pulmonary rehabilitation slide presentation

8/2/2019 Pulmonary Rehabilitation Slide Presentation

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A n Overviewby

Michele Andrew

Pulmonary Rehabilitation


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Consequences of RespiratoryDisease

Peripheral Muscle dysfunction Respiratory muscle dysfunction

Nutritional abnormalities Cardiac impairment Skeletal disease Sensory defects Psychosocial dysfunction


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Mechanisms for these morbidities

Deconditioning Malnutrition

Effects of hypoxemia Steroid myopathy or ICU neuropathy Hyperinflation Diaphragmatic fatigue Psychosocial dysfunction from anxiety, guilt,

dependency and sleep disturbances.


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Definition of PulmonaryRehabilitation

A multidisciplinary continuum of services directedto persons with pulmonary diseases and theirfamilies, usually by an interdisciplinary team ofspecialists, with the goal of achieving andmaintaining the individuals maximum level of independence and functioning in the community

Sat Sharma, MD, FRCPC, Professor of

Pulmonary Medicine, U. of Manitoba


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Principle Goals of PulmonaryRehabilitation

Aims to reduce symptoms, decrease disability,increase participation in physical and socialactivities and improve overall quality of life.These goals are achieved through patient andfamily education, exercise training, psychosocialintervention and assessment of outcomes.The interventions are geared toward theindividual problems of each patient andadministered by the multidisciplinary team.


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Benefits of Pulmonary Rehab.

The benefits are seen in irreversible pulmonarydisorders because much of the disability is notfrom the lung disease but from the secondarymorbidities.

Evidence from the 2008 Pulmonary RehabilitationGuidelines shows great benefit in the followingareas:


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Benefits

Improved Exercise CapacityReduced perceived intensity of dyspnea

Improve health-related QOLReduced hospitalization and LOSReduced anxiety and depression from COPDImproved upper limb functionBenefits extend well beyond immediate period oftraining.


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Patient Selection

Obstructive DiseasesRestrictive Diseases

InterstitialChest Wall

NeuromuscularOther Diseases

ReferencePulmonary Rehabilitation; Guidelines To SuccessJohn E. Hodgkin,MD; Bartolome Celli, MD;GerilynConners, RRT2009


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Gains can be achieved from pulmonaryrehabilitation regardless of age, gender, lungfunction or smoking status.

Severe nutritional depletion and low fat -freemass may be associated with an unsatisfactoryresponse to rehab.

Exclusions: Conditions that may interfere withthe disease process of that could cause riskduring exercise training.


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Objective AbnormalitiesFEV1 less than 80% predictedFEV1/FVC less than 70 %DLCO less than or equal to 65% of predicted

Resting hypoxemia less than or equal to 90%Exercise Testing demonstrating hypoxemia lessthan 90%

Enrolling active smokers is controversial but theymay benefit significantly with a focus on smokingcessation.Patient Motivation is a necessary consideration.


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Setting for Pulmonary RehabilitationOutpatientInpatientHome

Community BasedChoice varies depending on

Distance to programInsurance payer coverage

Patient preferencePhysical, functional, psychosocial status of patient


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Components of a Comprehensive

ProgramExercise TrainingEducationPsychosocial/behavioral interventionOutcome Assessment


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Exercise TrainingDoes not alter underlying respiratory impairmentDoes improve dyspneaTargets endurance training of 60% max for 20-30minutes, repeated 2-5 times a weekInterval training of 2-3 minutes high intensity withequal periods of rest or low level exercise istolerated well.

Unsupported arm exercise aids ADLs andrespiratory accessory muscle use.Respiratory muscle training benefits have notbeen well established.


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Education

Encourages active participation in health care

Better understanding of disease

Improved compliance


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Energy Conservation

Energy conservation and work simplificationassist in maintaining ADLSMethods include

Paced BreathingBody mechanicsAdvanced planning

Prioritization of activitiesUse of assistance devices grabbers, etc.


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Medication and other therapies

Types of medication, action, adverse effects,dose and proper us of inhaled medications .

Instructions in inhaler technique.

Appropriate use of oxygen


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End of Life Education

Poor prognosis and increased risks over time

Decision to initiate life support brining in patientsown values with physicians prognosis

Provides patients with understanding of lifesustaining interventions and the importance ofadvanced planning


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Psychosocial Intervention

Anxiety, depression, difficulties coping withchronic disease

Aided by regular patient education session orsupport groups

Instruction in progressive muscle relaxation,stress reduction, panic control


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Chest Physical TherapyPursed Lip Breathing shifts breathing patternand inhibits dynamic airway collapse.Posture techniques forward leaning reducesrespiratory effort, elevating depressed diaphragmby shifting abdominal contents.Diaphragm Breathing Some patients withextreme air trapping and hyperinflation haveincreased WOB with this techniquePostural Draining valuable in patients whoproduce more than 30cc/24 hours/ Coughingtechniques


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Nutritional Assessment

Diet history, BMI

Over or Under weight.

Classes in weight management and/or nutritional

counseling to improve weight management


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Outcome AssessmentAn important component of pulmonaryrehabilitation, being used to determine individualpatient responses and evaluate overalleffectiveness of program.

Dyspnea 10 pt scale, Borg scale, Visual AnalogScaleExercise Ability Borg Scale, 6MDW/Progressiveexercise testing pre and post rehab.

Health Status Respiratory-related QOL; CRDQActivity Levels Respiratory-Specific functionalStatus, Duke Functional Status Scale.


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Future Directions of P.R.

Impact of PR on Health Care Costs and survivalEffectiveness of education, breathing strategiespsychosocial supportBest intensity, duration and optimum form ofexercise training. Benefits of strength training andbest UBE.Use of noninvasive positive pressure ventilationduring exercise.Benefits of a maintenance program to slowprogression.


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Future Directions

Optimal Frequency of a PR program leading topsychologic gains and decreased hospitalizationrate.

Simplifying or minimizing current assessmentinstruments without sacrificing their intent.

Effectiveness of P.R. in diseases other thanCOPD.


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Future of PulmonaryRehabilitation

Medicare Improvements for Patient and ProviderAct of 2008

A specific benefit for Pulmonary RehabilitationeffectiveJanuary 1, 2010CMS must write regulations who is eligible,duration, services, etc.

pulmonary rehabilitation slide presentation

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