PULMO REHAB Flashcards
PULMONARY REHABILITATION: 1st step, assessment protocol
Identification of criteria describing reason for Exercise Tolerance impairment
- Respiratory System: Lung Function Tests, Minute Ventilation, Maximal VoluntaryVentilation, Ventilatory Reserve,Dyspnea assessment, Oxygenation
- Cardiovascular System: HRmax, HRreserve, VO2
- Skeletal muscle: MRC scale, Dynamometry.
Tableau
PULMONARY REHABILITATION: components, goals, indications & contraindications
C: Training principles:
• Individuality
• Progressive overload
• Reversibility: ‘use it or lose it’
• Specificity (Frequency Intensity Type Timing; FITT) • Variation
G: - ↓ Symptom burden
- ↑ (Maximal) exercise capacity: ventilatory limitation - ↑ Quality of life
- ↑ Autonomy
- ↑ Participation daily life activities
- ↑ Health behaviour change
- ! Not improving lung function variables
Improve oxigenation Improve capnia
I & C: Obstructive diseases
Chronic obstructive pulmonary disorder Persistent asthma
Bronchiectasis
- Restrictive diseases
Interstitial fibrosis
Sarcoidosis
Kyphoscoliosis
Parkinson’s disease
Lung cancer
Pulmonary hypertension
Before & after lung transplantation Before & after lung reduction surgery
Absolute contraindications for pulmonary rehab
- Significant ischemia on ECG
- Recent myocardial infarction or other cardiac event - Unstable angina
- Uncontrolled cardiac arrhythmias
- Acute embolus or pulmonary infarction
- Acute myocarditis or pericarditis
- Suspected or known dissection aneurysm
- Acute infection
Relative contraindications for pulmonary rehab
- Severe arterial hypertension
- Tachyarrhythmias or bradyarrhythmias. Electrolyte abnormalities
- Hypertrophic cardiomyopathy
- High-degree atrioventricular block
- Uncontrolled metabolic disease
- Chronic infectious disease
- Neuromuscular, musculoskeletal or rheumatoid disorders that exacerbated by exercise
PULMONARY REHAB: rehab, + effects, safety in rehab
R: - Focus on patients with exercise limitations (not only COPD). COPD subjects = largest proportion of patients referred for PR
- Cardiac rehabilitation: lots of similarities with PR – important differences in exercise training program
+: - Benefits on exercise capacity, muscle function, health- related quality of life, symptoms, healthcare utilization
+++: based on randomized clinical trials & meta- analyses
++: encouraging results but further evidence needed +: indirect evidence
-: no improvement
Tableau
S: At start of each PR session: - Blood pressure
- Saturation
- Heart rate
- Peak expiratory flow - Symptoms
- Medication use
Considerations, contraindications for exercise & location of pulmonary rehabilitation, long term maintenances
C: Bronchodilator taken before training improve performance - Ensure hydration
- Minimum of 2 staff members
- 1:5 ratio for moderate risk patients
- Warming up / cooling down
- Subjects on anticoagulant: avoid high impact activity or sports => risk of bleeding
- Post sternotomy: no UL exercise before union at 8-12 weeks
C: Exercise training stopped if:
- Generally unwell
- Fever & acute systemic illness
- Resting blood pressures >200 mmHg systolic & >110 mmHg diastolic
- Failure to ↑ blood pressure during exercise
- Unexplained drop in blood pressure (+ symptomatic hypotension)
- Symptoms of dizziness, angina, nausea, headache
=> refer to doctor
- Resting or uncontrolled tachycardia (HR>100 bpm)
- Uncontrolled atrial or ventricular arrhythmias
- New/recurrent symptoms of lethargy, palpitation
- Unstable angina
- Unstable heart failure (swelling of ankles and/or weight gain >2kg over 2 days)
- Unstable/uncontrolled diabetes
=> refer to doctor
L: Outpatient
- Most prevalent
- In hospital / community (large individual differences)
- Part-time
Inpatient (90% OF ITALIAN PR):
- After exacerbation / severe disease - Lack of home management support - Transportation difficulties
- Similar benefits to outpatient
Home-based
- Most convenient for patient / long-term
- Difficult in subjects needing supervision
- No group support
- Limited presence of multidisciplinary team - Availability of exercise equipment – safety? - Similar effects
Rehabilitation in ICU
- Early mobilization of critically ill patients
Lifelong adherence to healthy habits (previous stages) - Very difficult to achieve (Change in behavior)
- Continued training programs:
• At least 1x/week
• Supervision
• Sufficiently high intensity - Fun activities
PULMONARY REHABILITATION: timing, non COPD patient
T: During exacerbation
- ↓ Muscle strength & ↓ PA
- Challenging risk of re-exacerbation - Potential
After exacerbation
- Within 1 month after hospital discharge - Usual care
- No increased risk
Stable disease
- Exacerbation-free during >8 weeks - Most evidence
Non COPD: PR also effective in subjects with: - Asthma
- Bronchiectasis
- Interstitial lung disease
- Lung cancer: cystic fibrosis
- Before/after lung surgery (ex: lung transplantation, lung volume reduction surgery)
PULMONARY REHABILITATION: education, medication, nutrition, frequency & smocking cessation
E: Education
- Reinforce info without difficult medical terms
- Self-managment strategies => disease control: action plans, diaries, pedometers
Psychological counseling
- Motivational interviewing - Stress reduction
Social support
- From social worker: education / advice
- From partner: active loved one => more active themselves - From other patients (ex: during rehabilitation)
M: Respiratory medication
- Short-acting medication: emergency or quick relief
- Corticosteroids: inflammation (side effects: weight gain, voice changes, nausea, upset stomach, muscle weakness) - Long-acting medication: long-term
Prevention of infections => Vaccination Cardiac medication
- Anticoagulants: ↓ clotting of blood
- Beta-blockers: ↓ heart rate, ↓ blood pressure TRAINING
- Angiotensin-Converting Enzyme (ACE) Inhibitors: ↑ ⌀ blood vessels, ↑ blood flow
- Statine: ↓ LDL cholesterol, ↓ risk of plaques
- Calcium Channel Blockers: relaxes blood vessels
N: Underweight
- More prevalent in advanced respiratory disease (ex: COPD) - Muscle wasting
Normal BMI
Overweight
- More prevalent in mild COPD/cardiovascular diseases - Increased cardiovascular mortality
- Decreased functionality
F&L: Optimal duration: unknown
- At least 8 weeks
- Programs > 6 months: better long-term effect - “As long as needed, as short as possible”
- Optimal frequency: unknown
- At least 3x/week with regular supervision
- Home-based exercise programs with online support: encouraging results
- Endurance/interval training: 3-5 times per week
- Resistance training: 2-3 times per week
- Maintenance: at least 1 time per week
SC: - Difficult to achieve
- Requires change in behavior
- ↑ body weight
- +++: reduction of incidence/progression of cardiovascular / respiratory / cancer diseases & mortality
- ↑ effectiveness of medication, teeth hygiene..
PULMONARY REHABILITATION: physical activity paradox, exercise training & other training modalities
PAP: PA programs no substitute to exercise training. Patients with poor exercise capacity referred to rehabilitation
ET: Targeting intensity
- Resistance training
- Load on muscle increase
- General metabolic load decrease
- Type of devices (resistance training): upper limb as well - Patients exhale during concentric part of exercise
Intensity:
• Is crucial
• Too high => risk for acute myocardial infarction • Close monitoring
• Moderate-intensity recommended
Defining Intensity:
1)Borg/rate of perceived exertion
2) Heart rate
• Maximal effort CPET vs age-220 (not accurate)
• Medication lowering blood pressure (standardization)
• Reserve Heart Rate method: [(HRmax- HRrest)*%intensity] + HRrest HRmax- HRrest= HRreserve
% intensity: depends on type of training
ACSM: HRreserve of 40-80% = 40-80% VO2max or 55-90% HRmax takes into account resting HR (training state)
• In conjunction with rate of perceived exertion scale
HR (heart rate) – Borg score/Rate of perceived exertion:
• Measure during/after each exercise
• Patients should train within HR zone and/or RPE/Borg scale
• If lower limit of HR zone and RPE/Borg<4/10 è increase intensity Exercise testing
If subjects take Beta-blockers or calcium channel blockers: ↓ heart response to exercise
Check medication at each training session
How does exercise training reduce VE? • Less VO2 required for given work rate • Less lactate production for given task
Aerobic & anaerobic
- Endurance (continuous)
- Interval
- Strength (resistance): increase muscle volume & mass
Intensity
- Minimal training intensity needed
- Defining intensity:
• No general consensus
• Based on assessment methods (6MWT, CPET, 1 RM- test, endurance test)
• Based on type of exercise limitation (Ventilatory or Cardiovascular)
Modality
Continuous ‘endurance’ training
- 20-30 min/session
- Majority of ADL of subjects with COPD require aerobic activity - Evidence:
• ↑ aerobic capacity (specificity of training)
• ↓ dyspnea sensation
• ↑ Quality of Life
• ↓ limitations ADL (less strong evidence)
Interval training
- Alternative to endurance training
- 20-30 min/session:
• Shorter bouts (30 seconds to 2 minutes for cycling) of high intensity • Relative rest periods of lower intensity
- Especially in severe patients:
• High intensity possible but only for short period
• Reach higher intensities with less hyperinflation
Endurance (continuous) vs interval training
- No significant differences between groups (picture)
Strength training (anaerobic training)
- ↑ muscle force/power/strength, ↑ exercise capacity
- Strength & endurance training: combination of both
improves muscle function and exercise tolerance!
- Higher ↑ muscle force with resistance training combine both methods (or interval) - Less dyspnea sensation during resistance training
OTM: - Water-based
• No adverse events
• Useful for physical comorbidities
• Clear benefits compared to no training
- Other training methods: • Nordic walking
• Tai-chi
=> similar effects to PR but not equivalent to PR
- Neuromuscular electrical stimulation (NMES)
• Low intensity currents => muscle contractions
• In subjects with muscle weakness, low BMI & severe ventilatory limitation
- Downhill walking:
• Decrease VE & VO2
• Increase muscle waist
- Supplemental oxygen:
• Complex issue (Master program)
• Exercise induced desaturation <90%: no extra effect on exercise
capacity
• Desaturation at rest: safety issue
• No desaturation at all: not recommended (Oxygen = drug)
• Standardization needed
• Barrier for patients
- One legged cycling: small, but significant, improvement in VO2 peak with associated improved walking distances & health-related quality of life
- Addition of Non Invasive Mechanical Ventilation • Complex issue
• Exercise induced desaturation uncorrected with oxygen suply
<90%: possible extra effect on exercise capacity
• Improvements on:
‣ Dyspnea during exercise training
‣ Walk test
‣ Exercise tolerance
Lack of RCT
