Week 12 - Pulmonary Rehab Flashcards
Aim of pulmonary rehab
- Reduced symptom burden
- Maximise exercise capacity
- Promote autonomy
- Improve participation in ADLs
- Enhance health-related quality of life
- Promote health behaviour change
What patient groups are excluded from PR?
- MSK / neuro disorders that prevent exercise
- Unstable CVD
- Severe cognitive impairment
- Severe psychotic disturbance
- Relevant infectious disease
What patient groups can benefit from PR?
- COPD
- Chronic asthma
- Bronchiectasis
- Interstitial lung disease (ILD)
- Pre/post lung surgery
- Pulmonary arterial hypertension
- Lung cancer
Improved benefits of PR:
- Exercise capacity
- Health-related QOL
- Muscle strength
- Health behaviours
Reduced benefits of PR:
- Dyspnoea
- Health care costs
- Reduction in hospital admissions/length of stay
What limits an untrained person w/o disease:
Peripheral system
What limits a trained individual?
Cardiovascular system
CV limitations to exercise:
- HR
- Rhythm
- BP
- Chest pain
Pulmonary limitation:
- Vt
- RR
- VE/MVV (max voluntary ventilation)
- POB (pattern of breathing)
- SpO2/Dyspnoea score
- End expiratory lung volume (EELV)
Pulmonary limitation in COPD:
- 2 main impairments: impaired ventilation (resp. system mechanics & muscle impaired) / Impaired gas exchange
Steps that happen with impaired ventilation due to COPD:
- Increased RR & Vt
- Insufficient time for lung emptying
- Gas trapping > dynamic hyperinflation > Increased EELV
- Flattened / shortened diaphragm
- Decreased inspiratory reserve
- Increased WOB
- Reach MAX VE / DYSPNOEA
Gas exchange can be impaired due to decreased:
Ventilation, perfusion, diffusion
Measurements that identify pulmonary limitations in COPD:
- Abnormally high RR
- Severe dyspnoea
- Decreased SpO2
- Abnormal POB
- Lower Vt than normal
- VE/MVV > 70%
- Increased EELV
Peripheral muscle limitations in patients w/ COPD:
- Decreased muscle mass (strength)
- Decreased oxidative enzymes
- Change in muscle fibre type (decreased type 1, increased type 2) - (decreased muscle endurance)
What is a consequence of muscle changes in those w/ COPD:
Early onset of lactic acidosis > early muscle fatigue
Late stage COPD CV limitations:
- R sided heart failure (RHF) is common
- Decreased SV / CO
- Decreased PA
Benefits of PR in those w/ COPD:
- As long as lung function doesn’t change, these benefits occur:
- Improvement of peripheral mm function / exercise endurance :
- Increase in muscle strength/ decrease in fatigue
- increase muscle endurance
How does PR increase muscle endurance in those w/ COPD?
- It reverses muscle fibre distribution (maintains slow twitch fibres)
- Increases capillary density in muscles
- Increases oxidative enzymes
How does PR help w/ dyspnoea:
- Increased O2 extraction @ the working muscle.
- Lower lactate prod. > decrease ventilation > decreased dyspnoea
- Delays dynamic hyperinflation (DHI)
With a metabolic acidosis, how does the resp. system try to compensate?
- By producing a respiratory alkalosis through hyperventilating
Psychological benefits of PR in COPD:
- Improves: emotional function/self-confidence/coping strategies
- Reduces: depression/social impediments/ mood disturbance
What can PR include?
- Initial assessment
- Exercise training
- Eduction
- Nutritional intervention
- Psychosocial support
- Final assessment/ strategies for ongoing exercise
PR assessment:
- Medical Hx
- Physical Exam
- Investigation (SpO2/CXR)
- Exercise testing
- QoL measure
Typical length of programs:
- 4-8 weeks minimum
- Standard programs: 8-12 weeks
- At least 20 sessions
- Those w/ severe COPD need longer (up to 6 months to see changes)
Frequency of training:
- MINIMUM 3 x week , 2x-supervised, 1x- @ home
Intensity of training:
- High elicits the greatest training response
- Low intensity is also effective (60-65% peak work rate)
Walking training intensity based of test:
- 80% of better (out of 2) avg. 6MWT speed
- 70% of peak walking speed on the ISWT
- Dysp score of 3-4
Intensity of cycle training:
- 60-80% of peak cycle work rate from cycle test
- Predictive equation from 6MWT
- OR dysp score of 3
What to do if pt desaturates while exercising?
- Regularly monitor SpO2
- Consider interval training
- Drops below 88% - assess for supplemental O2
- Cycling induces less O2 desaturation than walking
