Pulmonary
- Critical Care Associates
of East Texas
Jeffrey M.
Shea, M.D., F.C.C.P.
Catherine M. Martinez, M.D.
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Jeffrey M.
Shea, M.D., F.C.C.P. |
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What Is Pulmonary Rehabilitation? Rehabilitation is the restoration of the patient to the fullest medical, mental, emotional, social, and vocational potential of which they are capable. Pulmonary rehabilitation is a program for patients with chronic lung disease such as emphysema, chronic bronchitis, asthma, bronchiectasis and interstitial lung disease. It includes medical management, education, emotional support, exercise, breathing retraining and nutritional counseling. Goals Of Pulmonary Rehabilitation
When the patient has been diagnosed with COPD (chronic obstructive pulmonary disease), they should be encouraged to adhere to treatments, such as smoking cessation, regular exercise, and weight control. Patients should also have routine immunizations against pneumonia and flu. Who Is Involved In The Program? Formal programs will have the physician, nurse, rehabilitation therapist, psychosocial staff and dietitians. These professionals evaluate each patients overall physical and emotional status and develop a program for them. The physician, specially trained nurse, or a respiratory care practitioner is responsible as the program coordinator. When Should Patients Enter The Program? Patients should be considered for the program, despite optimal medical therapy:
Patients that are receiving optimal medical treatment prior to entering a pulmonary rehabilitation program may show no improvement in lung function. Pulmonary rehabilitation remains a cost-effective way demonstrating positive outcomes for patients with COPD (reduction in the number of patient hospital days and improved quality of life). Components Of Pulmonary Rehabilitation
This is a very necessary part of the program in the care of patients with COPD. The health care professionals of the program will provide education focused on behavioral changes and enhancing patient understanding of and adherence to prescribed therapy. The knowledge of the potential benefits of treatment will increase patient adherence to therapy. The program emphasizes education of both patients and families to improve understanding of the disease process, self-care, and to develop practical ways of coping with disabling symptoms and acute exacerbation’s. Smoking causes COPD, therefore, smoking cessation efforts are a critical part of the program. Avoiding exposure to involuntary smoke should also be encouraged. Group smoking cessation clinics are offered by agencies such as the American Lung Association. These programs offer strategies and support to patients who attempt to quit. Programs may include behavioral therapy, counseling, and medication treatment. Medication should be prescribed according to the severity of the disease, and the responses to and toleration of the patient for specific drugs. The following medication classes are used:
With COPD you have an increase in the work of breathing, reduced ventilatory capacity and reserve, and an alteration in the pattern of breathing. Activity or exercise leads to further increase in ventilatory demand. There is an increase in respiratory rate and may have decreased oxygenation during exercise. Exercise in patients with COPD leads to changes such as increase in the work of breathing, reduction in capacity in ventilation, increased rib cage and accessory muscle movement, expiratory abdominal muscle movement, and chest wall motion movement. Air trapping is common in patients with COPD especially during exercise and leads to alterations in functional capacity. Patients with severe COPD may breathe with the muscles of the upper chest, shoulders and neck muscles with limited or absent diaphragm contraction. Arm and leg exercise endurance testing with measurement of endurance time, metabolic, ventilatory, and cardiovascular should be determined prior to rehabilitation to determine exercise limitations and possible cardiopulmonary risk factors. Exercise Training: There are positive outcomes with exercise training in patients with COPD. Patients often increase maximum exercise capacity and endurance as well as physical activity, despite lack of improvement in lung function. Exercise training also provides patients the opportunity to learn about their capacity for physical work and to practice breathing retraining techniques to control shortness of breath. Four major parts of exercise prescriptions are mode, frequency, intensity, and duration. Exercise prescriptions in patients with COPD are similar to those for healthy individuals. The mode of exercise should involve activities that involve the large muscle groups and closely relate to daily activities, lower extremity exercise; walking or cycling are appropriate. Suggested frequency of training is 3 to 5 times a week. Exercise intensity is based on the individual’s motivation and ability to tolerate shortness of breath and extremity discomfort. Supervised sessions where patients are monitored closely for oxygen desaturation and cardiac events are recommended. Oxygen given during exercise may reduce shortness of breath and improve exercise tolerance. Widely variable exercise regimens have shown to be beneficial. Patients who participate in pulmonary rehabilitation programs are encouraged to continue daily exercise after their program is completed to maintain or further improve their functional state. Arm Exercise Training: Patients with COPD report severe shortness of breath with daily activities, such as lifting and grooming, at work levels that are lower than required for leg activities. Upper extremity exercise leads to greater breathing demand for a given level of work than lower extremity exercise. Exercise training benefits are specific to the muscles used and tasks involved in training, both lower and upper extremity training are necessary in overall reconditioning. Arm exercises, both supported and unsupported, are important in improving common daily activities requiring use of the arms. Respiratory muscle training does not lead to improvements in overall inspiratory muscle strength and endurance. It also may not lead to an increase in diaphragm strength in patients with severe COPD, but it helps to train the rib cage and accessory muscles. Studies show an improvement in exercise tolerance and shortness of breath with respiratory muscle training. With this training carried out with controlled breathing patterns it allows high pressure generated during inspiration and has shown improvements in respiratory muscle strength and endurance and a possible increase in functional status. Oxygen therapy is a modality of the pulmonary rehabilitation program that reduces mortality. Continuous oxygen treatment resulted in less mortality than nighttime oxygen treatment only. In patients with reduced oxygen levels, with holding oxygen therapy leads to an early mortality. Long-term oxygen therapy is associated with alleviation of right heart failure from cor pulmonale, improved cardiac function, enhanced neuropsychological function, increased exercise performance and activities of daily living, and reduced shortness of breath. Breathing strategies used in pulmonary rehabilitation to reduce dyspnea are diaphragmatic breathing and pursed lip breathing. Diaphragmatic Breathing: this strategy of breathing is where patients consciously expand their abdominal wall during inspiratory diaphragm descent. Patients relax their abdominal wall during inspiration, and with one hand on the abdomen and the other hand on the chest. Practice this technique for one-half to one hour, two to three times daily. Pursed-Lip Breathing: performed as breathing in through the nose and then blowing against partially closed lips. This technique is used more with patients who have COPD to reduce shortness of breath, especially during exercise. Psychological Effects of Breathing Retraining: shortness of breath has both intensity and distress components. Individuals with and without pulmonary disease to promote relaxation during periods of increased stress use controlled breathing techniques. It is possible that breathing retraining techniques affects the distress component of shortness of breath, as well as improves ventilation function. Anxiety and panic escalate shortness of breath but can be reduced with breathing retraining. Some patients with COPD are underweight which also results in pulmonary dysfunction. Malnutrition is associated with respiratory failure and increased mortality in COPD. Assessment for malnourished states, especially in the acute care settings, is an essential early step in the care of patients with COPD and respiratory decompensation. Adequate nutrition repletion for the patient must fulfill the individual’s energy requirements, as well as incorporate the proper proportions of protein, fat and carbohydrate. Increase mucus occurs in patients with COPD. Increased airway secretions may not correlate with airflow obstruction, but increased mucus production is associated with hospital admissions for acute exacerbations of COPD and may contribute to the risk of death in patients with severe ventilatory impairment. During acute exacerbations of COPD, viral and bacterial airway infection, stimulate mucus production and impair clearance mechanisms. Treatments are directed toward enhancing airway secretion clearance. Coughing: during the acute exacerbations patients may cough in an ineffective manner. Patients are taught to use a controlled cough or a forced expiratory technique (huff coughing). Controlled coughing is a slow, maximal inspiration and breath holding for several seconds followed by two or three coughs. Forced expiratory are one or two forced exhalations (huffs). Huff coughing limits airway collapse, constriction of the airways, and patient fatigue. Huff coughing may be difficult for the patient who is having shortness of breath. Chest Physiotherapy (CPT): CPT with postural drainage, and/or chest percussion and/or vibration, is used in patients with chronic bronchitis, bronchiectasis, and cystic fibrosis. Positive Expiratory Pressure (PEP) device: involves exhaling into a device that offers resistance to exhalation which keeps the airways open during exhalation and improves expiratory flow of air. A flutter valve can also be used to help expel mucus from the lungs and works along the same theory. Patients with COPD have anxiety, depression, fatigue, and difficulty coping with symptoms. Disability and decreased capacity to participate in social and recreational activities are common. Decreased ability to process and retain information due to chronic hypoxemia (reduced oxygen) may occur. Psychosocial intervention and support are important parts of pulmonary rehabilitation. It has been shown that the patient’s mood is improved with reduced anxiety and depression with pulmonary rehabilitation. Evaluation of the patient’s psychological state should be done. Antidepressant medications should be considered in patients with severe depression. Support groups are offered in pulmonary rehabilitation programs, where patients support one another, as well as receive support from Health Care professionals. Summary Pulmonary rehabilitation is a collaborative team effort, consisting of the patient and the health care members. Patients are actively involved in decision making at all levels of care. Arm and leg activities lead to different responses. Unsupported arm activities may provide a challenge in the severe COPD patient. Patients who cope well with the responses to illness often have a good sense of humor. We encourage it! Patients can be teachers also. We as health care professionals learn a lot about responses to COPD and strategies for coping with illness from them.
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