Pulmonary rehabilitation Flashcards
Definition of pulm rehab
(ATS/ERS 2013)
A comprehensive intervention
Based on a thorough patient Ax,
Followed by pt-tailored therapies,
That include but not limited to
Exercise training,
Education, and
Behaviour change
To improve physical and psychological condition, and
Promote long-term adherence to
health enhancing behaviours
Problem assoc with pulm rehab
A) Lack of access
B) Lack of uptake sec to
i) poor awarenss & knowledge among HCW
ii) whether eligible pt accept the offer for rehab, affected by:
- beliefs,
- expectation
C) Lack of completion, affected by
- practical factors: travel, transport, car parking, cost of attendance
- pt-related factors: physical disability, illness, depression, smoking status
Components of pulmonary rehabilitation
1) Pt Ax: nutrition status, OT Ax, dyspnoea Ax, QoL, exercise test
2) Program component: endurance and resistance training
3) Method of delivery: exercise program prescribed and monitored by a team with HCW with exercise prescription experience
4) Quality assurance: HCW trained to deliver the program
Conventional pulm rehab consists of
1) Supervised exercise training, education, self-Mx strategies and support
2) Delivered to group of pts
3) At least 2x/week for 8 weeks
4) Either inpt or outpt
Benefits of pulm rehab:
In COPD:
i) Improve exercise capacity
ii) Reduced dyspnoea
iii) Enhanced health-related QoL
iv) Reduced hosp admissions
v) Improved survival
Also effective in ILD, bronchiectasis, pulm HTN
Patients suitability for rehab enrolment
● Assess his understanding of his disease – it is long-term, now has recurrent AECOPD, rehab needed need to supplement medical treatment
● Determine patient’s expectations of his disease and participation in programme
● Assess motivation to attend
● Consider the logistic aspects of attendance- transport, family member’s support
3 main components of pulmonary rehabilitation
● Physical
o Duration vary from 8 -12 weeks
o Approximately two-hour session, twice weekly with intervening home sessions
o Prescribed & supervised exercise - includes both endurance training & resistance training
o Circuit-based programme
o Functional exercise – linked to patient goals (what patients want to achieve for the ADL)
o Patient’s progress is monitored & assessed objectively
● Social support - includes psychological support
● Education & self-management - techniques/coping strategies
Members that would typically be involved in a pulmonary rehabilitation programme
● Physiotherapists (the most important PR team member – responsible for prescribing, supervising, and measuring outcomes in exercise)
● Respiratory Nurses (where available)
● Dieticians
● Occupational Therapists
● Stop Smoking Service
● Social Worker
● Pharmacist
● Consultant/Medical officer
● Psychologist / Psychiatrist
Contraindications for pulmonary rehabilitation
● Recent MI (Last 6 weeks)
● Unstable angina
● Severe hypoxic lung failure unable to be corrected by supplementary oxygen
● Uncompensated heart failure
● Severe psychiatric impairment
● Non-consenting patient
Other factors worth considering include
● Unstable cardiac disease
● Locomotor issues
● Difficulties following instructions due to cognitive or psychiatric impairments
● The attendance of a support person to enable and encourage adherence
Parameters to monitor during and after exercise
● Modified BORG Scale (0-10)
● Oxygen saturations
● Respiratory rate
● Heart rate
● Blood pressure
Physical outcome measures could be used to assess the patient’s progress in pulmonary rehabilitation?
● Modified BORG Scale (0-10)
● Oxygen saturations
● Respiratory rate
● Heart rate
● Blood pressure
Physical outcome measures that could be used to assess the patient’s progress in pulmonary rehabilitation
1) Six-minute walk test (6MWT) - most commonly used
2) Incremental shuttle walk test (ISWT)
3) Timed up and Go test (TUG)
4) Ten-metre walk test
5) CPET
What tools can be used to measure activities of daily living (ADL) and psychological outcomes?
ADL outcome:
● St George’s Respiratory Questionnaire (SGRQ)
● Chronic Respiratory Disease Questionnaire (CRDQ)
● Medical Outcomes Short Form 36 Questionnaire (SF-36)
● Patient Health Questionnaire 9 (PHQ-9)
Psychological outcome:
● Hospital Anxiety and Depression Scale (HAD)
What topics are typically covered in a patient education session of pulmonary rehabilitation?
● Education on the underlying pulmonary disease
● Breathlessness management
● Anxiety management
● Energy conservation
● Medications
● Benefits of exercise
● Management of own condition
● MDT input from Dietician, OT, Stop Smoking Service, Pharmacist
Do you know of any techniques or devices that can be used to help patient manage their symptoms?
● Chest clearance techniques - e.g. flutter valve, chest percussion / postural drainage, LEGA, positive expiratory pressure devices
● Breathing strategies (such as pursed-lip breathing)
Apart from COPD, are there any other conditions that may benefit from pulmonary rehabilitation?
● Non-CF Bronchiectasis
● Interstitial Lung Disease (IPF, CFA)
● Pre-transplantation work-up in CF and ILD
● Pre-surgical work-up for general surgery
● Post-COVID
● Evidence weak for Asthma
What are the problems associated with pulmonary rehabilitation in general that you have observed?
● Not enough people being referred early (late referral)
● High drop-out rate (30%-50% in literature)
● Barriers to older and younger patients
● Older: Transport, Mobility, Cognition, Carer Role
● Younger: Work, Families, Embarrassment, Fear
● Risk of advising “normal exercise” – PR specialist and needs specialist management by team
● Lack of long-term maintenance (self-management?)
● Lack of flexibility in terms of group location/time
● Not enough programmes available
What may be the solutions to some of these problems?
● Consider pulmonary rehab for every COPD patient, regardless of age or severity
● If previously dropped-out, ask why and ask to reconsider (evidence that second-time attenders often stay)
● Link with specialist teams to advise and educate but provide basic information, details and explain the benefits
● Don’t just advise “go to the gym” – likely to worsen problem
● Give strategies for long-term self-management (“Teach a man to fish…”)
● Be more flexible to adapt to patient needs: evening classes-, weekend classes, home or community-based programme, consider online instruction
