Lecture 24: Pulmonary Rehab Management Flashcards
importance of good activity tolerance, clinical manifestations of decreased tolerance, and how to improve
poor tolerance/inactivity = increased risk mortality
manifestations = decreased walking/standing tolerance, inability to perform ADLs
APTA guidelines recommend increased PA via increase in total daily activity, # steps, and total time out of bed
ACSM, AHA, CDC guidelines for PA
150-300 min/week moderate intensity aerobic
OR
75-150 min/week vigorous aerobic
mod intensity strength 2 or more times per week
ACSM older adults guideline
if cannot do >150 min mod intensity PA, they should be as active as their abilities allow
balance should be performed in addition to aerobic/resistance
how to best handle activity tolerance/energy conservation with pulmonary patients
low intensity high frequency
- walk shorter distances more often instead of long distance all at once
- increase duration before intensity
if you fail walkie talkie test = stop task or stop talking
things to keep in mind when completing strength training with pulmonary pts
clinical presentation of pulm pts = sarcopenia, osteoporosis, mm wasting, frailty
literature limited for mod-high risk pts
mm function (power, speed, endurance) is altered w/o normal O2 delivery over long periods of time
**consider impact of chronic steroid use in pulmonary pts (more common than with CVD)
Considerations for parameters of strength training with Pulmonary pts
ACSM/AHA recommends 10-15 reps of RPE 11-13/4-6
slower progression of exercise reps and weight
lower 1RM
decreased resistance tolerance
Things to keep in mind regarding ROM in pulmonary pts
pt has prolonged sx precautions = may have decreased ROM that can affect chest wall movement, breathing, and posture
posture = major implications on breathing mechanics, lung capacity, and functional activity tolerance
pain free ROM beneficial post thoracotomy to prevent adhesions during healing
awareness of long thoracic nn damage with posterolateral thoracotomy
potential causes of cognitive impairments in pulmonary pts and implications
cognitive impairments in COPD is higher than normal population but wide reference of prevalence (3-61%)
potential causes
- chronic hypoxemia/hypoxia
- chronic hypercapnia
- supplemental O2 non-compliance
- impaired oxygenation during sleep due to pulm dysfunction
- hospitalization can affect (especially geriatric)
implication = ability to follow instructions/precautions, medication/O2 compliance, safety, ADLs, and qualification for post acute rehab
interventions for pulmonary patients with cognitive impairments
family involvement
frequent reorientation
healthy sleep/wake cycle
structured schedule
increased mobility and ADLs
common causes of pain in pulmonary pts
large sx incisions = painful; intercostal nn pain common
parietal pleura and thoracic cavity = highly innervated = pain
post op lines may irritate parietal pleura
post op pain has major effects on respiratory function
what happens when pain levels increase
higher pain = stimulates SNS
- decreased peripheral autonomic function
- increases stress hormone release
- decreased immune function
barriers to CVP rehab
baseline functional capacity, disability, or frailty
poor exercise tolerance
decreased knowledge of condition, poor health literacy
poor medical compliance
frequent hospitalization
QOL/depression
lack of resources or access
use of APTA CPG on supplemental O2
highlights use and importance of supplemental O2
establishes guidelines and recommendations for practice based on best available info and evidence
addresses need for standardization
effects of supplemental O2
improves SOB if SpO2 or PaO2 is decreased
alleviates pulmonary vasoconstriction response to hypoxemia
improves hemodynamics
enhances exercise performance if SpO2 or PaO2 is decreased
reduces perception of dyspnea
PT role in supplemental O2 use (recs from CPG)
if pt is using O2, need order and SpO2 target/goal
“once there is a rx for specific O2 saturation target level to be maintained during rest and activity, the PT may titrate the supplemental O2 flow to maintain SpO2 at or above the specified value”
investigate if pt is using different device than that prescribed
sup. O2 can be placed without an order in emergency situations as long as primary provider is notified
following PT, pt should return to the supplemental device and flow rate used prior to intervention
precautions to supplemental O2
pts with chronic hypercapnia or obstructive lung disease (especially COPD) = overoxygenating can reduce respiratory drive, preventing CO2 from being effectively exhaled
COPD pts - be aware of lower SpO2 goals and recs to keep SpO2 below certain value
if pt cannot be returned to O2 device/flow rate used prior to PT intervention, primary provider should be notified
CPG for supplemental O2 summarized
medical providers order O2
supplemental O2 should be set at or above 90% SpO2 unless otherwise specified by MD
sup. O2 = medication
vital signs should be monitored while on sup. O2
retention of CO2 (hypercapnia) is not a contraindication to sup. O2, but those pts may have altered O2 goals
no national recommendations/guidelines, or position statements to guide safe PT practice
when/how to wean from supplemental O2
not noted in CPG
strong use of clinical judgement
titrate down 1L/min at a time
ensure clear communication with RN, MD
provide documentation of response/vitals
pursed lip breathing has what effect
decreases S&S of dyspnea
slows RR and reduces wheezing
prevents alveolar collapse at end exhalation
paced breathing is used when? and how?
used with pts with very low endurance, anxiety, dyspnea on exertion
inhalation at beginning of activity, exhale during activity
goof practice for volitional coordination of breathing during activity to facilitate success with progression
describe inspiratory hold technique
indicated for hypoventilation, atelectasis, poor V/Q matching
improves air flow into poor ventilated lung regions
prolonged breath holding for 2-3 seconds at max inspiration
can be used in conjunction with vibration to aid in secretion clearance
describe stacked breathing
indicated for hypoventilation, atelectasis, poor V/Q matching, uncoordinated breathing
series of deep breaths that build on top of the previous breath without exhalation until max volume tolerated is reached
inspiratory hold in between each inhale
purpose of thoracic mobilization techniques in pulmonary pts
improves ability of thorax to expand via optimized biomechanics
types of thoracic mobilization techniques
towel roll or bolster along T/S in supine = improves anterior chest wall mobility
side lying over towel/bolster = increase lateral chest wall mobility
counter RT
- helpful with pts with high NM tone
- side lying + knees bent + arms in front
- upper trunk RT out with inhale, in with exhale
- pelvis/lower trunk can stay still or RT opposite of upper trunk
Butterfly RT = upright version of counter RT
what is inspiratory mm training
strength training for diaphragm in pts with decreased strength and endurance of inspiratory mm
increased ventilatory capacity = improved lung volumes, better V/Q matching, and improved SpO2/PaO2
decreased dyspnea = improved functional activity tolerance and higher QOL
overload principle for inspiratory mm training
low load applied over longer time
specificity principle for inspiratory mm training
resistance needs to be applied to inspiratory mm rather than expiratory
3 types of mm fibers in diaphragm
- slow twitch
- slow contraction
- uses aerobic metabolism
- fatigue resistant - fast twitch oxidative-glycolytic
- fast contraction
- aerobic metabolism initially
- can switch to anaerobic metabolism then fatigues faster - fast twitch glycolytic
- fast contraction
- uses anaerobic metabolism
- fatigues quickly
describe the adult diaphragm
~55% slow twitch mm fibers
fatigue is correlated to slow twitch fibers
weakness is correlated to fast twitch fibers
describe purpose/recommendation for endurance inspiratory mm training
increases capillary density, myoglobin, and glycogen concentration
proportion of fatigue resistant slow twitch mm fibers improves
recommendation = 30-60 min continuous deep diaphragmatic breathing 2-3x/day
purpose and recommendations for strength training with inspiratory mm training
involves resisted inhale
if tidal volume is far below 500mL, should start with active breathing exercises before adding resistance or weight
recommendations:
- early IMT technique = sniffing = engages focused diaphragm
>sniff quickly 3x with slow exhale helps increase awareness of correct diaphragmatic engagement
- weights can be placed on lower chest
>2-3 sets of 10 reps, 1-2x/day
>no recs on starting weight
what is maximum inspiratory pressure (MIP)
maximum inspiratory pressure (MIP) - measure of max force inspiratory mm can generate resistance
IMT devices do what
provide resistance against inhalation
recommendations for use of IMT devices
15-30 min, 2x/day
start with level of resistance that is comfortable to perform the above frequency then gradually increase from there
HF standardized IMT recommendations using MIP %
less than/equal to 30 min/day if using higher training intensity of >60% MIP
> 30% MIP sets or intervals performed to fatigue
5-7 days/week for 8-12 weeks
*HF only dx that has standardized recommendations using MIP %
thoracotomy post op precautions
usually last 6-8 weeks
no lifting >5lbs
no twist/RT
no strenuous activity with sx side
ROM encouraged as tolerated below 90-90
splinted coughing
secretion clearance techniques for CF
postural drainage with manual airway clearance
oscillation vest, Acapella, flutter valve devices
active cycle of breathing, forced expiratory technique
what to do for CF pts when they have periods of SOB
controlled breathing techniques
other things to work on with CF pts
exercise, strength, inspiratory mm training
thoracic stretching and postural reeducation to avoid kyphotic posture
describe asthma and pulmonary rehab techniques for these pts
activity shouldn’t begin unless appropriate meds initiated to reduce bronchospasm and inflammation
secretion clearance techniques (i.e. active cycle, vibration)
controlled breathing techniques
exercise and strength training g
thoracic stretching and postural reeducation to avoid kyphotic posture
consequences of transplanted lungs not having autonomic innervation any more
decreased mucociliary clearance, V/Q imbalance, ineffective cough, slowed receptor responses
pt may not be able to sense the need to cough
phrenic nn and diaphragm are not cut during transplant sx
initial interventions for lung transplant pts
pulmonary toilet
mobilization
positioning for optimal breathing/cough
postural drainage
airway clearance
decreased accessory breathing
active cycle of breathing and vibration are very effective in early stages
medication for lung transplant and the effect
oral and inhaled steroids for immunosuppression
lung transplant = highest rate of acute rejection
60-90% pts require HTN meds
results = steroid myopathy in proximal mm and osteoporosis are very common
resistance exercises should be initiated prior to transplant and continued at highest level that is safe post transplant
adequate warm up and cool down required for any aerobic exercise to compensate for lack of autonomic innervation
HF implications with pulmonary dysfunction
very challenging to fully separate the two bc of symptom overlap
frequently treating HF alongside pulmonary dysfunction
aerobic exercise recommendations for stable, class 2-3 HF
20-60 min
50-90% peak VO2 max
3-5x/week
> 8-12 weeks
treadmill, cycling, dance
interval training exercise recommendations for stable, class 2-3 HF
> 35 min
1-5 min high intensity (>90% VO2 max) alternating with same duration rest intervals (40-70% VO2 max)
2-3x/week
> 8-12 weeks
treadmill, cycling
resistance training recommendations for stable class 1-3 systolic HF
45-60 min/session
60-80% 1RM
2-3 sets/mm group
3x/week
> 8-12 weeks
combined exercise recommendations for stable class 2-3 systolic HF
20-30 min added to aerobic exercise training
60-80% 1RM
2-3 sets per mm group
3x/week
> 8-12 weeks
total exercise time shouldn’t be extended beyond what would be spent on aerobic alone due to reduced adherence
general endurance training guidelines for pulmonary pts
always start with low intensity (3-4/10) and increase duration before increasing intensity as pt progresses
duration should start with the length of time a pt can exercise until fatigued (increase by 1-2 min per day)
interval training very effective in initial phases
focus on functional tasks
ensure compensation of medical conditions
