Pulmonary Rehabilitation Talk in Cochin Thoracic Society

1. Dr Subin Ahmed MD
Assistant Professor
AIMS

3. DEFINITION
Art of medical practice wherein individually tailored
multidisciplinary program is formulated, which through
accurate diagnosis, therapy, emotional support and
education; stabilizes or reverses both physio and
psychopathology of pulmonary disease in attempts to return
the patient to highest possible functional capacity allowed by
pulmonary handicap and overall life situation

4. ATS – ERS definition (2005)
Evidence-based, multidisciplinary, and comprehensive
intervention for patients with chronic respiratory diseases who
are symptomatic and often have decreased daily life activities
Integrated into the individualized treatment of the
patient, pulmonary rehabilitation is designed to reduce
symptoms, optimize functional status, increase
participation, and reduce health care costs through stabilizing
or reversing systemic manifestations of the disease

5. The Timeline………
Charles Denison (1895): After recovery from PTB; Walking each
day- Made him feel better; Increased exercise tolerance;
Reduced respiratory and pulse rate
Albert Haas (1932): Carrying heavy books; Noticed weight gain
& Feeling of well being
Haas and Cordon (1969): first showed benefits of pulmonary
rehabilitation over conventional therapy in a cohort study
ACCP (1974): definition of pulmonary rehabilitation
ACCP (1979): Detailed monograph on pulmonary rehabilitation
in JAMA

6. Education
General
Psychological
exercise
support
training
Pulmonary
Rehabilitation
components
Nutritional Breathing
advice Retraining
Outcome
Assessment

7. PATHOPHYSIOLOGY

8. Consequences of Respiratory Disease
• Peripheral Muscle dysfunction
• Respiratory muscle dysfunction
• Nutritional abnormalities
• Cardiac impairment
• Skeletal disease
• Sensory defects
• Psychosocial dysfunction

9. 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

10. 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.

11. Benefits of Pulmonary
Rehabilitation
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

12. Patient Selection
 Obstructive Diseases
 Restrictive Diseases
 Interstitial
 Chest Wall
 Neuromuscular
 Other Diseases
COPD patients at all stages of disease appear to benefit from
exercise training programs improving with respect to both
exercise tolerance and symptoms of dyspnea and fatigue
(GOLD)

13. Exclusion criteria
Patients with severe orthopedic or neurological disorders
limiting their mobility
Severe pulmonary arterial hypertension
Exercise induced syncope
Unstable angina or recent MI
Refractory fatigue
Inability to learn, psychiatric instability and disruptive behavior

14. 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

15. Education
EXAMPLES OF EDUCATIONAL TOPICS
Breathing Strategies
Normal Lung Function and Pathophysiology of Lung Disease
Proper Use of Medications, including Oxygen
Bronchial Hygiene Techniques
Benefits of Exercise and Maintaining Physical Activities
Energy Conservation and Work Simplification Techniques
Eating Right

16. Education……
Irritant Avoidance, including Smoking Cessation
Prevention and Early Treatment of Respiratory Exacerbations
Indications for Calling the Health Care Provider
Leisure, Travel, and Sexuality
Coping with Chronic Lung Disease and End-of-Life Planning
Anxiety and Panic Control, including Relaxation Techniques
and Stress Management

17. Exercise training
Benefits of Exercise training
Pathophysiological Benefits of exercise
abnormality training
Decreased lean body mass Increases fat free mass
Decreased TY1 fibers Normalizes proportion
Decreased cross sectional area of muscle Increases
fibers
Decreased capillary contacts to muscle Increases
fibers
Decreased capacity of oxidative enzymes Increases
Increased inflammation No effect
Increased apoptotic markers No effect
Reduced glutathione levels Increases
Lower intracellular pH, increased lactate Normalization of decline in
levels and rapid fall in pH on exercise pH

18. Exercise training
Components of exercise training:
•Lower extremity exercises
•Arm exercises
•Ventilatory muscle training
Types of exercise:
•Endurance or aerobic
•Strength or resistance

19. Lower extremity exercise
Walking
Treadmill
Stationary bicycle
Stair climbing
Sit & Stand

20. Arm exercise training
Arm cycle ergometer
Unsupported arm lifting
Lifting weights
Strength exercise
When strength exercise was added to
standard exercise protocol;
led to greater increase in
muscle strength and muscle mass

21. Ventilatory muscle training
Resistive IMT: Threshold IMT:
Patient breaths through hand held Patient breaths through a device
device with which resistance to equipped with a valve which
flow can be increased gradually opens at a given pressure.
• Difficult to standardize the load
• Patients may hypoventilate • Easily quantitated and
• Leads to increased Pulmonary standardized
Arterial Pressure and fall in
oxygen tension

22. Chest Physical Therapy &
Breathing Retraining
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

23. Pursed Lip Flutter Device

24. Bronchial hygiene techniques
Postural drainage
Percussion & vibration
Directed cough
Forced expiratory technique (huff cough)
Active cycle of breathing
Autogenic drainage
Positive expiratory pressure

25. What does ATS-ERS & GOLD Say?
A minimum of 20 sessions should be given
At least three times per week
Twice weekly supervised plus one unsupervised home session
may also be acceptable.
Once weekly sessions seem to be insufficient
Each session to last 30 minutes
High-intensity exercise (>60% of maximal work rate) produces
greater physiologic benefit and should be encouraged; however,
low-intensity training is also effective for those patients who
cannot achieve this level of intensity (ATS-ERS)

26. ATS-ERS
Both upper and lower extremity training should be utilized
Lower extremity exercises like treadmill and stationary bicycle
ergometer & Arm exercises like lifting weights and arm cycle ergometer
are recommended
The combination of endurance and strength training generally has
multiple beneficial effects and is well tolerated; strength training would
be particularly indicated for patients with significant muscle atrophy
Respiratory muscle training could be considered as adjunctive therapy,
primarily in patients with suspected or proven respiratory muscle
weakness

27. The minimum length of an effective rehabilitation program is 6 weeks.
Daily to weekly sessions
Duration of 10 minutes to 45 minutes per session
Intensity of 50% of VO2 max to maximum tolerated
Endurance training can be accomplished through continuous or
interval exercise programs.
The latter involve the patient doing the same total work but divided into
briefer periods of high-intensity exercise, which is useful when
performance is limited by other comorbidities

28. Additional considerations
Optimal bronchodilator therapy should be given prior to exercise
training to enhance performance.
Patients who are receiving long-term oxygen therapy should have
this continued during exercise training, but may need increased
flow rates.
Oxygen supplementation during pulmonary rehabilitation,
regardless of whether or not oxygen desaturation during exercise
occurs, often allows for higher training intensity and/or reduced
symptoms in the research setting. (ATS/ERS STATEMENT)

29. Neuromuscular electrical stimulation
(NMES)
NMES may be an adjunctive therapy for patients with severe
chronic respiratory disease who are bed bound or suffering
from extreme skeletal muscle weakness.
ATS/ERS
Guidelines

30. Non invasive mechanical ventilation
Because NPPV is a very difficult and labor-intensive intervention, it
should be used only in those with demonstrated benefit from this
therapy
Further studies are needed to further define its role in pulmonary
rehabilitation.
ATS/ERS
guidelines

31. Nutritional Interventions
Why intervene?
High prevalence and association with morbidity and mortality
Higher caloric requirements from exercise training in
pulmonary rehabilitation, which may further aggravate these
abnormalities (without supplementation)
Enhanced benefits, which will result from structured exercise
training.

32. Body composition abnormalities
Increased activity related Energy expenditure
Hyper metabolic state
Decreased intake
Impairment of Energy balance
Imbalance in Protein synthesis and breakdown
Loss of fat; Loss of weight : BMI < 21
• 10% weight loss in 6 months
• 5% weight loss in 1 month

33. Caloric supplementation
Should be considered if :
BMI less than 21 kg/m2
Involuntary weight loss of >10% during the last 6 months or
more than 5% in the past month
Depletion in FFM or lean body mass.

34. Nutritional supplementation
Energy dense foods
Well distributed during the day
No evidence of advantage of high fat diet
Patients experience less dyspnea after carbohydrate rich
supplement than fat rich supplement. (probably due to delayed
gastric emptying)
Daily protein intake should be 1.5 gm/kg for positive balance

35. What to give…….
Small Frequent Meals
High-calorie snacks- creamy, rich puddings, crackers with peanut
butter, dried fruits and nuts.
Beverages- milk-shakes, regular milk and high-calorie fruit juices,
Breads and Cereals
Pep up Your Protein- milk or soy protein powder to mashed potatoes,
gravies, soups and hot cereal
Choose High-Calorie Fruits- bananas, mango, papaya, dates, dried
apples or apricots instead of apples, watermelon
Remember Your Vegetables potatoes, beets, corn, peas, carrots
Healthy, Unsaturated Fats
Soups and Salads

36. Nutritional Interventions
Physiological intervention: Strength exercise
Addition of strength training lead to increase in strength and mid
thigh circumference (measured by CT)
Pharmacological intervention : Anabolic steroids
Anabolic steroids
Nandrolone decanoate - 50 mg for male; 25 mg for females; 2
Weekly for 4 doses
Anabolic therapy alone increases muscle mass but not exercise
capacity

37. Nutritional Interventions
Growth hormone
rhGH 0.05 mg/kg for 3 weeks in addition to 35 Kcal/kg and 1gm
protein/kg per day has shown to increase fat free mass
But does not improve muscle strength or exercise tolerance ( hand
grip and maximal exercise ) and no change in well being of the
patient.

38. Nutritional Interventions
Testosterone
Testosterone 100 mg weekly for ten weeks in men with low
testosterone levels 320 ng/ml showed weight gain of 2.3 kg
Addition of exercise to testosterone has augmented weight gain
to 3.3 kg
Physiological consequences and long term effects not
studied

39. What the Guidelines Say…..
Increased calorie intake is best accompanied by exercise regimes
that have a nonspecific anabolic action
Anabolic steroids in COPD patients with weight loss increase body
weight and lean body mass; but have little or no effect on exercise
capacity. (GOLD)
Pulmonary rehabilitation programs should address body composition
abnormalities. Intervention may be in the form of caloric, physiologic,
pharmacologic or combination therapy. (ATS/ERS STATEMENT)

40. Psychological considerations
Screening for anxiety and depression should be part of the
initial assessment.
Mild or moderate levels of anxiety or depression related to the
disease process may improve with pulmonary rehabilitation
Patients with significant psychiatric disease should be
referred for appropriate professional care (ATS/ERS
STATEMENT)

41. Outcome Assessment
Providing patients with an opportunity to give
feedback about the program is a useful
measure of quality control.
Patient feedback also allows coordinators to
evaluate the components of pulmonary
rehabilitation that patients find most useful.
The questionnaire should also provide patients
with a variety of answering options
Exercise capacity measurement

42. Maintenance rehabilitation &
Repeat rehabilitation program
Current guidelines does not comment on maintenance &
repeat rehabilitation
Yearly repeat rehabilitation program had shown: Short term
benefits in the form of less frequent exacerbations
But no long term physiological effects on exercise tolerance,
dyspnea & HRQL
Foglio K. Chest. 2001; 119:1696–1704

43. Pulmonary Rehab. in Resource Poor
Settings
Assess the patient with spirometry, saturation, 6MWT, weight/FFMI
by biometric impedance, and bone density by sonography, AQ 20
and PHQ questionnaire
Treatment of osteoporosis and dietary advice by the physician
Exercise training by the physician or a trained staff, or an assistant at
the time of enrolment for 30 minutes
The exercise should simulate the patient’s home environment
The endurance and strength training can be done by walking/
cycling, walking uphill/climbing stairs and straight leg raise,
respectively

44. Pulmonary Rehab in Resource Poor
Settings……..
The exercise should be guided by his ability to tolerate exercise and
6MWT with periods of rest if desired. The speed and distance
should be increased gradually
The patient can be educated about breathing techniques by the
physician/assistant
The patients should exercise twice in a day for 30 minutes for at
least 5 to 6 days in a week
The patient may be given a diary to maintain
The patient may follow up once in a week or 15 days for
reinforcement/increment/supervision of exercises

50. What Does ACCP Say……..???

51. ACCP RECCOMENDATIONS (2007)
1. Recommendation: A program of exercise training of the
muscles of ambulation is recommended as a mandatory
component of pulmonary rehabilitation for patients with
COPD. Grade of Recommendation: 1A
2. Recommendation: Pulmonary rehabilitation improves the
symptom of dyspnea in patients with COPD. Grade of
Recommendation: 1A
3. Recommendation: Pulmonary rehabilitation improves health
related quality of life in patients with COPD. Grade of
Recommendation: 1A

52. ACCP RECCOMENDATIONS (2007)
4. Recommendation: Pulmonary rehabilitation reduces the
number of hospital days and other measures of health-care
utilization in patients with COPD. Grade of Recommendation:
2B
5. Recommendation: Pulmonary rehabilitation is cost-effective in
patients with COPD. Grade of Recommendation: 2C
6. Statement: There is insufficient evidence to determine if
pulmonary rehabilitation improves survival in patients with
COPD. No recommendation is provided.
7. Recommendation: There are psychosocial benefits from
comprehensive pulmonary rehabilitation programs in patients
with COPD. Grade of Recommendation: 2B

53. ACCP RECCOMENDATIONS (2007)
8. Recommendation: Six to 12 weeks of pulmonary rehabilitation
produces benefits in several outcomes that decline gradually
over 12 to 18 months. (Grade of Recommendation: 1A) Some
benefits, such as health-related quality of life, remain above
control at 12 to 18 months. (Grade of Recommendation: 1C)
9. Recommendation: Longer pulmonary rehabilitation programs
(12 weeks) produce greater sustained benefits than shorter
programs. Grade of Recommendation: 2C
10. Recommendation: Maintenance strategies following
pulmonary rehabilitation have a modest effect on long-term
outcomes. Grade of Recommendation: 2C

54. ACCP RECCOMENDATIONS (2007)
11. Recommendation: Lower-extremity exercise training at higher
exercise intensity produces greater physiologic benefits than lower
intensity training in patients with COPD. Grade of Recommendation:
1B
12. Recommendation: Both low- and high intensity exercise training
produce clinical benefits for patients with COPD. Grade of
Recommendation: 1A
13. Recommendation: Addition of a strength training component to a
program of pulmonary rehabilitation increases muscle strength and
muscle mass. Strength of evidence: 1A
14. Recommendation: Current scientific evidence does not support the
routine use of anabolic agents in pulmonary rehabilitation for for
patients with COPD. Grade of Recommendation: 2C

55. ACCP RECCOMENDATIONS (2007)
15. Recommendation: Unsupported endurance training of the upper
extremities is beneficial in patients with COPD and should be
included in pulmonary rehabilitation programs. Grade of
Recommendation: 1A
16. Recommendation: The scientific evidence does not support the
routine use of inspiratory muscle training as an essential component
of pulmonary rehabilitation. Grade of Recommendation: 1B
17. Recommendation: Education should be an integral component of
pulmonary rehabilitation. Education should include information on
collaborative self-management and prevention and treatment of
exacerbations. Grade of Recommendation: 1B
18. Recommendation: There is minimal evidence to support the benefits
of psychosocial interventions as a single therapeutic modality. Grade
of Recommendation: 2C

56. ACCP RECCOMENDATIONS (2007)
19. Statement: Although no recommendation is provided since
scientific evidence is lacking, current practice and expert opinion
support the inclusion of psychosocial interventions as a component
of comprehensive pulmonary rehabilitation programs for patients
with COPD
20. Recommendation: Supplemental oxygen should be used during
rehabilitative exercise training in patients with severe exercise-
induced hypoxemia. Grade of Recommendation: 1C
21. Recommendation: Administering supplemental oxygen during high-
intensity exercise programs in patients without exercise-induced
hypoxemia may improve gains in exercise endurance. Grade of
Recommendation: 2C

57. ACCP RECCOMENDATIONS (2007)
22. Recommendation: As an adjunct to exercise training in selected patients
with severe COPD, noninvasive ventilation produces modest additional
improvements in exercise performance. Grade of Recommendation: 2B
23. Statement: There is insufficient evidence to support the routine use of
nutritional supplementation in pulmonary rehabilitation of patients with
COPD. No recommendation is provided.
24. Recommendations: Pulmonary rehabilitation is beneficial for some
patients with chronic respiratory diseases other than COPD. Grade of
Recommendation: 1B
25. Statement: Although no recommendation is provided since scientific
evidence is lacking, current practice and expert opinion suggest that
pulmonary rehabilitation for patients with chronic respiratory diseases
other than COPD should be modified to include treatment strategies
specific to individual diseases and patients in addition to treatment
strategies common to both COPD and non-COPD patients.