Pulmonary rehabilitation is a multidisciplinary, individually designed intervention program, including exercise and education, that helps patients with chronic lung disorders manage the physiological and psychosocial symptoms of their condition and improve their level of daily functioning and well-being.
The purpose of a pulmonary rehabilitation program is to help patients with chronic obstructive pulmonary disease (COPD) or other chronic lung conditions manage their condition. Exercise and education are provided to help increase the patient's level of fitness and independent functioning; reduce dyspnea and psychological symptoms (anxiety, depression, social isolation); slow down or prevent the progression of disease; and improve quality and possibly length of life.
Pulmonary rehabilitation has not been found to improve pulmonary function, and that is not its goal. Other measures of physiologic improvement such as improved muscle function, cardiac function, and aerobic function have been found, and the main purpose of cardiac rehabilitation is to "reverse the deconditioning and psychosocial accompaniments of pulmonary disability." Pulmonary rehabilitation is also increasingly recognized as valuable in preparation for lung transplantation and lung volume-reduction surgery, which require patients to have good physical conditioning.
Patients should be examined by a physician before beginning rehabilitation. Certain coexisting medical conditions, especially those that preclude or limit exercise, may contraindicate pulmonary rehabilitation, or require
|Essentials of pulmonary therapy|
|Treatment components||Purpose||How to perform||When to use|
|SOURCE: Mackenzie, C.F., et al. Chest Physiotherapy in the Intensive Care Unit. Baltimore, MD: Williams & Wilkins, 1981.|
|Breathing exercises||Assists in removing secretions;||Patient is taught to produce a full inspiration||When patients are breathing|
|relaxation; and used to increase||followed by a controlled expiration; use hand||spontaneously|
|thoracic cage mobility and tidal volume||placement for sensory feedback|
|Coughing||Removal of secretions from the larger||Steps: (1) Inspiratory gasp;||When patients are breathing|
|airways||(2) Closing of the glottis;||spontaneously|
|(3) Contraction of expiratory muscles;|
|(4) Opening of the glottis|
|Percussion||Used with postural drainage for||Rhythmic clapping of cupped hands over bare||When coughing or suctioning,|
|mobilization of secretions||skin or thin material covering area of lung||breathing exercises, and patient|
|involvement; performed during inspiration||mobilization are not adequate|
|and expiration||to clear retained secretions|
|Postural drainage||Mobilize retained secretions through||Patient positioned so that involved segmental||Same as above|
|assistance of gravity||bronchus is uppermost|
|Vibration||Used with postural drainage for mobilization||Intermittent chest wall compression over area||Same as above|
|of secretions||of lung involvement; performed during|
modification and special precautions. Since treatment is individualized, any special needs will be addressed in the exercise prescription and program design. Some particular conditions that may contraindicate participation in pulmonary rehabilitation include acute respiratory infection, ischemic cardiac disease, congestive heart failure, serious liver dysfunction, disabling stroke, severe psychiatric or cognitive disorders, acute cor pulmonale, severe pulmonary hypertension, and metastatic cancer.
Pulmonary rehabilitation is a multidisciplinary, comprehensive program of education, exercise, and behavior modification, individually designed for patients with such lung diseases as COPD. COPD includes such conditions as chronic bronchitis and emphysema, which can be progressive and life-threatening. Other chronic lung conditions that may be suitable for pulmonary rehabilitation include cystic fibrosis, asthma, bronchiectasis, and environmental lung disease, as well as such neuromuscular disorders as Parkinson's disease and multiple sclerosis.
The rehabilitation program is designed to help patients learn more about their condition and how to manage its symptoms, as well as to take active steps, such as smoking cessation, oxygen use, and exercise, in order to improve their level of physical functioning; stop the progression of the disease as much as possible; and learn how to better live with the condition. Improved physical functioning, reduction in physical and psychological symptoms, and ability to perform activities of daily living (ADLs) more easily and independently, can contribute to improved quality of life.
A typical program, which is individually designed but involves group participation, may last up to three hours per session, a few days each week. Programs generally last a few weeks to a few months, and prepare the patient to continue exercise, symptom management, and other skills learned in the program on their own. An in-home follow-up program may also be included. Patients may participate in rehabilitation as inpatients or outpatients, and will also be encouraged to exercise on their own at home if it is safe for them to do so without monitoring. Some insurance companies cover all or part of the rehabilitation program.
The two main components of the daily program are exercise and education. Exercise is important for maintaining or improving muscle strength, endurance and overall fitness, which may have declined due to inactivity and symptoms of the disease. Decreased physical activity and associated decline in fitness play a large part in causing the physical limitations associated with COPD. A regular exercise program can improve overall fitness and energy, and make performance of ADLs easier.
The exercise program is individually prescribed to meet the physical needs of each patient, and includes a warm-up and cool-down period, and aerobic activity. The warm-up and cool-down periods may include stretching and light strength or resistance training. Exercises involving upper and lower extremities are important for overall fitness and for improvement in function during specific activities. For example, lower body exercise helps with ambulation, stair climbing, and general fitness; and conditioning of the arms facilitates improved functioning in many tasks that require arm and upper body use, such as grooming, cooking, and household
ADL—Activity of daily living.
Dyspnea—Difficulty breathing or shortness of breath
Spirometer—A device used to measure lung performance.
tasks. Some of the muscle groups used in arm and upper torso positioning serve respiratory functions, and thus upper extremity conditioning can also have a beneficial effect on ventilation.
The aerobic exercise component comprises such activities as walking or using a stationary bicycle, treadmill, or other equipment. Exercise is monitored by physical therapists, respiratory nurses, or other qualified health care providers. Blood pressure, heart rate, oxygen saturation, and dyspnea levels are evaluated to determine the appropriate exercise prescription, and may be monitored during exercise sessions. Ventilatory training may also be included in the exercise program for certain patients. This therapy involves controlled breathing exercises; such chest physical therapy techniques as postural drainage, chest percussion, directed cough, and vibration; and training of the inspiratory muscles.
The educational component of the rehabilitation program consists of classes, reading materials, and counseling or training sessions that cover various specific subjects, procedures, and issues of importance to patients with chronic pulmonary disease. Education is provided by a variety of professionals, including respiratory nurses, respiratory therapists, occupational therapists, physical therapists, social workers, and dieticians. A psychologist or other mental health professional may provide counseling to address depression, anxiety, social isolation, or other psychosocial symptoms related to COPD.
Some of the educational subjects covered include anatomy and physiology related to pulmonary function and disease; exercise theory; nutrition; techniques for using oxygen and inhalers; and ways to conserve energy. Education related to good nutrition and weight management can be helpful, because patients may be undernourished and have muscle wasting of the respiratory muscles, which can make breathing more difficult. If anemia is present, it can decrease oxygen-carrying capacity. Electrolyte imbalances affect cardiopulmonary performance, so these and other deficiencies should be treated in order to improve functioning. If patients are overweight, the extra weight increases oxygen and energy demands and may increase fatigue. Patients who have not yet stopped smoking should be strongly encouraged to do so.
Examination and referral by a physician are generally required before a patient begins pulmonary rehabilitation. A medical history should be provided to the rehabilitation team. Some tests that may be administered prior to the patient's entry into a rehabilitation program include pulmonary function tests (PFTs), chest x-rays, arterial blood gas (ABG) analysis, pulse oximetry, and sputum examination. PFTs are performed with a spirometer to measure lung performance and determine the presence and extent of lung disease. A chest x-ray can detect emphysema and other lung disease, including lung cancer, for which there is increased risk among smokers with COPD. Pulse oximetry measures oxygen in the blood and helps determine when supplemental oxygen is required. Exercise tests may be used to determine the length and intensity of the exercise prescription.
Patients may be able to participate in various follow-up or maintenance programs or support groups, as well as check-ins with their physician, in order to maintain benefits and continue monitoring their condition.
Risk of such complications as muscle injury or cardiac reactions is always present with exercise, but will be minimized by careful exercise prescription and monitoring. Disease-related complications that should be watched for include fever, unusual or extreme shortness of breath, irregular pulse, unanticipated weight changes, gastric complaints, or any other change that is unusual for the patient.
The primary goals of cardiac rehabilitation are to reduce symptoms and respiratory impairment, and to improve the patient's quality of life and possibly prolong their life. Some of the specific changes that affect overall improvement in health, functioning and quality of life include: improvement in pulmonary function, reduction of the work involved in breathing, increased efficiency of energy use, improved exercise performance, increased function in activities of daily living, alleviation of dyspnea,
Health care team roles
The various educational and therapeutic components of a comprehensive pulmonary rehabilitation program are best addressed by a variety of health care professionals. The team may include respiratory nurses; respiratory, physical and occupational therapists; psychologists or other mental health professionals; exercise specialists; and dieticians, as well as a program director. The physical therapist may be involved in exercise prescription and monitoring; providing education in areas related to anatomy, physiology, exercise, and physical therapy; and providing such other therapeutic treatments as chest physical therapy.
American Association of Cardiovascular and Pulmonary Rehabilitation. Guidelines for Pulmonary Rehabilitation Programs, 2nd ed. Champaign, IL: Human Kinetics, 1998.
Brannon, F. J., M. W. Foley, J. A. Starr, and L. M. Saul. Cardiopulmonary Rehabilitation: Basic Theory and Application, 3rd ed. Philadelphia: F. A. Davis, 1998.
Camp, Pat G. et. al. "Quality of Life After Pulmonary Rehabilitation: Assessing Change Using Quantitative and Qualitative Methods." Physical Therapy 8, no. 10 (October 2000).
Celli, Bartolome R., MD. "Pulmonary rehabilitation for COPD: A practical approach for improving ventilatory conditioning." Postgraduate Medicine 103, no. 4 (April 1998).
American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR). 7600 Terrace Avenue, Suite 203, Middleton, WI 53562. (608) 831-6989. <http://www.aacvpr.org/>.
American College of Chest Physicians (ACCP). 3300 Dundee Road. Northbrook, IL 60062-2348. (847) 498-1400.
American Physical Therapy Association (APTA). 1111 North Fairfax Street. Alexandria, VA 22314. (703) 684-2782. <http://www.apta.org>.
Mayo Clinic Web site. <http://www.mayoclinic.com>.
Diane Fanucchi, B.A., C.M.T.