1. Overview of PULMONARY REHABILITATION
DR. TUSHAR SAHASRABUDDHE
ASSOCIATE PROFESSOR,
DEPT. OF TB & RESPIRATORY DISEASES

2. DEFINITION OF COPD
“COPD is a disease state characterized by airflow limitation that is not fully reversible. The airflow limitation is usually both progressive and associated with abnormal inflammatory response of the lungs to noxious particles or gases.”
Am J Respir Crit Care Med 2001; 163(5):

3. Future global mortality
1990
2020
Ischaemic heart disease
Cerebrovascular disease
Lower respiratory infection
Diarrhoeal disease
Perinatal disorders
COPD
Tuberculosis
Measles
Road traffic accidents
Lung cancer
3rd
Murray & Lopez:
World Bank Global
Predictions
Nat Med 1998
6th

4. PREDICTIONS FOR DISABILITY 1990 TO 2020
1. Lower respiratory infections
2. Diarrhoeal diseases
3. Perinatal conditions
4. Unipolar major depression
5. Ischaemic heart disease
6. Cerebrovascular disease
7. Tuberculosis
8. Measles
9. Road traffic accidents
10. Congenital anomalies
11. Malaria
12. COPD
disability-
adjusted
life-years
Murray & Lopez:
WHO Global
Predictions
Nat Med 1997

5. PREVELANCE OF COPD IN INDIA
12.36 million adult patients (61.6% males)
8.15 million males
4.21 million females
Adults over 30 years :
5% males and 2.7% females
Indian J Chest Allied Sci 2001; 43:

6. NEW DEFINITION FOR COPD
Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease state characterized by airflow limitation that is not fully reversible.
The airflow limitation is usually progressive and is associated with an abnormal inflammatory response of the lungs to noxious particles or gases, primarily caused by cigarette smoking.
Although COPD affects the lungs, it also produces significant systemic consequences.
ATS/ERS 2004

7. PULMONARY REHABILITATION
It is an art of medical practice wherein an individually tailored, multidisciplinary prrogram is formulated which through accurate diagnosis, therapy, emotional support and education; stabilizes or reverses both the physio and psychopathology of pulmonary diseases and attempts to return the patient to the highest possible functional capcity allowed by his pulmonary handicap and overall life situation.

8. SETTINGS
the inpatient setting, including medical center, skilled nursing facility, or rehabilitation hospital
the outpatient setting
outpatient hospital-based clinic
comprehensive outpatient rehabilitation facility (CORF)
physician’s office
alternate or extended care facility
patient’s home

9. INDICATIONS dyspnea experienced during rest or exertion
hypoxemia, hypercapnia
reduced exercise tolerance or a decline in the patient’s ability to perform activities of daily living
an unexpected deterioration or worsening symptoms against a background of long-standing dyspnea and a reduced but stable exercise tolerance level
the need for surgical intervention (pre- and postoperative lung resection, transplantation, or volume reduction)
chronic respiratory failure and the need to initiate mechanical ventilation
increasing need for acute care intervention, including emergency room visits, hospitalizations, and unscheduled physician office visits

10. CONTRAINDICATIONS
Potential contraindications to pulmonary rehabilitation include ischemic cardiac disease, acute cor pulmonale, severe pulmonary hypertension, significant hepatic dysfunction, metastatic cancer, renal failure, severe cognitive deficit, and psychiatric disease that interferes with memory and compliance. The decision to provide or withhold pulmonary rehabilitation should be based on a thorough, individualized assessment.
Substance abuse without the desire to cease use would seriously interfere with successful pulmonary rehabilitation
Physical limitations such as poor eyesight, impaired hearing, a speech impediment, or orthopedic impairment may require modification of the pulmonary rehabilitation setting but should not interfere with participation in a pulmonary rehabilitation program.

11. COMPONENTS Assessment of need for pulmonary rehabilitation
Optimization of medical treatment
Patient education
Exercise conditioning and techniques
Psychological support
Monitoring of patient response and clinical monitoring
Infection control

12. LIMITATIONS
The patient may have a disease process that has progressed to the stage where rehabilitation is not possible.
The patient may not adhere to or complete the program because it appears to be complicated or because of a sense of hopelessness, depression, or a lack of motivation.
The patient/patient family may be reluctant to make changes in their usual program, medications, start new therapy, quit smoking, use supplemental oxygen, or exercise.
There might be concerns or limitations in transportation.
Financial resources might not be available.
The patient may have to stop the program because of an acute exacerbation, or worsening of another medical condition.
Related to the health care system
Reimbursement by intermediaries or third-party payers are not standardized.

13. THE TEAM
Medical director: should be a physician with an interest in and knowledge of pulmonary rehabilitation, pulmonary function, and exercise evaluation.
Program director/coordinator: should be trained in health-related profession and have clinical experience and expertise in the care of patients with chronic lung disease. She or he should understand the philosophy and goals of pulmonary rehabilitation and be knowledgeable in administration, marketing, education, patient training, and obtaining reimbursement.

14. TEAM MEMBERS Chest physician General physician Psychiatrist
Psychotherapist
Trained physiotherapist
Trained nurse
Social worker
Lab personnel
PFT & ECG technicians

15. INFRASTRUCTURE Patient education materials workbooks and videotapes
lung and skeletal models
anatomical posters
stethoscope
manual sphygmomanometer
pulse oximeter
supplemental oxygen source

16. INFRASTRUCTURE access to laboratory for arterial blood gas analysis
Stopwatch, peak flow meter, spirometer
calibrated cycle ergometer or motorized treadmill (Measured walking distance may be used if an ergometer or treadmill is not available.)
free-weights or elastic bands
patient’s own equipment, e.g., metered-dose inhaler and spacer, compressor nebulizer
emergency plan and supplies
electrocardiogram (EKG) monitoring during exercise, if indicated, and defibrillation and crash cart

17. OPTIMIZATION OF MEDICAL TRETMENT
Bronchodilators: Tiotropium, LABA, SR-theophyllins, ICS
Treatment of cardiac failure
Airway care: mucolytics, steam
LTOT (long term oxygen therapy)
Smoking cessation

18. PATIENT EDUCATION
pulmonary anatomy and physiology including the pathophysiology of lung disease
description and interpretation of medical tests
bronchial hygiene techniques
indications, actions, and side-effects of medications including non-prescription products, such as vitamins, over-the-counter medications, and herbal remedies

19. PATIENT EDUCATION functional self-management
self assessment and symptom management
infection control with emphasis on avoidance, early intervention, and immunization
environment control
indications for seeking additional medical resources
sleep disturbances, e.g., insomnia and sleep apnea as they relate to chronic lung disease
sexuality and intimacy

20. PATIENT EDUCATION nutrition smoking cessation
psychosocial intervention and support
available community services, including patient/family support groups
advance care planning
travel issues
recreation/leisure activities
stress management
indications for oxygen, and methods of delivery

21. LOWER LIMB TRAINING
Walking, treadmill, stationary bicycle, stair climbing, combination
Reversal of deconditioning, increased aerobic enzymes in muscles, decrease in lactate
Psychological benefits: motivation, loss of fear of dyspnoea, antidepressant effect
Evidence A

22. UPPER LIMB TRAINING
Arm ergometer, lifting weights, arm elevation, arm cranking
Increase in vital capacity, oxygen uptake, better arm work
Evidence B

23. VENTILATORY MUSCLE TRAINING
Inspiratory resistance training
Abdominal breathing
Pursed lip breathing
Abdominal muscle training
Delays fatigue, improve exercisetolerance
Evidence B

24. PSYCHOLOGICAL SUPPORT
Loneliness, reduced social support, negative self image, anxiety, depression, defects in cognitive tasks such as attention, verbal tasks, sexual dysfunction
Psychological interventions
Health behaviour interventions
Adherence interventions

25. EXPECTED OUTCOME Improvement of dyspnoea A
Improvement of exercise tolerance A
Improvement of quality of life B
Reduction in healthcare utilization B
Survival benefit C

26. Thank You