Pulmonary Rehabilitation

DR/RABAB HUSSEIN ALI

Pulmonary rehabilitation

Is an evidence based, comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities. Integrated into the individualised treatment of the patient pulmonary rehabilitation is designed to reduce symptoms, optimise functional status, increase participation, and reduce health care costs through stabilising or reversing systemic manifestations of the disease

ATS/ERS statement on pulmonary rehabilitation (2006) American journal of respiratory and critical care medicine, 173:1390-1413

PULMONARY REABILITATION

Goals

- General : Improve physical and psychological or emotional functioning of patients in interaction with theire environment - Specific :
- Reduce symptoms - Improve activity and daily function QOL - Restore the highest level of independant function (in every day activities) - Enhance knowledge of the disease - Improve self-management

PULMONARY REABILITATION Components of the rehabilitation program

1- Optimal medical treatment 2- Smoking cessation 3- Exercise training 4- Breathing retraining

5- Chest physiotherapy
6- Education 7- Psychological aspects and support 8- Nutritional therapy 9- Nursing care

BronchoPulmonary Hygiene is
A treatment intervention employed for improving pulmonary hygiene including 1. deep breathing and coughing exercises 2. Gravity-assisted Positioning 3. Manual techniques

4. Manual hyperinflation
5. Airway suctioning 6. Mobilization

to assist in mobilizing secretions in the lungs from the peripheral airways into the more central airways so that they can be expectorated or suctioned.

Indications

Prophylactic
Pre-operative high risk surgical patient Post-operative patient who is unable to mobilize secretions Neurological patient who is unable to cough effectively Patient receiving mechanical ventilation who has a tendency to retain secretions Patients with pulmonary disease, who needs to improve bronchial hygiene

contd

Therapeutic
- Atelectasis due to secretions
- Retained secretions - Abnormal breathing pattern due to primary or

secondary pulmonary dysfunction

- COPD and resultant decreased exercise tolerance

- Musculoskeletal deformity that makes breathing

pattern and cough ineffective

Assessment

Neurological system Cardiovascular system Respiratory system Renal system Hematological system

Gastrointestinal system

Respiratory system

Auscultation Percussion Expansion Chest X-ray Mode of ventilation Oxygen therapy Airway pressures Sputum

1. Ventilation movement of air in & out of the lungs; facilitates respiration

2. Respiration exchange of oxygen & carbon dioxide 3. Perfusion relates the ability of the cardiovascular system to pump oxygenated blood to the tissues & return deoxygenated blood to the lungs.

4. Diffusion is responsible for the moving the molecules from one area to another Diffusion of respiratory gases occurs at the alveolocapillary membrane, & the rate of diffusion can be affected by the thickness of the membrane. Increased thickness of the membrane impedes diffusion because gases take longer to transfer across. The elasticity of the lung tissue allows the lungs to stretch & fill with air during inspiration & return to a resting position after exhalation.

During inspiration => diaphragm contracts => moves downward in the thorax => intercostal muscles move the chest outward => elevating ribs & sternum => expands thoracic cavity
Expansion creates more chest space =>pressure within lungs

Air flows from area of higher pressure to lower pressure thus filling the air in the lungs Accessory muscles of respiration = pectoralis minor & sternocleidomastoid

During expiration => respiratory muscles relax => thoracic cavity decreases => stretched elastic tissue recoils => intrathoracic pressure increases (d/t compressed pulmonary space & air moves out of the respiratory tract)

Abdominal muscles = rectus abdominis, transverse abdominis, & internal & external obliques

Assessment
General Observation

Patient Position
Respiration

- Airway

ET/Tracheostomy

Ventillator Mode

Vital Signs Temperature, BP, RR, HR, ICP Tubes - NG Tube, CV line, Peripheral line, Chest tubes, Catheters Drugs

 contd
Examination

Auscultations Respiratory pattern Cyanosis Clubbing Radiograph

Skills: Self Monitoring

Early recognition Early treatment Less medication needed Feel better faster

Skills: Self Monitoring

Difficulty breathing Chest tightness Cough interfering with activity or sleep Inability to speak in sentences Wheezing

Headache Dark circles under eyes Change in face color Change in appetite Change in activity level Retractions suprasternal supraclavicular intercostal substernal subcostal

Itchy, watery, glassy eyes

Sore, scratchy, itchy throat Stroking of neck Fever

Congestion
Sneezing Runny nose

Goals

Prevent accumulation of secretions Improve mobilization and drainage of secretions Promote relaxation to improve breathing patterns

Goals

Promote improved respiratory function Improve cardio-pulmonary exercise tolerance Teach bronchial hygiene programs to patients with chronic respiratory dysfunction

Precautions

Untreated tension pneumothorax

Abnormal coagulation profile

Status epilepticus or status

asthamaticus

Immediately following intra cranial surgery

Precautions

Head injury with raised ICP

Osteoporotic bones
Recent acute myocardial infarction, unstable vitals Immediately after tube feedings Sutures

Physiotherapy Techniques

1. Deep breathing and coughing exercises 2. Gravity-assisted Positioning 3. Manual techniques

4. Manual hyperinflation
5. Airway suctioning 6. Mobilization

Deep Breathing and Coughing Exercises

Facilitates

proper respiratory functioning. Are frequently indicated for clients with restricted chest expansion like, COPD or post- chest surgery

(a) Pursed lip breathing

(b) Diaphragmatic breathing

Abdominal and pursed-lip breathing

Commonly employed breathing exercise Permits deep full breaths with little effort Pursed-lip creates a resistance to the air flowing out of the lungs, thereby prolonging exhalation and preventing airway pressure.

Abdominal and pursed-lip breathing

As

if about to whistle and breaths out slowly and gently, tightening the abdominal muscles to exhale more effectively. to a count of 3 and exhales to a count of 7

Inhales

Diaphragmatic Breathing

Is breathing that promotes the use of the diaphragm rather than the upper chest muscles Used to increase the volume of air exchange during inspiration & expiration Requires the client to relax intercostals and accessory respiratory muscles while taking deep inspirations With practice, it reduces respiratory effort & relieves rapid, ineffective breathing Useful for clients with pulmonary disease, post-operative clients & for women in labor to promote relaxation

Procedure:

Lie down with knees slightly bent. Place one hand on the abdomen and the other on the chest.

Inhale slowly & deeply through the nose while letting the abdomen rise more than the chest.
Purse the lips. Contract the abdominal muscles & begin to exhale. Press inward & upward with the hand on the abdomen while continuing to exhale.

Repeat the exercise for 1 full minute; rest for at least 2 minutes.
Practice the breathing exercises at least twice a day for a period of 5 to 10 minutes. Progress to doing diaphragmatic breathing while upright & active.

Coughing Exercises

Forceful coughing often is less effective than using controlled or huff coughing techniques.

Cough is a sudden, audible expulsion of the air from the lungs - is a protective reflex to clear the trachea, bronchi, & lungs of irritants and secretions

Carina the point of bifurcation of the right & left main stem bronchus, is the most sensitive area for cough production

Coughing permits the client to remove secretions from both the upper & lower airways The normal series of events in cough mechanism are deep inhalation, closure of the glottis, active contraction of the expiratory muscles, & glottis opening. The effectiveness of coughing is evaluated by sputum expectoration, the clients report of swallowed sputum, or clearing of adventitious sounds by auscultation.

1.Cascade cough the client takes a slow, deep breath ad holds it for 2 seconds while contracting expiratory muscles.

The client opens the mouth & performs a series of coughs throughout exhalation; thereby coughing at progressively lowered lung volumes. This promotes airway clearance & a patent airway in clients with large volumes of sputum.

2. Huff cough stimulates a natural cough reflex & is generally effective only for clearing central airways 3. Quad cough is used for clients without abdominal muscle control (SC injuries)

While the client breathes out with a maximal expiratory effort, the client or nurse pushes inward & upward on the abdominal muscles toward the diaphragm, causing the cough.

Procedure:

After using bronchodilators treatment (if prescribed), inhale deeply and hold your breath for a few seconds. Cough twice. The first cough loosens the mucus; the second expels the secretions. For huff coughing, lean forward and exhale sharply with a huff sound. This technique helps you keep your airways open while moving secretions up & out of the lungs. Inhale by taking rapid short breaths in succession (sniffling) to prevent mucus from moving back into smaller airways.

Rest.
Try to avoid prolonged episodes of coughing because these may cause fatigue & hypoxia.

Gravity-assisted Positioning
Physiological effects of Positioning
1. Optimizes oxygen transport 2. Increases lung volumes 3. Reduces the work of breathing 4. Minimizes the work of heart 5. Enhances mucuciliary clearance (postural drainage)

Postural Drainage isnt

a separate technique. Its just an example of positioning which has the particular aim of clearing airway secretions with the assistance of gravity.

Postural Drainage
Patients are positioned with the area to be drained the

upper most, but modifications should be done wherever

necessary.

Drainage times vary, but ideally each position requires

10 minutes (gumery et al, 2001).

Positioning
Positioning restores ventilation to dependent lung regions more effectively than PEEP or large tidal volumes (Froese & Bryan, 1974). Positioning has a marked influence on gas exchange because of unevenly damaged lungs (Tobin, 1994). Side lying reduces lung densities in the upper most lung (Brismar, 1985).

contd

Right side lying may be more beneficial for cardiac output than left side lying (Wong, 1998). Simply turning from supine to side lying can clear atelectasis from dependent regions (Brismar, 1985). Positioning affects lung volume Lung volume is related to the position of the diaphragm

contd

Positioning affects compliance (Wahba et al found that work of breathing is 40% higher in supine than in sitting) Positioning affects arterial oxygenation by improving V/Q mismatch (V/Q is usually mismatched if the affected lung is dependent- Gillespie et al) Bad lung up position

Positioning

Which position to choose

Chest Maneuver

Chest Vibrations Chest Percussion/Clapping

Clapping/Chest Percussion
Percussion consists of rhythmic clapping on the chest with loose wrist & cupped hand. Effect : Dislodges & loosens secretions from the lung

Hand Position

Chest Vibration

Vibrations consists of a fine oscillation of the hands directed inwards against the chest, performed on exhalation

after deep inhalation.

Effects: Helpful in moving loosened mucous plugs towards larger airway

Manual Hyperinflation

Was originally defined as inflating the lungs with oxygen and manual compression to a tidal volume of 1 liter requiring a peak inspiratory pressure of between 20 and 40 cm H2O (Med j Aust, 1972).

More recent definitions include providing a larger tidal volume than base line tidal volume to the patient (Aust j physiotherapy, 1996) and using a tidal volume which is 50% greater than that delivered by the ventilator (chest, 1994).

Indications

To aid removal of secretions To aid reinflation of atelectatic segments To assess lung compliance To improve lung compliance

Techniques

Slow deep inspiration Inspiratory hold (at full inspiration) Fast expiratory release Hand-held PEEP

Hazards of MHI

Reduction in blood pressure Reduced saturation Raised intracranial pressure Reduced respiratory drive

Contraindications

Undrained Pnuemothorax Potential bronchospasm Severe bronchospasm Gross cardiovascular instability inducing arrhythmias and hypovolaemia Unexplained Haemoptysis Patient on High PEEP

Advantages of MH
Reverses atelectasis (Lumb 2000)

Improves oxygen saturation and

lung compliance (Patman et

al.,1999)

Improves sputum clearance (Hodgson et al., 2000)

Disadvantages of MH

Haemodynamic and metabolic upset (Stone, 1991 & Singer et al.,1994)

Risk of barotrauma Discomfort and anxiety

Suctioning

Suctioning is the mechanical aspiration of pulmonary secretions from a patient with an artificial airway in place. Indications Inability to cough effectively Sputum plugging To assess tube patency

Contraindications

Frank haemoptysis Severe brochospasm Undrained pneumothorax Compromised cardiovascular system

Guidelines:

The suction catheter used must be less than half the diameter of endotracheal tube.

The vacuum pressure should be as low as possible. (60150mmHg)

Suction should never be routine, only when there is an indication

Hazards of suctioning

Mucosal trauma Cardiac arrhythmias Hypoxia Raised intracranial pressure

What to suction?

Nasal and oral suction Endotracheal suction Tracheostomy suction Closed-circuit suction

Mobilization

Critically Ill

(Frequent Position changes, Kinetic & Kinematic Therapy)

Stable

(Progressive tilting & Ambulation)

Mobilization
ICU rehabilitation has been shown to accelerate recovery (oleary & coackley, 1996) Early mobilization for unconscious patients starts right from turning the patient every two hours. ( Brooks- brunn, 1995). Graded exercises can be started as soon as the patient regains consciousness.

Mobilization

Activity is required to maintain sensory input, comfort, joint mobility and healing ability (Frank et al, 1994). Activity minimizes the weakness caused by loss of up to half the patients muscle mass (Griffiths & Jones, 1999). Graded ambulation can be started depending on patients condition

Thank you