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PULMONARY REHABILITATION

     Dr.Amith Sreedharan
  Dept of Pulmonary Medicine
       SCBMCH Cuttack
DISEASE
  TREATMENT

            IMPAIRMENT
REHABILITATION

              DISABILITY
REHABILITATION

              HANDICAP
ATS – ERS definition (2005)
• Evidence-based, multidisciplinary, and
  comprehensive intervention for patients with
  chronic respiratory diseases who are symptomatic
  and often have decreased daily life activities.

• Integrated into the individualized treatment of the
  patient,pulmonary rehabilitation is designed to
  reduce symptoms,optimize functional status,
  increase participation, and reduce health care
  costs through stabilizing or reversing systemic
  manifestations of the disease
Aims of Pulmonary Rehabilitation
 Increase exercise tolerance and reduce dyspnea
 Increase muscle strength and endurance
  (peripheral and respiratory)
 Improve health related quality of life
 Increase independence in daily functioning
 Increase knowledge of lung condition and
  promote self management
 Promote long term commitment to exercise
Essentials of Pulmonary Rehabilitation
•   Exercise training
•   Education
•   Nutritional therapy
•   Psychosocial / Behavioural intervention
•   Outcome assessment
•   Promotion of long-term adherence
Pathophysiology
                                              INACTIVITY
INFLAMMATION
CACHEXIA
MALNUTRITION
CORTICOSTEROIDS

                                 ANXIETY
                                                  ↓ EXERCISE TOLERANCE
ATROPHY OF MUSCLES               DEPRESSION
REDUCTION IN TYPE 1,2b FIBERS
DECREASED GLYCOGEN STORES
                                 GAS EXCHANGE LIMITATION
                                 CARDIAC DYSFUNCTION

DECREASED CAPILLARISATION        RESPIRATORY MUSCLE WEAKNESS
ALTERED METABOLISM AT REST       VENTILATORY LIMITATION
OXIDATIVE STRESS
↓ OXIDATIVE METABOLIC CAPACITY
                                 SKELETAL MUSCLE DYSFUNCTION
BENEFITS OF EXERCISE TRAINING
PATHOPHYSIOLOGICAL ABNORMALITY               BENEFITS OF EXERCISE TRAINING
DECREASED LEAN BODY MASS                 INCREASES FAT FREE MASS
DECREASED TY1 FIBERS                     NORMALIZES PROPORTION
DECREASED CROSS SECTIONAL AREA OF        INCREASES
MUSCLE FIBERS
DECREASED CAPILLARY CONTACTS TO          INCREASES
MUSCLE FIBERS
DECREASED CAPACITY OF OXIDATIVE          INCREASES
ENZYMES
INCREASED INFLAMMATION                   NO EFFECT
INCREASED APOPTOTIC MARKERS              NO EFFECT
REDUCED GLUTATHIONE LEVELS               INCREASES

LOWER INTRACELLULAR `pH, INCREASED       NORMALIZATION OF DECLINE IN pH
LACTATE LEVELS AND RAPID FALL IN PH ON
EXERCISE
Exercise training
Components of exercise training:
Lower extremity exercises
Arm exercises
Ventilatory muscle training
Types of exercise:
Endurance or aerobic
Strength or resistance
Exercise training
• Benefits of exercise training ( mainly endurance
  training) :
 Improves exercise tolerance
 Improve motivation for exercise
 Reduce mood disturbance
 Decreases dyspnea
 Strength training improves bulk and strength of
  muscles but does not add to overall exercise
  tolerance or health status
LOWER EXTREMITY EXERCISE
•   WALKING
•   TREADMILL
•   STATIONARY BICYCLE
•   STAIR CLIMBING
Benefits in COPD
• Increased work capability as assessed by
  incremental treadmill protocol, 6 min walking
  distance and 12 min walking distance
• 40 – 102% increase in endurance of maximal
  work rate
• Significant improvement in subjective
  assessment using Borg dyspnea scale
• No changes in hemodynamics during exercise
ARM EXERCISE TRAINING
• ARM CYCLE ERGOMETER
• UNSUPPORTED ARM LIFTING
• LIFTING WEIGHTS
POTENTIAL BENEFITS
• Has the potential to improve arm exercise
  performance by decreasing ventilatory
  demand during arm work, and by improving
  arm endurance.
• Arm training improves the ventilatory
  contribution of those muscles by increasing
  shoulder girdle muscle strength.
COPD
• Increases exercise capacity of the arms.
• Decreases metabolic and ventilatory demand
  for similar arm work (measured by Vo2)
• No significant effect on outcomes, such as
  functional status and performance when arm
  training used alone.
Strength exercise
• When strength exercise was added to
  standard exercise protocol led to greater
  increase in muscle strength and muscle mass
  But NO additional benefit in:
Exercise capacity as assessed by 6MWD
HRQOL
Physiological parameters of heart rate or
  blood lactate levels
Ventilatory muscle training
        Resistive IMT:           Threshold IMT:
• Patient breaths through        • Patient breaths through a
  hand held device with            device equipped with a
  which resistance to flow         valve which opens at a
  can be increased gradually       given pressure.
 Difficult to standardize the
  load                            Easily quantitated and
 Patients may                     standardized
  hypoventilate.
 Leads to increased Pulm.
  Atr. Pressure and fall in
  oxygen tension
ATS/ERS statement (2005)
• A minimum of 20 sessions should be given.
• At least three times per week ;Twice weekly
  supervised plus one unsupervised home session
  may also be acceptable. Once weekly sessions
  seem to be insufficient
• Each session to last 30 minutes
• High-intensity exercise (>60% of maximal work
  rate) produces greater physiologic benefit and
  should be encouraged
• however,low-intensity training is also effective for
  those patients who cannot achieve this level of
  intensity
ATS/ERS STATEMENT (2005)
• Both upper and lower extremity training should be
  utilized
• Lower extremity exercises like treadmill and
  stationary bicycle ergometer & Arm exercises like
  lifting weights and arm cycle ergometer are
  recommended
• The combination of endurance and strength training
  generally has multiple beneficial effects and is well
  tolerated; strength training would be particularly
  indicated for patients with significant muscle atrophy.
• Respiratory muscle training could be considered as
  adjunctive therapy, primarily in patients with
  suspected or proven respiratory muscle weakness
GOLD GL (2009)
• The minimum length of an effective rehabilitation
  program is 6 weeks.
• Daily to weekly sessions
• Duration of 10 minutes to 45 minutes per session
• Endurance training can be accomplished through
  continuous or interval exercise programs.
• The latter involve the patient doing the same
  total work but divided into briefer periods of
  high-intensity exercise, which is useful when
  performance is limited by other comorbidities
Additional considerations
• Optimal bronchodilator therapy should be given prior to
  exercise training to enhance performance.
• Patients who are receiving long-term oxygen therapy should
  have this continued during exercise training, but may need
  increased flow rates.
• Oxygen supplementation during pulmonary rehabilitation,
  regardless of whether or not oxygen desaturation during
  exercise occurs, often allows for higher training intensity
  and/or reduced symptoms in the research setting.
                                   ATS/ERS STATEMENT 2005
• Reasonable to recommend supplementary oxygen to those
  showing significant hypoxia ( Spo2 < 90%) during exercise
Neuromuscular electrical stimulation
                (NMES)
• In severely disabled COPD patients with incapacitating
  dyspnea, 6 week NMES of muscles involved in ambulation
  improved muscle strength and endurance, whole body
  exercise tolerance, and breathlessness.
• 14 COPD patients with Ty 2 RF on MV through
  tracheostomy tube received NMES as a part of
  rehabilitation. Significant reduction in duration required for
  transfer from bed to chair
                                          (CHEST 2003)
• NMES may be an adjunctive therapy for patients with
  severe chronic respiratory disease who are bed bound or
  suffering from extreme skeletal muscle weakness.
NIMV
• Proportional assist ventilation while exercise training,
  enabled a higher training intensity, leading to a
  greater maximal exercise capacity
• Addition of nocturnal domiciliary NPPV in
  combination with pulmonary rehabilitation in stable
  COPD patients ( FEV1 0.96 L, PaO2 65.4 and PaCO2
  45.6) resulted in improved exercise tolerance and
  quality of life.
• Because NPPV is a very difficult and labor-intensive
  intervention, it should be used only in those with
  demonstrated benefit from this therapy. Further
  studies are needed to further define its role in
  pulmonary rehabilitation
Body composition abnormalities:
               ÌNTERVENTIONS
↑ ACTIVITY RELATED       HYPERMETABOLIC         PROTEIN
                                              DECREASED
ENERGY EXPENDITURE       STATE               SUPPLEMENT
                                              INTAKE


        CALORIC
  IMPAIRMENT OF ENERGY        IMBALANCE IN PROTEIN
  BALANCE
     SUPPLEMENTS              SYNTHESIS AND BREAKDOWN


                                          LOSS OF FFM
                                                ANABOLIC
LOSS OF FAT                               ANTHROPOMETRY
                                                STEROIDS
                                          BIOIMPEDANCE ANALYSIS
                                          DEXA GROWTH
       LOSS OF WEIGHT: BMI <21                 HORMONE
       10% WEIGHT LOSS IN 6 MONTHS
       5% WEIGHT LOSS IN 1 MONTH
Under weight : Low BMI
• One-third of outpatients and up to two thirds of
  those referred for pulmonary rehabilitation are
  under weight
• Underweight patients with COPD have
  significantly greater impairment in HRQL than
  those with normal weight
• In COPD, there is an association between
  underweight status and increased mortality,
  independent of the degree of airflow obstruction.
Low lean body mass (FFM)
• Because normal-weight patients with COPD and
  low FFM ( FFM<16 kg/m2 for men and <15
  kg/m2 for women) have more impairment in
  HRQL than underweight patients with normal
  FFM,this body composition abnormality
  appears to be an important independent
  `marker of weight loss.
• Patients with COPD and reduced FFM have
  lower exercise tolerance as measured using 12-
  minute walk distance.
Caloric supplementation
Should be considered if :   May be unsuccessful if :

• BMI less than 21          • A reduction in
  kg/m2                       spontaneous food intake
• Involuntary weight loss   • Suboptimal
  of >10% during the last     implementation of
  6 months or more than       nutritional supplements
  5% in the past month        in daily meal and activity
                              pattern.
• Depletion in FFM or
  lean body mass.           • Presence of systemic
                              inflammation
Caloric supplementation
• Much of the weight gain with caloric
  supplementation is in the form of fat but not
  fat free mass
• Meta- analysis of 9 RCTs showed nutritional
  support alone cannot increase exercise
  capacity or anthropometric measures
• Nutritional supplementation combined with
  supervised exercise training increased body
  weight and FFM in underweight patients
Nutritional supplementation
• Energy dense foods
• Well distributed during the day
• No evidence of advantage of high fat diet
• Patients experience less dyspnea after
  carbohydrate rich supplement than fat rich
  supplement. (probably due to delayed gastric
  emptying)
• Daily protein intake should be 1.5 gm/kg for
  positive balance
Physiological intervention:
              Strength exercise
  • 8 weeks of strength exercise lead to increase
    in FFM
  • Addition of strength training lead to increase
    in strength and mid thigh circumference
    (measured by CT)
  • No difference in 6MWD, HRQOL


                                 INCREASED MUSCLE MASS
STRENGTH EXERCISE     IGF-1      (FAT FREE MASS)
Pharmacological intervention :
              Anabolic steroids
 ANABOLIC STEROIDS
 NANDROLONE DECANOATE
 50mg MALE
                              • Anabolic steroids
 25 mg FEMALE                   increased lean body
 2 WEEKLY 4 DOSES
                                mass
                              • No side effects seen
 IGF-1                        • Anabolic therapy alone
 Anti Glucocorticoid action     increases muscle mass
 Erythropoietic action          but not exercise
                                capacity

INCREASED FAT FREE MASS
Growth hormone
• rhGH 0.05 mg/kg for 3 weeks in addition to 35
  Kcal/kg and 1gm protein/kg per day has shown to
  increase fat free mass.
• Daily administration of 0.15 IU/kg rhGH during 3
  wk increases lean body mass when assessed in
  underweight patients with COPD.
• But does not improve muscle strength or exercise
  tolerance ( hand grip and maximal exercise ) and no
  change in well being of the patient.
Testosterone
• Testosterone 100 mg weekly for ten weeks in
  men with low testosterone levels 320 ng/ml
  showed weight gain of 2.3 kg
• Addition of exercise to testosterone has
  augmented weight gain to 3.3 kg
• Physiological consequences and long term
  effects not studied.
INTERVENTION                WEIGHT GAIN   FFM GAIN   EXERCISE CAPACITY


CALORIC SUPP.                    +           -               -


CALORIC SUPPLEMENTATION +       ++           +              +
EXERCISE TRAINING

STRENGTH EXERCISE                -           +               -


ANABOLIC STEROIDS               ++           ++              -


ANABOLIC STEROIDS +             ++          +++              ?
EXERCISE
Guidelines
• Increased calorie intake is best accompanied by
  exercise regimes that have a nonspecific anabolic
  action
• Anabolic steroids in COPD patients with weight loss
  increase body weight and lean body mass but have
  little or no effect on exercise capacity.
• Pulmonary rehabilitation programs should address
  body composition abnormalities. Intervention may be
  in the form of caloric, physiologic, pharmacologic or
  combination therapy
                            ATS/ERS STATEMENT 2005
Self management education
Should involve :
• Patient
• Family
• Primary care physician
• Other health care providers
ATS/ERS STATEMENT 2005
Bronchial hygiene techniques
•   Postural drainage
•   Percussion & vibration
•   Directed cough
•   Forced expiratory technique (huff cough)
•   Active cycle of breathing
•   Autogenic drainage
•   Positive expiratory pressure
Breathing strategies
•   Adopting specific postures : Leaning forward
•   Slow deep breathing
•   Pursed lip breathing
•   Diaphragmatic breathing
Pursed lip breathing
• Improves ventilation           1.   Relax your neck and shoulder muscles.
• Releases trapped air in the
  lungs                          2. Breathe in (inhale) slowly through your
• Keeps the airways open         nose for two counts, keeping your mouth
  longer and decreases the       closed. Don't take a deep breath; a normal
  work of breathing              breath will do. It may help to count to
• Prolongs exhalation to slow    yourself: inhale, one, two.
  the breathing rate
                                 3. Pucker or "purse" your lips as if you were
• Improves breathing             going to whistle or gently flicker the flame
  patterns by moving old air     of a candle.
  out of the lungs and
  allowing for new air to        4. Breathe out (exhale) slowly and gently
  enter the lungs                through your pursed lips while counting to
• Relieves shortness of breath   four. It may help to count to yourself:
• Causes general relaxation      exhale, one, two, three, four
Diaphragmatic Breathing
• Sit or lie comfortably, with loose garments.
• Put one hand on your chest and one on your
  stomach.
• Slowly inhale through your nose or through
  pursed lips (to slow down the intake of breath).
• As you inhale, push your belly/ stomach out and
  feel your stomach expand with your hand.
• Slowly exhale through pursed lips to regulate the
  release of air while squeezing your stomach
• Rest and repeat
Psychological considerations
    DYSPNEA                    CHRONIC
                               DISEASE
                                            ABNORMALITIES IN
                  DISABILITY                BLOOD GAS


FEAR & ANXIETY
                               IRRITABILITY
                               DEPRESSIVE SYMPTOMS
                               PESSIMISM
                               HOPELESSNESS
                               WITHDRAWAL FROM SOCIAL
  HEIGHTENED                   INTERACTIONS
  PHYSIOLOGICAL
  AROUSAL

                                NEUROPSYCHIATRIC IMPAIRMENTS
Psychological considerations
• Screening for anxiety and depression should be part
  of the initial assessment.
• Mild or moderate levels of anxiety or depression
  related to the disease process may improve with
  pulmonary rehabilitation
       (Withers NJ. J Cardiopulm Rehab1999;19:362-5)
• Patients with significant psychiatric disease should
  be referred for appropriate professional care.
                                   ATS/ERS STATEMENT
• Antidepressants and anxiolytics appear not to have
  additional general value
Patient selection and Assessment
• Gains can be achieved from pulmonary
  rehabilitation regardless of age, sex, lung function,
  or smoking status
                         ATS/ERS statement 2005
• No justification for selection on the basis of age,
  impairment, disability or smoking status.
                               BTS statement 2001
• COPD patients at all stages of disease appear to
  benefit from exercise training programs, improving
  with respect to both exercise tolerance and
  symptoms of dyspnea and fatigue
                                      GOLD 2009
Initial assessment
Exclusion criteria
• Patients with severe orthopedic or
  neurological disorders limiting their mobility
• Severe pulmonary arterial hypertension
• Exercise induced syncope
• Unstable angina or recent MI
• Refractory fatigue
• Inability to learn, psychiatric instability and
  disruptive behavior.
Outcome assessment
 Control of symptoms of cough and fatigue:
 Real time evaluation: VAS & Borg dyspnea scale
 Recall of symptoms
 Performance evaluation: Ability to do ADL
 Directly observed or self reported
 Exercise tolerance:
 6 minute walking test
 Cardiopulmonary exercise testing
 Quality of life:
 Chronic respiratory disease questionnaire
 St Georges’s respiratory questionnaire
 SF- 36
 Assessment of respiratory and peripheral muscle strength
  (GOLD 2009)
Maintenance rehabilitation &
     Repeat rehabilitation program
• Continued participation in supervised program
  is essential for sustenance of benefits.
• Yearly repeat rehabilitation program had
  shown:
Short term benefits in the form of less
  frequent exacerbations
But no long term physiological effects on
  exercise tolerance,dyspnea & HRQL.
THANK YOU

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Pulmonary Rehabilitation

  • 1. PULMONARY REHABILITATION Dr.Amith Sreedharan Dept of Pulmonary Medicine SCBMCH Cuttack
  • 2. DISEASE TREATMENT IMPAIRMENT REHABILITATION DISABILITY REHABILITATION HANDICAP
  • 3. ATS – ERS definition (2005) • Evidence-based, multidisciplinary, and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities. • Integrated into the individualized treatment of the patient,pulmonary rehabilitation is designed to reduce symptoms,optimize functional status, increase participation, and reduce health care costs through stabilizing or reversing systemic manifestations of the disease
  • 4. Aims of Pulmonary Rehabilitation  Increase exercise tolerance and reduce dyspnea  Increase muscle strength and endurance (peripheral and respiratory)  Improve health related quality of life  Increase independence in daily functioning  Increase knowledge of lung condition and promote self management  Promote long term commitment to exercise
  • 5. Essentials of Pulmonary Rehabilitation • Exercise training • Education • Nutritional therapy • Psychosocial / Behavioural intervention • Outcome assessment • Promotion of long-term adherence
  • 6. Pathophysiology INACTIVITY INFLAMMATION CACHEXIA MALNUTRITION CORTICOSTEROIDS ANXIETY ↓ EXERCISE TOLERANCE ATROPHY OF MUSCLES DEPRESSION REDUCTION IN TYPE 1,2b FIBERS DECREASED GLYCOGEN STORES GAS EXCHANGE LIMITATION CARDIAC DYSFUNCTION DECREASED CAPILLARISATION RESPIRATORY MUSCLE WEAKNESS ALTERED METABOLISM AT REST VENTILATORY LIMITATION OXIDATIVE STRESS ↓ OXIDATIVE METABOLIC CAPACITY SKELETAL MUSCLE DYSFUNCTION
  • 7. BENEFITS OF EXERCISE TRAINING PATHOPHYSIOLOGICAL ABNORMALITY BENEFITS OF EXERCISE TRAINING DECREASED LEAN BODY MASS INCREASES FAT FREE MASS DECREASED TY1 FIBERS NORMALIZES PROPORTION DECREASED CROSS SECTIONAL AREA OF INCREASES MUSCLE FIBERS DECREASED CAPILLARY CONTACTS TO INCREASES MUSCLE FIBERS DECREASED CAPACITY OF OXIDATIVE INCREASES ENZYMES INCREASED INFLAMMATION NO EFFECT INCREASED APOPTOTIC MARKERS NO EFFECT REDUCED GLUTATHIONE LEVELS INCREASES LOWER INTRACELLULAR `pH, INCREASED NORMALIZATION OF DECLINE IN pH LACTATE LEVELS AND RAPID FALL IN PH ON EXERCISE
  • 8. Exercise training Components of exercise training: Lower extremity exercises Arm exercises Ventilatory muscle training Types of exercise: Endurance or aerobic Strength or resistance
  • 9. Exercise training • Benefits of exercise training ( mainly endurance training) :  Improves exercise tolerance  Improve motivation for exercise  Reduce mood disturbance  Decreases dyspnea  Strength training improves bulk and strength of muscles but does not add to overall exercise tolerance or health status
  • 10. LOWER EXTREMITY EXERCISE • WALKING • TREADMILL • STATIONARY BICYCLE • STAIR CLIMBING
  • 11. Benefits in COPD • Increased work capability as assessed by incremental treadmill protocol, 6 min walking distance and 12 min walking distance • 40 – 102% increase in endurance of maximal work rate • Significant improvement in subjective assessment using Borg dyspnea scale • No changes in hemodynamics during exercise
  • 12. ARM EXERCISE TRAINING • ARM CYCLE ERGOMETER • UNSUPPORTED ARM LIFTING • LIFTING WEIGHTS
  • 13. POTENTIAL BENEFITS • Has the potential to improve arm exercise performance by decreasing ventilatory demand during arm work, and by improving arm endurance. • Arm training improves the ventilatory contribution of those muscles by increasing shoulder girdle muscle strength.
  • 14. COPD • Increases exercise capacity of the arms. • Decreases metabolic and ventilatory demand for similar arm work (measured by Vo2) • No significant effect on outcomes, such as functional status and performance when arm training used alone.
  • 15. Strength exercise • When strength exercise was added to standard exercise protocol led to greater increase in muscle strength and muscle mass But NO additional benefit in: Exercise capacity as assessed by 6MWD HRQOL Physiological parameters of heart rate or blood lactate levels
  • 16. Ventilatory muscle training Resistive IMT: Threshold IMT: • Patient breaths through • Patient breaths through a hand held device with device equipped with a which resistance to flow valve which opens at a can be increased gradually given pressure.  Difficult to standardize the load  Easily quantitated and  Patients may standardized hypoventilate.  Leads to increased Pulm. Atr. Pressure and fall in oxygen tension
  • 17. ATS/ERS statement (2005) • A minimum of 20 sessions should be given. • At least three times per week ;Twice weekly supervised plus one unsupervised home session may also be acceptable. Once weekly sessions seem to be insufficient • Each session to last 30 minutes • High-intensity exercise (>60% of maximal work rate) produces greater physiologic benefit and should be encouraged • however,low-intensity training is also effective for those patients who cannot achieve this level of intensity
  • 18. ATS/ERS STATEMENT (2005) • Both upper and lower extremity training should be utilized • Lower extremity exercises like treadmill and stationary bicycle ergometer & Arm exercises like lifting weights and arm cycle ergometer are recommended • The combination of endurance and strength training generally has multiple beneficial effects and is well tolerated; strength training would be particularly indicated for patients with significant muscle atrophy. • Respiratory muscle training could be considered as adjunctive therapy, primarily in patients with suspected or proven respiratory muscle weakness
  • 19. GOLD GL (2009) • The minimum length of an effective rehabilitation program is 6 weeks. • Daily to weekly sessions • Duration of 10 minutes to 45 minutes per session • Endurance training can be accomplished through continuous or interval exercise programs. • The latter involve the patient doing the same total work but divided into briefer periods of high-intensity exercise, which is useful when performance is limited by other comorbidities
  • 20. Additional considerations • Optimal bronchodilator therapy should be given prior to exercise training to enhance performance. • Patients who are receiving long-term oxygen therapy should have this continued during exercise training, but may need increased flow rates. • Oxygen supplementation during pulmonary rehabilitation, regardless of whether or not oxygen desaturation during exercise occurs, often allows for higher training intensity and/or reduced symptoms in the research setting. ATS/ERS STATEMENT 2005 • Reasonable to recommend supplementary oxygen to those showing significant hypoxia ( Spo2 < 90%) during exercise
  • 21. Neuromuscular electrical stimulation (NMES) • In severely disabled COPD patients with incapacitating dyspnea, 6 week NMES of muscles involved in ambulation improved muscle strength and endurance, whole body exercise tolerance, and breathlessness. • 14 COPD patients with Ty 2 RF on MV through tracheostomy tube received NMES as a part of rehabilitation. Significant reduction in duration required for transfer from bed to chair (CHEST 2003) • NMES may be an adjunctive therapy for patients with severe chronic respiratory disease who are bed bound or suffering from extreme skeletal muscle weakness.
  • 22. NIMV • Proportional assist ventilation while exercise training, enabled a higher training intensity, leading to a greater maximal exercise capacity • Addition of nocturnal domiciliary NPPV in combination with pulmonary rehabilitation in stable COPD patients ( FEV1 0.96 L, PaO2 65.4 and PaCO2 45.6) resulted in improved exercise tolerance and quality of life. • Because NPPV is a very difficult and labor-intensive intervention, it should be used only in those with demonstrated benefit from this therapy. Further studies are needed to further define its role in pulmonary rehabilitation
  • 23. Body composition abnormalities: ÌNTERVENTIONS ↑ ACTIVITY RELATED HYPERMETABOLIC PROTEIN DECREASED ENERGY EXPENDITURE STATE SUPPLEMENT INTAKE CALORIC IMPAIRMENT OF ENERGY IMBALANCE IN PROTEIN BALANCE SUPPLEMENTS SYNTHESIS AND BREAKDOWN LOSS OF FFM ANABOLIC LOSS OF FAT ANTHROPOMETRY STEROIDS BIOIMPEDANCE ANALYSIS DEXA GROWTH LOSS OF WEIGHT: BMI <21 HORMONE 10% WEIGHT LOSS IN 6 MONTHS 5% WEIGHT LOSS IN 1 MONTH
  • 24. Under weight : Low BMI • One-third of outpatients and up to two thirds of those referred for pulmonary rehabilitation are under weight • Underweight patients with COPD have significantly greater impairment in HRQL than those with normal weight • In COPD, there is an association between underweight status and increased mortality, independent of the degree of airflow obstruction.
  • 25. Low lean body mass (FFM) • Because normal-weight patients with COPD and low FFM ( FFM<16 kg/m2 for men and <15 kg/m2 for women) have more impairment in HRQL than underweight patients with normal FFM,this body composition abnormality appears to be an important independent `marker of weight loss. • Patients with COPD and reduced FFM have lower exercise tolerance as measured using 12- minute walk distance.
  • 26. Caloric supplementation Should be considered if : May be unsuccessful if : • BMI less than 21 • A reduction in kg/m2 spontaneous food intake • Involuntary weight loss • Suboptimal of >10% during the last implementation of 6 months or more than nutritional supplements 5% in the past month in daily meal and activity pattern. • Depletion in FFM or lean body mass. • Presence of systemic inflammation
  • 27. Caloric supplementation • Much of the weight gain with caloric supplementation is in the form of fat but not fat free mass • Meta- analysis of 9 RCTs showed nutritional support alone cannot increase exercise capacity or anthropometric measures • Nutritional supplementation combined with supervised exercise training increased body weight and FFM in underweight patients
  • 28. Nutritional supplementation • Energy dense foods • Well distributed during the day • No evidence of advantage of high fat diet • Patients experience less dyspnea after carbohydrate rich supplement than fat rich supplement. (probably due to delayed gastric emptying) • Daily protein intake should be 1.5 gm/kg for positive balance
  • 29. Physiological intervention: Strength exercise • 8 weeks of strength exercise lead to increase in FFM • Addition of strength training lead to increase in strength and mid thigh circumference (measured by CT) • No difference in 6MWD, HRQOL INCREASED MUSCLE MASS STRENGTH EXERCISE IGF-1 (FAT FREE MASS)
  • 30. Pharmacological intervention : Anabolic steroids ANABOLIC STEROIDS NANDROLONE DECANOATE 50mg MALE • Anabolic steroids 25 mg FEMALE increased lean body 2 WEEKLY 4 DOSES mass • No side effects seen IGF-1 • Anabolic therapy alone Anti Glucocorticoid action increases muscle mass Erythropoietic action but not exercise capacity INCREASED FAT FREE MASS
  • 31. Growth hormone • rhGH 0.05 mg/kg for 3 weeks in addition to 35 Kcal/kg and 1gm protein/kg per day has shown to increase fat free mass. • Daily administration of 0.15 IU/kg rhGH during 3 wk increases lean body mass when assessed in underweight patients with COPD. • But does not improve muscle strength or exercise tolerance ( hand grip and maximal exercise ) and no change in well being of the patient.
  • 32. Testosterone • Testosterone 100 mg weekly for ten weeks in men with low testosterone levels 320 ng/ml showed weight gain of 2.3 kg • Addition of exercise to testosterone has augmented weight gain to 3.3 kg • Physiological consequences and long term effects not studied.
  • 33. INTERVENTION WEIGHT GAIN FFM GAIN EXERCISE CAPACITY CALORIC SUPP. + - - CALORIC SUPPLEMENTATION + ++ + + EXERCISE TRAINING STRENGTH EXERCISE - + - ANABOLIC STEROIDS ++ ++ - ANABOLIC STEROIDS + ++ +++ ? EXERCISE
  • 34. Guidelines • Increased calorie intake is best accompanied by exercise regimes that have a nonspecific anabolic action • Anabolic steroids in COPD patients with weight loss increase body weight and lean body mass but have little or no effect on exercise capacity. • Pulmonary rehabilitation programs should address body composition abnormalities. Intervention may be in the form of caloric, physiologic, pharmacologic or combination therapy ATS/ERS STATEMENT 2005
  • 35. Self management education Should involve : • Patient • Family • Primary care physician • Other health care providers
  • 37. Bronchial hygiene techniques • Postural drainage • Percussion & vibration • Directed cough • Forced expiratory technique (huff cough) • Active cycle of breathing • Autogenic drainage • Positive expiratory pressure
  • 38. Breathing strategies • Adopting specific postures : Leaning forward • Slow deep breathing • Pursed lip breathing • Diaphragmatic breathing
  • 39. Pursed lip breathing • Improves ventilation 1. Relax your neck and shoulder muscles. • Releases trapped air in the lungs 2. Breathe in (inhale) slowly through your • Keeps the airways open nose for two counts, keeping your mouth longer and decreases the closed. Don't take a deep breath; a normal work of breathing breath will do. It may help to count to • Prolongs exhalation to slow yourself: inhale, one, two. the breathing rate 3. Pucker or "purse" your lips as if you were • Improves breathing going to whistle or gently flicker the flame patterns by moving old air of a candle. out of the lungs and allowing for new air to 4. Breathe out (exhale) slowly and gently enter the lungs through your pursed lips while counting to • Relieves shortness of breath four. It may help to count to yourself: • Causes general relaxation exhale, one, two, three, four
  • 40. Diaphragmatic Breathing • Sit or lie comfortably, with loose garments. • Put one hand on your chest and one on your stomach. • Slowly inhale through your nose or through pursed lips (to slow down the intake of breath). • As you inhale, push your belly/ stomach out and feel your stomach expand with your hand. • Slowly exhale through pursed lips to regulate the release of air while squeezing your stomach • Rest and repeat
  • 41. Psychological considerations DYSPNEA CHRONIC DISEASE ABNORMALITIES IN DISABILITY BLOOD GAS FEAR & ANXIETY IRRITABILITY DEPRESSIVE SYMPTOMS PESSIMISM HOPELESSNESS WITHDRAWAL FROM SOCIAL HEIGHTENED INTERACTIONS PHYSIOLOGICAL AROUSAL NEUROPSYCHIATRIC IMPAIRMENTS
  • 42. Psychological considerations • Screening for anxiety and depression should be part of the initial assessment. • Mild or moderate levels of anxiety or depression related to the disease process may improve with pulmonary rehabilitation (Withers NJ. J Cardiopulm Rehab1999;19:362-5) • Patients with significant psychiatric disease should be referred for appropriate professional care. ATS/ERS STATEMENT • Antidepressants and anxiolytics appear not to have additional general value
  • 43. Patient selection and Assessment • Gains can be achieved from pulmonary rehabilitation regardless of age, sex, lung function, or smoking status ATS/ERS statement 2005 • No justification for selection on the basis of age, impairment, disability or smoking status. BTS statement 2001 • COPD patients at all stages of disease appear to benefit from exercise training programs, improving with respect to both exercise tolerance and symptoms of dyspnea and fatigue GOLD 2009
  • 45. Exclusion criteria • Patients with severe orthopedic or neurological disorders limiting their mobility • Severe pulmonary arterial hypertension • Exercise induced syncope • Unstable angina or recent MI • Refractory fatigue • Inability to learn, psychiatric instability and disruptive behavior.
  • 46. Outcome assessment  Control of symptoms of cough and fatigue:  Real time evaluation: VAS & Borg dyspnea scale  Recall of symptoms  Performance evaluation: Ability to do ADL  Directly observed or self reported  Exercise tolerance:  6 minute walking test  Cardiopulmonary exercise testing  Quality of life:  Chronic respiratory disease questionnaire  St Georges’s respiratory questionnaire  SF- 36  Assessment of respiratory and peripheral muscle strength (GOLD 2009)
  • 47. Maintenance rehabilitation & Repeat rehabilitation program • Continued participation in supervised program is essential for sustenance of benefits. • Yearly repeat rehabilitation program had shown: Short term benefits in the form of less frequent exacerbations But no long term physiological effects on exercise tolerance,dyspnea & HRQL.