxygen and aerosol therapy Medications: their use and abuse Medications: use of MDIs and spacers Dietary guidelines and good nutrition Recreation and vocational counseling Activities of daily living Follow-up planning and program evaluation Graduation

Pulmonary Rehabilitation Program Results

– Evaluate• Patient

• Program outcomes

– Preprogram/current program status– Data

• Physiological

• Psychological

• Sociological

Date post:	17-Dec-2015
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CRC 432 Subacute Care Pulmonary Rehabilitation. Pulmonary Rehabilitation Goals –Maximize...

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