2. Introduction
• American thoracic society and the European respiratory society have adopted following definition
of pulmonary rehabilitation, “pulmonary rehabilitation is a comprehensive intervention based on a
thorough patient assessment followed by patient tailored therapies that include, but are not limited
to, exercise training, education, and behaviour change, designed to improve the physical and
psychological condition of people with chronic respiratory disease and to promote the long-term
adherence to health-enhancing behaviours.”
• Pulmonary rehabilitation aims to reduce symptoms, decrease disability, increase participation in
physical and social activities and improve overall quality of life.
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3. Components
• Initial assessment
• Education
• Supervised progressive exercise training
• Energy conservation
• Stress management
• Functional and ADL training
• Nutritional guidelines
• Outcome
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4. Benefits
• Improve exercise capacity
• Reduced perceived intensity of dyspnoea
• Increase knowledge about pulmonary disease and its management
• Reduced length of hospitalization stay
• Improve health related quality of life(HRQL)
• Reduced anxiety and depression
• Return to work for some patients
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5. Inclusion criteria
• Obstructive disease
• Emphysema, bronchitis
• Restrictive disease
• Pulmonary fibrosis, sarcoidosis
• Exposure to risks for COPD
• Cigarette smoking, occupational exposure, infection of lungs
• Chest wall
• Chest wall surgeries, intra-thoracic surgeries
• Patient with symptoms of wheezing, coughing or dyspnoea require preventive care.
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6. Exclusion criteria
• Patient with severe limitation in their chest mobility
• Inability to learn
• Psychiatric instability
• Disruptive behaviour
• Unstable angina
• Recent embolism or myocardial infarct
• Second or third degree heart block
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7. Assessment
• History
• History of present illness, past medical history, drug history, surgical history, family history,
social history.
• Subjective assessment
• Symptom assessment-Wheeze, chest pain, incontinence, breathlessness, cough, sputum
• Breathlessness and quality of life- Borg scale of perceived dyspnoea
• Quality of life-London chest activity of daily living scale
• Objective assessment
• Observation- chest shape, breathing pattern, chest movement
• Palpation- trachea position, chest expansion
• Percussion
• auscultation
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8. • Respiratory function test- PFT
• Exercise testing- 6 min walk test, shuttle walk test
• Heart rate, blood pressure, respiratory rate and other vitals.
• Test results
• ABG analysis
• Chest radiograph
• Nutrition assessment- BMI, dietary history, fluid intake, alcohol consumption
• Education assessment- knowledge of the disease and its treatment, barrier to learning, cultural
diversity
• Psychosocial assessment- anxiety and depression, interpersonal conflict, family and home
situation, coping skills, motivation for pulmonary rehabilitation
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9. Education
• Normal lung anatomy and physiology
• Pathophysiology of chronic lung disease
• Description and interpretation of medical tests
• Breathing strategies
• Secretion clearance
• Respiratory devices
• Benefits of exercise and maintaining physical activities
• Activity of daily life
• Early recognition and treatment of exacerbation
• Coping with chronic lung disease
• Eating right
• Irritant avoidance
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10. Exercise training
Exercise training in pulmonary rehabilitation should encompass both upper and lower extremity
endurance training, strength training and respiratory muscle training. Duration, frequency, mode and
intensity of exercise should be included in the patient’s individualized exercise prescription, based on
disease severity, degree of conditioning, functional evaluation and initial exercise test data.
Frequency and duration of exercise- it vary from 3-5 times per week, 20-90 minutes per session
and extend over a period of 4-12 weeks. If the patient is very debilitated, the duration of initial
exercise session can be shorter with more frequent rest breaks; however, the ultimate goal is to
achieve fewer or no rest break and at least 30 minutes of endurance exercises within the first few
week of rehabilitation.
Intensity of exercises- high intensity training of 60- 80 % of peak work rate must be undertaken to
gain maximal physiological improvements in aerobic fitness. Interval training, alternating period of
low and high intensity is effective for person who can not tolerate high intensity. Lower-intensity
aerobic exercise training leads to significant improvement in exercise endurance.
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11. • Modes of exercises- it includes walking, cycling, arm ergometry, arm lifting exercise with or
without weight, water exercise, modified aerobic dance and seated aerobics. Warm up and cool
down sessions must be included
Upper and lower extremity exercises
• Lower extremity- walking, stationary cycling, bicycling, stair climbing, swimming
• Upper extremity- arm cycle ergometer, unsupported arm lifting, lifting weight
Strength training- hand and ankle weights, free weight, machine weight, elastic resistance, using
one’s body weight, such as stair climbing and squats.
Flexibility, posture and body mechanics
• VMT
• Frequency- 4-5 times per week
• Intensity- >30-40% Pimax (maximal inspiratory pressure measured at mouth)
• Duration- 30min/day or two 15 minutes session
• Breathing frequency- 12-15breaths per minute
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12. Initial exercise plan for very debilitated lung disease patient
Week 1 Week 3
Bike × 15 minutes(2 rest stops)
Ambulation using rollator ×15 minutes(3 rest stops)
Strength training using elastic bands, dumbbells,
weight cuff for arm and leg, 10 reps each.
Stretching of hams and calf×3 reps(30 sec hold),
overhead pulley both arm×10 slow reps.
Supervised diaphragmatic and pursed lip breathing ×1
minutes
Bike × 20 minutes(1 rest stops)
Ambulation using rollator ×20 minutes(1 rest stops)
Strength training using elastic bands, dumbbells,
weight cuff for arm and leg, 20 reps each.
Stretching of hams and calf×3 reps(30 sec hold),
overhead pulley both arm×20 slow reps.
Supervised diaphragmatic and pursed lip breathing ×30
seconds.
Week 2 Week 4
Bike × 15 minutes(1 rest stops)
Ambulation using rollator ×17 minutes(3 rest stops)
Strength training using elastic bands, dumbbells,
weight cuff for arm and leg, 15 reps each.
Stretching of hams and calf×3 reps(30 sec hold),
overhead pulley both arm×15 slow reps.
Supervised diaphragmatic and pursed lip breathing ×1
minutes
Bike × 20 minutes(0 rest stops)
Ambulation using rollator ×20 minutes(0 rest stops)
Strength training using elastic bands, dumbbells,
weight cuff for arm and leg, 20 reps each. Emphasize
diaphragmatic, pursed lip breathing and paced
breathing during exercise.
Stretching of hams and calf×3 reps(30 sec hold),
overhead pulley both arm×20 slow reps.
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13. Energy conservation
• Functional and ADL training
Instructions for energy conservation, activity pacing and use of adaptive equipment to optimize
the patient ability for daily activities.
• Stress management
It is important as chronic disease places stress on family members as well as for patient. So
provide them with coping strategies, stress reduction, management techniques, behavioral
strategies, and financial assistances as possible.
• Smoking cessation
• There is a strong correlation between smoking and COPD. Conseling for smoking should be
done.
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14. Nutritional guidelines
• Pulmonary rehabilitation programme should address body composition abnormalities. Intervention
may be in the form of caloric, physiologic, pharmacologic or combination therapy.(ATS/ERS)
• Caloric supplementation is considered if BMI is less than 21kg/m², involuntary weight loss of
>10% during last 6 months or more than 5% in the past month and depletion in FFM or lean body
mass.
• Energy dense food should be well distributed during the day.
• Patient experience less dyspnoea after carbohydrate rich supplement. But there is no evidence of
high fat diet.
• Daily protein intake should be 1.5g/kg for positive balance.
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15. Outcome measures
• Patient centred clinical outcomes evaluates how effective the intervention was in the areas of
importance to respiratory patient. Outcome assessment requires a minimum of two time points: one
before pulmonary rehabilitation(baseline) and one immediately after completing rehabilitation.
• Common outcomes are exercise capacity, symptoms and health related quality of life.
• Other are functional performance and home based activity, psychological outcomes, patient
adherence, smoking cessation, weight modification, mortality, patient satisfaction, knowledge and
self efficacy, health care utilization and patient satisfaction.
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16. Outcome areas for pulmonary patients
Outcomes Area measured Type of measures
Exercise capacity Distance walked
Oxygen consumption
6-minute walk test
Shuttle walk test
Cardiopulmonary exercise stress
test
Symptoms Dyspnoea
Fatigue
Symptom-specific
questionnaires
Domains of HRQL or functional
status questionnaires
Health related quality of
life(HRQL)
Several domains, varying by
questionnaire(physical function,
emotional function, mastery or
impact, and symptoms).
Generic questionnaires
Disease-specific questionnaires
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18. References
• Guidelines for pulmonary rehabilitation programs, fourth edition
• Elizabeth Dean, Donna Frownfelter, Clinical Case, 3rd edition
• Alexandra Hough, Physiotherapy in Respiratory Care, third edition
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