Definition
- Can be delivered as an:
- Inpatient service
- Outpatient service
- Community based programme
- HEP
Aims (ATS/ERS Guidelines - Nici
et al 2006)
- The pulmonary rehabilitation programme is designed to:
- Reduce symptoms
- Optimise functional ability
- Increase participation
- Reduce health cost
- Evidence based
- Multidisciplinary
- Comprehensive
- Individualised treatment
- Stabilising or reversing systemic manifestations of the disease
ACCP/AACVPR Evidence-Based
Guidelines (2007)
- Exercise the muscles of ambulation
- PR increases
- Dyspnoea
- Health related quality of life
- 6-12 weeks
- Benefits gradually decline over 12 to 18 months
- Both low and high intensity produces benefits for COPD patients
- Unsupported endurance training of the upper extremity is beneficial to COPD patients
- Current evidence is lacking, however current practice and expert opinion suggests that PR for chronic respiratory diseases other than COPD should be modified to include treatment strategies specific to individual diseases and patients
Who Benefits?
- COPD
- Bronchiectasis
- ILDs, CF and NM disease (ACCP/AACVPR, 1997)
- Asthma (Didour, 1997)
- Transplant (Chumillas et al, 1998)
Indications
- Dyspnoea
- Reduced exercise capacity
- Restricted in ADLs
- Motivated to change lifestyle
- Breathlessness limiting capacity
Contraindications
- Symptomatic angina
- Recent embolism or MI
- DVT
- Resting systolic BP > 240 mmHg
- Resting diastolic BP > 120 mmHg
- Haemoptysis
- Ax and Exercise
- Goal setting
- Self-management education
- Psychosocial support
- Outcome measures
Exercise (ACSM Guidelines,
2010)
- FITT
- 70-80% VO2 max
- Obtained through the 6MWT
- BORG scale 3-5
- 30-60 minutes two to three times a week
- Endurance and resistance training
- Circuit
- Respiratory muscle
- Stretching
- SPOR
- Time, frequency and intensity
- Speed or gradient on treadmill
- Resistance or weight
- Lowering sit to stand
- Number of sets/reps
- RPM
- Effects of pulmonary rehab
- ME, MS, CE, CF, F
- Safety
- Monitor HR, BP and Sats
- Endurance activities increases systolic pressure in direct proportion to the increasing intensity of exercise
- Subjective symptoms
- Use of emergency inhalers
- Breathing control techniques
- Oxygen therapy
- Adherence
- Reasons
Warm Up
- Pulse raiser
- Stretching
- Skills practice
- Gradual in intensity
- Increase
- Temperature
- Allowing for a 10% increase in chemical reactions
- HR (sympathetic NS)
- CO
- Depth and rate of inhalation
- Indicates the greater use of respiratory muscles
- Ventilation
- Nervous stimulation of the muscles
- Divert blood away from non-essential areas such as the gut
Cool Down
- Active recovery exercises
- Decreasing intensity
- Gradual readjustment to a normal resting state
- Slow decrease of CV rates and RR as well as metabolism
- Dissipation of waste products and prevention of DOMS
- Encourages venous return
- Reduces chances of dizziness
- Lowers adrenaline levels, reducing stress on the heart
Short Term Effects of Exercise
- Recruitment and distension reduces vascular resistance therefore increasing blood flor
- Increased tidal volume
- Bronchodilation and vasodilation
- Reduce fatigue through more efficient oxygen delivery and waste product removal
Long-Term Effects of Exercise
- Cardiac hypertrophy
- Increased blood plasma volume in endurance exercises
- Blood becomes more dilute
- Oxygen delivery and waste removal efficacy increases
- Increased capillarisation at the muscles
- Oxygen consumption decreases due to increased physiological and biomechanical efficiency
- Recovery rates improve
- Blood flow to skin improves, enhancing sweat production and cooling
- Most cost-effective part of rehabilitation (Tougaard et al, 1992)
- Increases participants confidence and reduces anxiety (Small & Graydon, 1992)
- Hypoxaemia may impair memory therefore retention of information is optimal if
- The room is free of distractions
- Language is simple
- Key information is reinforced regularly
- Teaching sessions are brief
- Participants are reminded to check body tension, take medication and practise their breathing
- Memory aids around the house
- Topics include
- How we breathe
- Relations between symptoms and pathology
- Nature of breathlessness
- Non-damaging symptom
- Composed of three mechanisms
- Work of breathing
- Breathlessness occurs when the typically balanced load and drive are disturbed
- Increased resistive load with increased airflow resistance
- Increased drive to breath with pneumonia
- Fatigue leads to an increased perception of effort
- Corticol and subcortical inputs
- Uncertainty, distress, anxiety, previous life experiences
- Central chemoreceptors
- Sense a rise in PaCP2 mediated through pH
- CRD accounts for 2/3s of cases of breathlessness (Pratter, 1989)
- COPD has slow onset with productive cough
- Asthma is episodic on exhalation with tight chest and wheeze
- Pneumonia is exertional with pleuritic pain and cough
- Breathing re-education
- Shallow breathing wastes energy due to ventilating dead space
- Rapid breathing wastes energy due to turbulence
- However encouraging deep, slow breathing beyond what is natural tends to be counterproductive as it works against elastic recoil
- Abdominal breathing may be counterproductive:
- Positives
- Decreased BP and breathlessness
- Increased inspiratory muscle strength
- Negatives
- Disruption of breathing
- Increased work of breathing
- Avoidance of breath holding, as it increases tension and breathlessness
- Desensitisation
- Perform activities that mildly provoke breathlessness and use above techniques to regain breath whilst adjusting to the sensation in order to reduce fear
- Pacing
- Slow activities down to maintain stable levels and concern energy
- Relaxation
- Facilitated by positioning, sensitive handling and sharing of information
- Patients should be warm, comfortable and have adequate fresh air
- The effects include:
- Reduced breathlessness, anxiety and airway obstruction (Gift, 1992)
- Reduced RR, O2 consumption, HR and BP (Hodgkin and Petty, 1987)
- Importance of HEP
- Management of panic attacks
- Community resources
- Prevention for infection
- Energy Conservation
Outcome Measures
- QOL
- HAD
- St George’s
- CRDQ
- SF 36
- CAT
- Exercise Capacity
- 6MWT
- 10MWT
- TUAG
- Breathlessness
- BORG
- Visual Analogue Scale
Maintaining Long-Term Effects
& Promoting Self-Efficacy (Hough, 2001)
- Reasons for decreased effects post-rehab include
- Poor adherence with exercise and activity prescription
- Exacerbations of respiratory disease
- Developments of co-morbidities
- Gradual deterioration of the disease itself
- Solutions could be:
- Longer PR
- Reintroducing a modified form after an exacerbation
- Incorporating and stressing the importance of HEPs during the sessions
- Promoting self-management strategies
- Soicher (2012)
- Over 200 patients
- 3 month PR
- Followed up after 4, 6, 8 and 12 months
- Weekly time spent in endurance activity showed an overall decline
- Limited by self-report of physical activity
- Strengths include large sample size with longitudinal design that is required to observe behavioural patterns
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