CRC 432 Subacute Care Pulmonary Rehabilitation

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CRC 432 Subacute CarePulmonary Rehabilitation
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Pulmonary Rehabilitation

• Goals
• Maximize patients functional ability
• Minimize impact in
• Patient
• Family
• Community
• Improve quality of life
• Control alleviate symptoms

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Pulmonary Rehabilitation

• Historical Perspective
• 1951 Dr Barach recommended physical
  reconditioning for COPD patients
• Walk without becoming dyspneic
• Barach was ignored O2 therapy bed rest
  prescribed
• Skeletal muscle deterioration
• Fatigue weakness
• Increased dyspnea
• Homebound, room bound, bed bound

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Pulmonary Rehabilitation

• Historical Perspective
• 1962 Pierce confirmed Barach
• Pierce found that exercising COPD patients
• Decreased pulse
• Decreased respiratory rates
• Decreased minute ventilation
• Decreased CO2 production
• Improved pulmonary function

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Pulmonary Rehabilitation

• Historical Perspective
• Paez demonstrated
• Efficiency of motion
• Decreased O2 consumption
• Smoking cessation included
• Education added
• Pathophysiology
• Equipment
• Medications

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Pulmonary Rehabilitation

• Scientific Basis
• Focus on patient
• Include clinical sciences
• Quantify degree of physiologic impairment
• Establish outcomes for reconditioning
• Include social sciences
• Psychological
• Social
• Vocational

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Pulmonary Rehabilitation

• Physical Reconditioning
• Exercise increases energy demands
• Increased circulation
• Increased ventilation
• Increased O2 deliver
• Increase CO2 elimination
• If O2 demands NOT met
• Blood lactate level increase
• CO2 increases as lactic acid buffered
• Increased stimulus to breathe

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Pulmonary Rehabilitation
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Pulmonary Rehabilitation

• This point is called the onset of blood lactate
  accumulation, or OBLA
• Abrupt rise in PaCO2 minute ventilation called
  ventilatory threshold
• Beyond VT, metabolism anaerobic respiration
  (decreased NRG production efficiency, lactic acid
  rise, fatigue)

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Pulmonary Rehabilitation

• Physical Reconditioning
• MVV index of respiratory systems ability to
  handle increased physical activity
• MVV FEV1 x 35
• Normal 60-70 of pred MVV during max exercise
• Indicates adequate respiratory reserve
• Indicates ventilation NOT primary limiting factor
  for ending exercise

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Pulmonary Rehabilitation

• Physical Reconditioning
• MVV decreased with COPD
• COPDs have limited exercise ability
• Increased CO2 production
• Respiratory acidosis
• SOB
• O2 consumption increases faster than normal

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Pulmonary Rehabilitation

• Physical Reconditioning
• Rehab programs must
• Physically recondition
• Increase exercise tolerance

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Pulmonary Rehabilitation

• Psychosocial Support
• Indicators bettor predictors of frequency LOS
  for COPD patients compared to PFTs
• Psychosocial indicators better determine rehab
  program completion than physical reconditioning
• COPD negatively affects persons outlook on life
• Can reduce motivation

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Pulmonary Rehabilitation

• Psychosocial Support
• Depression/hostility occur with acute chronic
  disease
• Economic loss fear of death produce hostility
• Interaction among patients is beneficial
• Patients lacking social support at higher risk
  for re-hospitalization
• Intolerance for physical exertion lessens social
  activity

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Pulmonary Rehabilitation

• Psychosocial Support
• Physical reconditioning psychosocial support
  linked
• Reducing exercise intolerance improving
  cardiovascular response to exercise
  independent, active lifestyle
• Improve social importance self-worth
• Occupational training job placement important

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Pulmonary Rehabilitation

• Program Goals
• Control respiratory infection
• Basic airway management
• Improve ventilation cardiac status
• Improve ambulation other physical activities
• Reduce medical costs
• Reduce hospitalizations

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Pulmonary Rehabilitation

• Program Goals
• Reduce LOS when hospitalized
• Reduce of MD office visits
• Provide psychosocial support
• Occupational training/job placement
• Family education, counseling, support
• Patient education, counseling, support

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Pulmonary Rehabilitation

• PROGRAM OBJECTIVES
• Development of diaphragmatic breathing skills
• Development of stress management and relaxation
  techniques
• Involvement in a daily physical exercise regimen
  to condition both skeletal and respiratory-related
  muscles
• Adherence to proper hygiene, diet, and nutrition
• Proper use of medications, oxygen, and breathing
  equipment (if applicable)
• Application of airway clearance techniques (when
  indicated)
• Focus on group support
• Provisions for individual and family counseling

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Pulmonary Rehabilitation

• Chronic lung disease progressive irreversible
• Rehabilitation does NOT alter progressive
  deterioration
• Rehabilitation improves utilization of O2 by
• Increasing muscle use effectiveness
• Promoting effective breathing techniques

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Pulmonary Rehabilitation

• O2 cost for given amount of ventilation is
  excessive
• Training skeletal muscle groups alone NOT
  beneficial
• Training respiratory related muscles improves
  exercise tolerance

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Pulmonary Rehabilitation

• Evaluation of Rehabilitation Program Outcomes
• Changes in exercise tolerance
• Before and after 6 minute walking distance
• Review of patient home exercise logs
• Strength measurement
• Flexibility and posture
• Performance on specific exercises (e.g.,
  ventilatory muscle, upper extremity)
• Changes in symptoms
• Dyspnea measurement comparison
• Frequency of cough, sputum production, or
  wheezing
• Weight loss or gain
• Psychological test instruments

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Pulmonary Rehabilitation

• Evaluation of Rehabilitation Program Outcomes
• Other changes
• Activities of daily living (ADL) changes
• Postprogram follow-up questionnaires
• Preprogram and postprogram knowledge tests
• Compliance improvement with pulmonary
  rehabilitation medical regimen
• Frequency and duration of respiratory
  exacerbations
• Frequency and duration of hospitalizations
• Frequency of emergency department visits
• Return to productive employment

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Pulmonary Rehabilitation

• Potential Hazards
• Cardiovascular abnormalities
• Cardiac arrhythmias (can be reduced with
  supplemental oxygen during exercise)
• Systemic hypotension
• Blood gas abnormalities
• Arterial desaturation
• Hypercapnia
• Acidosis
• Muscular abnormalities
• Functional or structural injuries
• Diaphragmatic fatigue and failure
• Exercise-induced muscle contracture

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Pulmonary Rehabilitation

• Potential Hazards
• Miscellaneous
• Exercise-induced asthma (more common in young
  patient with asthma than in patients with COPD)
• Hypoglycemia
• Dehydration

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Pulmonary Rehabilitation

• Patient Selection
• Evaluation
• Testing
• Patient Evaluation
• History (medical, psychological, vocational,
  social)
• Questionnaire/interview form
• Physical exam
• CXR

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Pulmonary Rehabilitation

• Patient Evaluation
• CBC
• Electrolytes
• Urinalysis
• PFTs (spirometry, volumes, DLCO, pre/post)
• Cardiopulmonary exercise evaluation
• Quantifies initial exercise capacity
• Provides basis for exercise prescription
• Renders baseline data for assessing progress
• Shows degree of hypoxemia/desat during exercise

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Pulmonary Rehabilitation

• Common Physiological Parameters Measured During
  Exercise Evaluation
• Blood pressure
• Heart rate
• ECG
• Respiratory rate
• Arterial blood gases (ABGs)/O2 saturation
• Maximum ventilation (VEmax)
• O2 consumption (either absolute VO2 or METS, the
  metabolic equivalent of energey expenditure)
• CO2 production (VCO2)
• Respiratory quotient (RQ)
• O2 pulse

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Pulmonary Rehabilitation

• Exercise Evaluation
• Graded levels (ergometer or treadmill)
• 3-min intervals allow steady state
• ABGs at rest at peak exercise

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Pulmonary Rehabilitation

• Relative Contraindications to Exercise Testing
• Patients who cannot or will not perform the test
• Severe pulmonary hypertension/cor pulmonale
• Known electrolyte disturbances (hypokalemia,
  hypomagnesemia)
• Resting diastolic blood pressure gt 110 mm Hg or
  resting systolic blood pressure gt 200 mm Hg
• Neuromuscular, musculoskeletal, or rheumatoid
  disorders exacerbated by exercise
• Uncontrolled metabolic disease (e.g., diabetes)
• SaO2 or SpO2 lt 85 with the subject breathing
  room air
• Untreated or unstable asthma

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Pulmonary Rehabilitation

• Indications for Pulmonary Rehabilitation
• Symptomatic patients with COPD
• Patients with bronchial asthma and associated
  bronchitis (asthmatic bronchitis)
• Patients with combined obstructive and
  restrictive ventilatory defects
• Patients with chronic mucocilliary clearance
  problems
• Patients having exercise limitations due to
  severe dyspnea

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Pulmonary Rehabilitation

• Patient Selection
• Ex-smokers
• Smoking cessation program for smokers
• Patients Excluded
• Concurrent problems limit or preclude exercising
• Condition complicated by malignant neoplasms,
  e.g., bronchogenic carcinoma

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Pulmonary Rehabilitation

• Program Design
• Open-ended format
• Participate until predetermined objectives
  achieved
• No set timeframe
• Completed at patients pace
• Good format for self-directed patients
• Good format for schedule difficulties
• Good format for individual attention
• Lack group support/involvement

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Pulmonary Rehabilitation

• Program Design
• Closed design
• Set timeframe (8 to 16 weeks 1 to 3 sessions/wk)
• Insurance coverage may dictate length for which
  person qualifies
• Sessions last 1 to 3 hours
• Presentations formal
• Offer group support/involvement
• Schedule determines program completion

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Pulmonary Rehabilitation

• Content

Component Focus Time
Frame Education Welcome (group interaction) 5
mins Review of program diaries (past
weeks activities) 20 mins Presentation of
education topic 20 mins Questions, answers,
and group discussion 15 mins Physical Physi
cal activity and reconditioning 45
mins Reconditioning Individual goal-setting and
session summary 15 mins Total 120 minutes
(2 hours)
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Pulmonary Rehabilitation

• Physical Reconditioning
• Excise prescription with target HR based on
  initial exercise evaluation
• Target HR set using Karvonens formula
• THR (MHR-RHR) x (50 to 70) RHR

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Pulmonary Rehabilitation

• Physical Reconditioning
• MHR 150 bpm
• RHR 90 bpm
• THR (150 90) x (0.6) 90 126 bpm

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Pulmonary Rehabilitation

• Exercise Prescription
• Lower extremity aerobic exercises
• Timed walking
• Upper extremity aerobic exercises
• Respiratory muscle training
• Monitoring during Exercise
• Pulse oximetry
• Blood pressure

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Pulmonary Rehabilitation

• Lower Extremity
• Walking (treadmill/flat surface)
• Goals for distance, time, grade on treadmill
• 6 minute flat surface/increase distance
• Bicycling (stationary)
• Upper Extremity
• Arm ergometers
• Rowing machines

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Pulmonary Rehabilitation

• Inspiratory resistance breathing device
• Adjustable flow resistor
• One-way valve
• Inhale through restricted orifice (variable size)
• Change inspiratory load
• Exhalation through one-way valve

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Pulmonary Rehabilitation

• Instruction
• Sit upright
• Breathe slowly through device (10 12 bpm)
• MIP lt 30 of measured Pimax, use next smaller
  orifice
• Repeat effort until 30 is consistently achieved
• 1 or 2 daily sessions for 10 15 minutes/session
• When 30 is consistently achieved, increase
  resistance
• Increase session time to 30 minutes

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Pulmonary Rehabilitation

• Introduction and welcome, program orientation
• Respiratory structure, function, and pathology
• Breathing control methods
• Relaxation and stress management
• Proper exercise techniques and personal routines
• Methods to ad secretion clearance (bronchial
  hygiene)
• Home oxygen and aerosol therapy
• Medications their use and abuse
• Medications use of MDIs and spacers
• Dietary guidelines and good nutrition
• Recreation and vocational counseling
• Activities of daily living
• Follow-up planning and program evaluation
• Graduation

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Pulmonary Rehabilitation

• Program Results
• Evaluate
• Patient
• Program outcomes
• Preprogram/current program status
• Data
• Physiological
• Psychological
• Sociological