DEFINITIONS AND GOALS

Rehabilitation - “the restoration of the individual to the fullest medical, mental, emotional, social, and vocational potential of which he

or she is capable.”

Goal is to maximize functional ability and to minimize the impact the disability has on the individual, the family, and the community.

Pulmonary rehabilitation is the “art of medical practice wherein an individually tailored, multidisciplinary program 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 capacity allowed by his or

her pulmonary handicap and overall life situation.”

The general goals of pulmonary rehabilitation are to control and alleviate symptoms, restore functional capabilities as much as

possible, and improve quality of life. Pulmonary rehabilitation does not reverse or stop progression of the disease, but it can

improve a patient’s overall quality of life.

HISTORICAL PERSPECTIVE
1952, Barach and colleagues recommended reconditioning programs for patients with chronic lung disease to help improve their

ability to walk without dyspnea.

In 1962, Pierce and associates published results confirming Barach’s insight into the value of reconditioning. They observed that

patients with COPD who participated in physical reconditioning exhibited lower pulse rates, respiratory rates, minute volumes, and

carbon dioxide (CO2) production during exercise.

When combined with smoking cessation, optimization of blood gas results (arterial pO2, pCO2, and pH), and proper medication use,

pulmonary rehabilitation offers the best treatment option for patients with symptomatic pulmonary disease.

In fall 2006, the American College of Chest Physicians (ACCP) and the American Association of Cardiovascular and

Pulmonary Rehabilitation (AACVPR) released their evidence-based guidelines relating to pulmonary rehabilitation aimed at

improving the way pulmonary rehabilitation programs are designed, implemented, and evaluated through patient outcomes.

SCIENTIFIC BASIS
Rehabilitation must focus on the patient as a whole and not solely on the underlying disease. For this reason, effective pulmonary

rehabilitation programs combine knowledge from both the clinical and the social sciences. Knowledge from the clinical sciences can

help quantify the degree of physiologic impairment and establish outcome expectations for reconditioning. Application of the social

sciences is helpful in determining the psychological, social, and vocational impact of the disability on the patient and family

and in establishing ways to improve the patient’s quality of life.

Physical Reconditioning

At rest, an individual maintains homeostasis by balancing external, internal, and cellular respiration.

Aerobic exercises, increases energy demands. To maintain homeostasis during exercise, the cardiorespiratory system must keep

pace.

Ventilation and circulation increase to supply tissues and cells with additional O2 and to eliminate the higher levels of CO2

produced by metabolism.

O2 consumption and CO2 production also increase in linear fashion as exercise intensity increases.

Onset of blood lactate accumulation (OBLA)- If the body cannot deliver sufficient O2 to meet the demands of energy

metabolism, blood lactate levels increase above normal.

Ventilatory Threshold -an abrupt upswing in both CO2 and VE.

*metabolism becomes anaerobic, the efficiency of energy production decreases, lactic acid accumulates and fatigue sets in.
* caused by excess lactic acid is buffered, CO2 levels increase and the stimulus to breathe increases.

note: Patients with COPD who lack adequate pulmonary function have severe limitations to their exercise capabilities. Their

high rate of CO2 production during exercise results in respiratory acidosis and a shortness of breath out of proportion to the level

of activity. In addition, as ventilation increases, the rate of O2 consumption in a patient with COPD increases significantly as

depicted in Figure 55-3. Together, these factors limit patient tolerance for any significant increase in physical activity.

Pulmonary rehabilitation must include efforts to recondition patients physically and increase their exercise tolerance.

Reconditioning involves strengthening essential muscle groups, improving overall O2 utilization and enhancing the body’s

cardiovascular response to physical activity.

Psychosocial Support

Psychosocial indicators generally are good predictors of morbidity in patients with COPD. Studies show that the relative success

of reconditioning plays less of a role in determining whether patients complete a program than meeting their psychosocial support

needs.

There is a well-established relationship between physical, mental, and social well-being in humans. However, emotional states such

as anxiety and stress can aggravate an existing physical problem.

* physical manifestations of disease, such as recurrent dyspnea, can increase an individual’s stress level.
*Patients with COPD often have a tendency to develop severe anxiety, hostility, and stress as a direct consequence of their

disability. Because patients are fearful of economic loss and death, they can develop hostility toward the disease and often toward the

people around them.

*In terms of social function, the physiologic impairment of chronic lung disease combined with other variables can severely

restrict a patient’s ability to perform routine tasks requiring physical exertion. Moreover, patients’ potential loss of confidence in

their ability to care for themselves reduces feelings of dignity and self-worth.

*Many patients disabled with pulmonary disease are in their economically productive years and are anxious to return to economic self-

sufficiency. For these patients, occupational retraining and job placement are key ingredients in a good rehabilitation program. An

occupational therapist can play a vital role here and should be included, if possible, as a member of the interdisciplinary rehabilitation

team and in the pulmonary rehabilitation program. The pulmonary rehabilitation program should be based on the individual needs and

expectations of each patient. Evaluation and placement of the rehabilitation patient may require the skills of vocational counselors and

occupational therapists along with the cooperation of business and industry.

STRUCTURE OF A PULMONARY REHABILITATION PROGRAM

*Pulmonary rehabilitation programs vary in their design and implementation but generally share common goals.

Objectives can include the following:

 Development of diaphragmatic breathing skills

 Development of stress management and relaxation techniques

 Involvement in a daily physical exercise regimen to condition both skeletal and respiratory-related muscles

 Adherence to proper hygiene, diet, and nutrition

 Smoking cessation (if applicable)

 Proper use of medications, O2, and breathing equipment (if applicable)

 Application of airway clearance techniques (when indicated)

 Focus on group support

 Provisions for individual and family counseling

 Control of respiratory infections

 Basic airway management

 Improvement in ventilation and cardiac status

 Improvement in ambulation and other types of physical

activity

 Reduction in overall medical costs

 Reduction in hospitalizations

 Psychosocial support

 Occupational retraining and placement (when and where

possible)

 Family education, counseling, and support • Patient education, counseling, and support

 Control of respiratory infections

Patient Evaluation and Selection

Before beginning a pulmonary rehabilitation program, clinicians need to define and establish criteria for entry or selection. They need

to be aware of any comorbidity a patient may have along with the effects exercise may have on blood chemistry and a patient’s

overall physical status. Patient selection requires comprehensive evaluation and testing.

PATIENT EVALUATION

Patient evaluation begins with a complete patient history—medical, psychological, vocational, and social. A well- designed patient

questionnaire and interview form assist with this step. The patient history should be followed by a complete physical

examination.

A recent chest film, resting electrocardiogram (ECG), complete blood count, serum electrolytes, and urinalysis provide additional

information on the patient’s current medical status.

To determine the patient’s cardiopulmonary status and exercise capacity, both pulmonary function testing and a cardiopulmonary

exercise evaluation may be performed. Pulmonary function testing includes assessment of pulmonary ventilation, lung volume

determinations, diffusing capacity (DLCO), and spirometry before and after bronchodilator use.

Cardiopulmonary exercise evaluation (CPX) -

Purposes:

 First, it quantifies the patient’s initial exercise capacity. This quantification provides the basis for the exercise

prescription (including setting a target heart rate) and yields the baseline data for assessing a patient’s progress over time.

 helps determine the degree of hypoxemia or desaturation that can occur with exercise; this provides the objective basis for

titrating O2 therapy during the exercise program.

evaluation of hypoxemia or desaturation or both18 and pulmonary rehabilitation.

*involves serial or continuous measurements of several physiologic parameters during various graded levels of exercise on

either an ergometer or a treadmill: Common Physiologic Parameters Measured During Exercise Evaluation

• Arterial blood gases/O2 saturation

• Maximum ventilation (VE max)

• O2 consumption (either absolute VO2 or METS)

• CO2 production (VE/VCO2)

• Respiratory quotient (RQ)

• O2 pulse ( VO2:heart rate)

To allow for steady-state equilibration, these graded levels are usually spaced at 3-minute intervals. Work levels are increased

progressively until either (1) the patient cannot tolerate a higher level or (2) an abnormal or hazardous response occurs.

Blood gas and arterial saturation measures are obtained at rest and at peak exercise. Samples from single arterial punctures are as

good as samples drawn from indwelling catheters.

*peak exercise puncture is unsuccessful, a sample drawn within 10 to 15 seconds of test termination usually suffices.

Owing to inherent problems, pulse oximetry has a limited but nonetheless important role in exercise evaluation.

*best use of pulse oximetry is as a monitor to warn clinicians of gross desaturation events during testing.

*Pulse oximetry,can be used to assess the patient’s response to supplemental O2 during exercise.

Relative contraindications to exercise testing include the following:

• Severe pulmonary hypertension or cor pulmonale

• Known electrolyte disturbances (hypokalemia, hypomagnesemia)

• Resting diastolic blood pressure greater than 110 mm Hg or

resting systolic blood pressure greater than 200 mm Hg

• Neuromuscular, musculoskeletal, or rheumatoid disorders

exacerbated by exercise

• Uncontrolled metabolic disease (e.g., diabetes)

• SaO2 or SpO2 less than 85% with the subject breathing

room air

• Untreated or unstable asthma

• Angina with exercise

*Exercise evaluation also can help differentiate among patients with primary respiratory or cardiac limitations to increased

work capacity.

To minimize patient risk during exercise evaluation, certain safety measures are implemented. First, the patient should undergo

a physical examination just before the test, including

a resting ECG. Second, a qualified physician should be present throughout the entire test. Third, emergency resuscitation

equipment (cardiac crash cart with monitor, defibrillator, O2, cardiac drugs, suction equipment, and airway equipment) must be

readily available. Fourth, staff conducting and assisting with the procedure should be certified in basic and advanced life-

support techniques. Last, the test should be terminated promptly whenever indicated.
*With regard to test preparation, patients should fast 8 hours before the procedure.

*The patient should wear comfortable, loose-fitting clothing and footwear . The mouthpiece or face mask used during the

test should be sized properly and fit comfortably with no leaks. Test conditions should be as standardized as possible to

allow for comparison of results before and after rehabilitation periodically from year to year as the patient is treated and

Patient Selection

*Patients most likely to benefit from participation in pulmonary rehabilitation are patients with persistent symptoms caused by

COPD who have low maximum O2 uptakes at baseline.

*Regardless of underlying conditions, patients also should be ex-smokers.

*Patients are excluded from pulmonary rehabilitation activities if (1) concurrent problems limit or preclude participation in

exercise or (2) their condition is complicated by malignant neoplasms, such as lung cancer.

Candidates considered for inclusion in a pulmonary rehabilitation program generally fall into one of the following groups:
• Patients in whom there is a respiratory limitation to exercise resulting in termination at a level less than 75% of the predicted

maximum O2 consumption (VO2max)

• Patients in whom there is significant irreversible airway obstruction with a forced expiratory volume in 1 second (FEV1) of less than 2

L or an FEV1% (ratio of FEV1 to forced vital capacity [FVC]) of less than 60% (refer to the Global Initiative on Obstructive Lung

Disease [GOLD] standards for COPD severity)

• Patients in whom there is significant restrictive lung disease with a total lung capacity (TLC) of less than 80% of predicted and single

breath carbon monoxide diffusing capacity (DLCO) of less than 80% of predicted

• Patients with pulmonary vascular disease in whom single breath DLCO is less than 80% of predicted or in whom exercise is limited

to less than 75% of maximum predicted O2 consumption (predicted VO2 max)

Groups or classes for pulmonary rehabilitation should be kept homogeneous.

*Placing individuals in a program who are at different stages of cardiopulmonary disability can be very defeating. Individuals with mild

to moderate impairment may become discouraged on how severe lung disease can become, and individuals with severe impairment

may feel they cannot keep up with or maintain the level of activity exhibited by others with less severe impairment.