Pulmonary rehabilitation in specific conditions - Neuromuscular disorders - Lung volume reduction surgery - Lung transplantation

1. Disease specific approaches in
Pulmonary Rehabilitation
PRESENTED BY:
SUMI VARGHESE
M.SC. RESPIATORY /THERAPY (ADULT RESPIRATORY CARE)

2. Neuromuscular & Chest Wall Disorders
Neuromuscular
disorders
Motor neuron
disorders Muscular dystrophies
Spinal muscular
atrophy
Peripheral
neuropathies
Neuro muscular
junctions

3. Respiratory dysfunction in Neuromuscular and chest wall disorders :
 “Weak bellows”
 Hypoventilation – shallow breathing pattern
 Reduced chest wall compliance
 Gas exchange disturbances
 Respiratory failure
 The magnitude of derangement depends on severity of illness

4. Disease burden
 Exercise intolerance
 Exertional dyspnea
 Impaired cough – exp. muscle weakness
 Degenerative neuromuscular disorders
 Sleep disordered breathing

5. Exercise training
Nature and goals of training program should be individualised to the following :
o Disease type and severity
o Individual patient needs and functional limitations
Aerobic and strength training : ambulation, cycling, water-based exercise
Frequent, shorter training sessions
Interval training
Avoid excessive muscle fatigue
Inspiratory muscle training in selected patients
Consider consulting with neurologist or physiatrist in formulating exercise prescription

6. Additional considerations
Supplemental oxygen – SpO2 88%
Identify need for assistive or orthotic equipment to maintain independence with ADLs
Mechanical ventilation
o Assisted ventilation during exercise
o Nocturnal non invasive ventilation (CPAP Vs BiPAP)
Inpatient PR : severe functional limitation or intensive nursing or medical care needs

7. Educational topics
Respiratory manifestations or complications of neuromuscular or chest wall disease
Secretion clearance and cough techniques
Recognizing signs of destabilization and infection
Rationale and benefits of NIV
Supplemental oxygen
Tracheostomy and MV

8. Lung Volume Reduction Surgery (LVRS)
LVRS :–
Severely emphysematous lung tissue is resected in a effort to improve pulmonary function, respiratory
mechanics, and exercise tolerance
For highly selected patients with severe emphysema
Noted benefits-
o Improved elastic recoil, reduced hyperinflation, and improved respiratory muscle function
o National Emphysema Treatment Trial (NETT)

9. PR program modifications for LVRS
PR assessments to help determine the selection of surgical candidates
Communication between PR and surgical team
Pre operative exercise training to reduce post operative complications
Education
o Risks Vs benefits of surgery
o Lung expansion techniques and mobilization post operatively
o Pain management

10. PR program modifications for LVRS
Nutritional support
Post operative exercise training
o Adjusted training regimen: increased intensity and duration over time
o Modification of immediate post operative rehabilitation as a result of :
• Prolonged air leaks
• Extended tube thoracotomy

11. Lung Transplantation
Indications
oAdvanced emphysema
oPulmonary hypertension
oIdiopathic pulmonary fibrosis
oCystic fibrosis

12. PR for patients undergoing lung transplantation
Disease specific approach to exercise training
oIntensity- as tolerated
oIntensity less than post transplant training
oStable patients may exercise at home
oPeriodic review of home exercise program and
maintenance of exercise
oMaintain SpO2 >90%
Education
oRisks Vs benefits of transplantation
oPotential complications
oPostoperative care
oBenefits and adverse effects of immunosuppression
oLung expansion and secretion clearance techniques
oNutrition
oMethods of assisted ventilation
oAnxiety management, coping and relaxation techniques

13. PR for patients undergoing lung transplantation
Immediate post transplant period
oOptimize airway clearance and lung expansion
oMonitoring of changing requirements for supplemental oxygen
oImproved stability in erect posture
oRange of motion
oUpper and lower extremity training
oFunctional mobility and stable gait
oPostural drainage directed cough techniques
oAnalgesia titrated to exercise

14. PR for patients undergoing lung transplantation
Exercise training
oStrength and endurance training of lower and upper
extremities
oContinue oxygen saturation monitoring
oEmphasize postural awareness and breathing efficiency
oBack protection
oIncrease and intensity and duration of exercise over time
oAssess need for assistive device
Educational topics
oBack protection
oSymptoms and signs of infections and
immunosuppression
oMaintenance of proper nutrition
o importance of maintaining regular exercise

15. References
American Association of Cardiovascular and Pulmonary Rehabilitation. Disease Specific
Approaches in Pulmonary rehabilitation. In Guidelines for Pulmonary Rehabilitation
Programs.; 2005. p. 80-86