pulmonary rehab Flashcards
define pulmonary rehab
Pulmonary rehabilitation is a comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies, which include, but are not limited to, exercise training, education, and behavior change, designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence of health-enhancing behaviors.”
parameters for pulm rehab
PR Model of Care (National COPD Clinical Care Programme)
PR should be at least 6 weeks duration, with the pre and post programme assessments as additional to this
Programmes should include a minimum of twice-weekly supervised sessions (at least 12 sessions).
A third session per week of prescribed exercise is recommended and can be unsupervised.
Other opportunities for physical activity are encouraged, as per the physical activity guidelines i.e. 30 minutes of physical activity 5 days per week .
who goes to PR
Patients with stable COPD should be referred to PR if their exercise capacity is limited by breathlessness, i.e. MRC 3-5 (mMRC 2-4).
Also, those who have significant disability or have been discharged from hospital with an MRC score of 2 (mMRC score of 1) should be offered a place if suitable.
It is recommended that all patients are offered a place within three months of receipt of referral (BTS Quality Standards, 2014) .
Where capacity and skill-set allows, PR programmes should accept other chronic respiratory disease patients with a functional limitation due to breathlessness e.g. MRC 2 (mMRC 1) if referred.
other chronic resp diseases
Bronchiectasis: Short-term improvements in exercise capacity and HRQOL were achieved with supervised PR and ET programs, but sustaining these benefits is challenging in people with bronchiectasis. (Lee et al. 2017)
ILD: Pulmonary rehabilitation seems to be safe for people with ILD. Improvements in functional exercise capacity, dyspnoea and quality of life are seen immediately following pulmonary rehabilitation (Dowman et al. 2014)
Asthma: Studies have documented that pulmonary rehabilitation has beneficial effects in patients with asthma, at any stage of the disease, improving exercise capacity, asthma control, and quality of life and reducing wheezing, anxiety, depression, and bronchial inflammation.(Zampogna et al. 2020)
Lung Cancer: Evidence is increasing that the benefit of pulmonary rehabilitation can be applied to patients with lung cancer. Comprehensive pulmonary rehabilitation has made its way as a cornerstone of integrated care for patients with lung cancer. (Wang et al. 2016)
While there is much to learn about how it should be integrated with active cancer therapy, there is little doubt that exercise-based therapies such as PR will have an important role to play.(Steiner et al. 2020)
assessment
HR, SpO2, BP, BMI
Measures of Dyspnoea. (Modified BORG Score, mMRC)
Exercise test: 6 minute walk test, Incremental shuttle walk test (each test should be done twice with an appropriate rest break to rule out a learning effect)
Quality of life: one disease specific and one generic
Agreed goals (SMART goals)
Where possible a measure of quadriceps muscle strength is highly recommended.
assessment goal setting
+ assessment
I want to be able to play with my grandkids
By the end of the 6 weeks I want to be able to walk to the post office at and back without taking any rest breaks
By the end of the 6 weeks I want to be able to walk to the end of Dun Laoghaire pier in 30 minutes without sitting for a rest
Disease Specific Health Related Quality of Life
The COPD Assessment Test (CAT) (Gupta et al. 2014)
St. George’s Respiratory Questionnaire (SGRQ)
Leceister Cough Questionnaire (Berkhof et al. 2012, Murrary et al. 2009, Han et al. 2014)
The Quality of Life-Bronchiectasis (QOL-B) (Quittner et al. 2014)
Bronchiectasis health Questionnaire (BHQ) for Bronchiectasis (Spinou et al. 2017)
Asthma Quality of Life Questionnaire (AQLQ for Asthma). (Juniper et al. 1992)
King’s Brief Interstitial Lung Disease (K-BILD) health status questionnaire (Patel et al. 2012)
A Tool to Assess Quality of Life in IPF (ATAQ-IPF)(Swigris et al. 2010)
The Hospital Anxiety and Depression scale (HADS)
The EuroQol (EQ-5D).
General Anxiety Disorder 7-item (GAD-7).
The Patient Health Questionnaire (PHQ-9)
FITT exercise component frequency intensity time and type
10-15 minute warm up period.
30 minute programme of activity (moderate to somewhat severe intensity) guided by the Borg Score or RPE.
10-15 minute cool down period.
Brief periods of upper and lower body flexibility exercises are recommended to maintain muscle length and prevent injury and soreness (Jenkins et al. 2010). Flexibility training should also focus on improving thoracic mobility and posture to help increase the vital capacity in patients with chronic respiratory disease
exercise component - indivdually tailored
Interval versus continuous
Intensity of activity: Borg dyspnoea of 4 to 6 (moderate to [very] severe) or Rating of Perceived Exertion of 12 to 14 (somewhat hard) is often considered a target training intensity. (Spruit et al. 2013)
Moderate intensity interval training will be the training method of choice for those who experience increased ventilatory limitation during the 6MWT. For those participants familiar with this training method, they will be commenced at a 1 minute exercise at moderate intensity followed by 1 minute passive rest for a total of 20mins. For those not use to exercising, training time will be of 30 sec duration at moderate intensity followed by a 30 sec passive rest for a total of 10 minutes.
The ACSM recommends that resistance training should be performed on a minimum two non-consecutive days each week, with one set of 8 to 12 repetitions for healthy adults or 10 to 15 repetitions for older and frail individuals. Eight to 10 exercises should be performed that target the major muscle groups.
Oddvar Holten Diagram to estimate 1RM
Different percentages of 1RM can be used depending on the goal of training
oddvar holten diagram
Can be dangerous in practice to perform a full 1 RM
Individual picks a weight and performs and as many repetitions as they can with that weight.
E.g. 10 reps with 5kg for shoulder press
10 reps is approximately 80% of 1RM
5 X (100/80)= 6.25kg
1RM = 6.25Kg
The more reps that are done the less accurate this method is
inspiratory muscle training
IMT may be considered as an adjunct to the exercise training component of PR in patients with poor baseline inspiratory muscle strength as measured by inspiratory muscle testing protocols. The reported frequency and intensity of IMT training range from 30% to 80% of baseline PiMax making it difficult to make recommendations (Beaumont et al. 2017)
educational component suggested topics
Respiratory anatomy, physiology and disease education.
Nutritional advice.
Chest clearance and breathing control techniques.
Role of medication and inhaler therapy.
Self-management knowledge and skills.
Psychological and behavioral intervention, anxiety management and goal setting.
Symptoms control and exacerbation management.
Smoking cessation.
Incontinence management.
Relaxation and energy conservations.
Advance care planning and planning for the future
safety considerations
Preparticipation exercise screening.
Class size should be limited to less than 15 to allow safe and individual attention to be provided.
Ratio 1:8 (UK) 1:4 (US) for exercise training and 1:16 (UK), 1:8 (US) for the education session. It is recommended that two staff members are always present during the exercise class for safety reasons. One senior member of staff must be present at all times.
During Exercise testing consider stopping or resting if: (i) Increased heart rate such that it approaches age predicted maximum (ii) SaO2 < 90% or 4% decrease (iii) Marked wheeze and inability to finish sentence
During training sessions consider stopping or resting if: (i) Increased heart rate such that it approaches age predicted maximum (ii) SaO2 < 80% (or as per local respiratory lead) or (iii) Marked wheeze and inability to finish sentence
Patients should be advised regarding the following:
Check the battery and/or level of oxygen gas left in their ambulatory oxygen therapy device.
Bring short-acting bronchodilator if prescribed
Bring GTN spray to the assessment/classes if prescribed.
If diabetic, patients should be advised to bring their glucometers and a glucose supplement to encourage independent management of any hypoglycemic events.
If allergic patients are carrying hypodermic needles they should advise their therapist/CNS.
muscle dysfunction
Muscle Dysfunction -defined as the loss of either strength or endurance properties of muscles, is a major co-morbidity in COPD that results in the impairment of the patients’ exercise capacity and quality of life
Quadriceps weakness was demonstrable in one-third of COPD patients attending hospital respiratory outpatient services. Quadriceps weakness exists in the absence of severe airflow obstruction or breathlessness. (Seymour et al. 2010)
The BODE index or I-BODE index may be a better indictor of skeletal muscle dysfunction.
Endurance of the upper limb muscles appears to be well preserved (probably related to the activity of the muscle groups.)
aetiology of muscle dysfunction
Several factors and biological mechanisms have been shown to participate in the multifactorial etiology of muscle dysfunction in COPD. Cigarette smoke, hypoxia, hypercapnia and acidosis, metabolic alterations of several types, malnutrition, genetics, systemic inflammation, aging, co-morbidities, concomitant treatments (corticosteroids), exacerbations, and inactivity are counted among the most relevant etiologic factors that contribute to muscle dysfunction in COPD patients through the action of several biological mechanisms.
exercise training and muscle dysfunction
Improved muscle strength Improved muscle endurance Improved muscle mass Improved oxidative capacity ? Effect on inflammatory state
