Pulmonary Rehabilitation

DR/RABAB HUSSEIN ALI

Pulmonary rehabilitation

‘Is an evidence based, comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities. Integrated into the individualised treatment of the patient

pulmonary rehabilitation is designed to reduce symptoms, optimise functional status, increase participation, and reduce health care costs through stabilising or reversing systemic manifestations of the disease’

ATS/ERS statement on pulmonary rehabilitation (2006) American journal of respiratory and critical care medicine, 173:1390-1413

PULMONARY REABILITATION

Goals

- General : Improve physical and psychological or emotional functioning of patients in interaction with theire environment

- Specific :

- Reduce symptoms

- Improve activity and daily function QOL

- Restore the highest level of independant function (in every day activities)

- Enhance knowledge of the disease

- Improve self-management

PULMONARY REABILITATION Components of the rehabilitation

program

1- Optimal medical treatment

2- Smoking cessation

3- Exercise training

4- Breathing retraining

5- Chest physiotherapy

6- Education

7- Psychological aspects and support

8- Nutritional therapy

9- Nursing care

BronchoPulmonary Hygiene is…A treatment intervention employed for improving pulmonary hygiene including

1. deep breathing and coughing exercises

2. Gravity-assisted Positioning

3. Manual techniques

4. Manual hyperinflation

5. Airway suctioning

6. Mobilization

to assist in mobilizing secretions in the lungs from the peripheral airways into the more central airways so that they can be expectorated or suctioned.

Indications

• Prophylactic - Pre-operative high risk surgical patient

- Post-operative patient who is unable to mobilize secretions

- Neurological patient who is unable to cough effectively

- Patient receiving mechanical ventilation who has a tendency to retain secretions

- Patients with pulmonary disease, who needs to improve bronchial hygiene

…contd

• Therapeutic - Atelectasis due to secretions

- Retained secretions

- Abnormal breathing pattern due to primary or

secondary pulmonary dysfunction

- COPD and resultant decreased exercise

tolerance

- Musculoskeletal deformity that makes breathing

pattern and cough ineffective

Assessment

Neurological system

Cardiovascular system

Respiratory system

Renal system

Hematological system

Gastrointestinal system

Respiratory system

• Auscultation• Percussion• Expansion• Chest X-ray • Mode of ventilation• Oxygen therapy• Airway pressures• Sputum

1. Ventilation – movement of air in & out of the lungs; facilitates respiration

2. Respiration – exchange of oxygen & carbon dioxide

3. Perfusion – relates the ability of the cardiovascular system to pump oxygenated blood to the tissues & return de-oxygenated blood to the lungs.

4. Diffusion – is responsible for the moving the molecules from one area to another

• Diffusion of respiratory gases occurs at the alveolocapillary membrane, & the rate of diffusion can be affected by the thickness of the membrane.

• Increased thickness of the membrane impedes diffusion because gases take longer to transfer across.

The elasticity of the lung tissue allows the lungs to stretch & fill with air during inspiration & return to a resting position after exhalation.

During inspiration => diaphragm contracts => moves downward in the thorax => intercostal muscles move the chest outward => elevating ribs & sternum => expands thoracic cavity

Expansion creates more chest space =>pressure within lungs

Air flows from area of higher pressure to lower pressure thus filling the air in the lungs

Accessory muscles of respiration = pectoralis minor & sternocleidomastoid

During expiration => respiratory muscles relax => thoracic cavity decreases => stretched elastic tissue recoils => intrathoracic pressure increases (d/t compressed pulmonary space & air moves out of the respiratory tract)

Abdominal muscles = rectus abdominis, transverse abdominis, & internal & external obliques

AssessmentGeneral Observation Patient Position

Respiration - Airway ET/Tracheostomy

Ventillator Mode

Vital Signs – Temperature, BP, RR, HR, ICP

Tubes - NG Tube, CV line, Peripheral line, Chest tubes, Catheters

Drugs

… contd

Examination

Auscultations

Respiratory pattern

Cyanosis

Clubbing

Radiograph

Skills: Self Monitoring

Early recognition

Early treatment

Less medication needed

Feel better faster

Skills: Self Monitoring

Difficulty breathing

Chest tightness

Cough interfering with activity or sleep

Inability to speak in sentences

Wheezing

Itchy, watery, glassy eyes

Sore, scratchy, itchy throat

Stroking of neck

Fever

Congestion

Sneezing

Runny nose

• Headache

• Dark circles under eyes

• Change in face color• Change in appetite• Change in activity level• Retractions

– suprasternal– supraclavicular– intercostal– substernal– subcostal

Goals Prevent accumulation of secretions

Improve mobilization and drainage of secretions

Promote relaxation to improve breathing patterns

Goals

Promote improved respiratory function

Improve cardio-pulmonary exercise tolerance

Teach bronchial hygiene programs to patients

with chronic respiratory dysfunction

Precautions

Untreated tension pneumothorax

Abnormal coagulation profile

Status epilepticus or status

asthamaticus

Immediately following intra cranial

surgery

Precautions

• Head injury with raised ICP

• Osteoporotic bones

• Recent acute myocardial infarction, unstable vitals

• Immediately after tube feedings

• Sutures

Physiotherapy Techniques

1. Deep breathing and coughing exercises

2. Gravity-assisted Positioning

3. Manual techniques

4. Manual hyperinflation

5. Airway suctioning

6. Mobilization

Deep Breathing and Coughing Exercises

Facilitates proper respiratory functioning.

Are frequently indicated for clients with restricted chest expansion like, COPD or post- chest surgery

(a) Pursed – lip breathing

(b) Diaphragmatic breathing

Abdominal and pursed-lip breathing

• Commonly employed breathing exercise

• Permits deep full breaths with little effort

• Pursed-lip creates a resistance to the air flowing out of the lungs, thereby prolonging exhalation and preventing airway pressure.

Abdominal and pursed-lip breathing

As if about to whistle and breaths out slowly and gently, tightening the abdominal muscles to exhale more effectively.

Inhales to a count of 3 and exhales to a count of 7

Diaphragmatic Breathing

• Is breathing that promotes the use of the diaphragm rather than the upper chest muscles

• Used to increase the volume of air exchange during inspiration & expiration

• Requires the client to relax intercostals and accessory respiratory muscles while taking deep inspirations

• With practice, it reduces respiratory effort & relieves rapid, ineffective breathing

• Useful for clients with pulmonary disease, post-operative clients & for women in labor to promote relaxation

Procedure:

Lie down with knees slightly bent. Place one hand on the abdomen and the other on the chest. Inhale slowly & deeply through the nose while letting the abdomen rise more than the chest. Purse the lips. Contract the abdominal muscles & begin to exhale. Press inward & upward with the hand on the abdomen while continuing to exhale. Repeat the exercise for 1 full minute; rest for at least 2 minutes. Practice the breathing exercises at least twice a day for a period of 5 to 10 minutes. Progress to doing diaphragmatic breathing while upright & active.

Coughing Exercises

Forceful coughing often is less effective than using controlled or huff coughing techniques.

Cough – is a sudden, audible expulsion of the air from the lungs

- is a protective reflex to clear the trachea, bronchi, & lungs of irritants and secretions

Carina – the point of bifurcation of the right & left main stem bronchus, is the most sensitive area for cough production

Coughing permits the client to remove secretions from both the upper & lower airways

The normal series of events in cough mechanism are deep inhalation, closure of the glottis, active contraction of the expiratory muscles, & glottis opening.

The effectiveness of coughing is evaluated by sputum expectoration, the client’s report of swallowed sputum, or clearing of adventitious sounds by auscultation.

1.Cascade cough – the client takes a slow, deep breath ad holds it for 2 seconds while contracting expiratory muscles.

The client opens the mouth & performs a series of coughs throughout exhalation; thereby coughing at progressively lowered lung volumes.

This promotes airway clearance & a patent airway in clients with large volumes of sputum.

2. Huff cough – stimulates a natural cough reflex & is generally effective only for clearing central airways

3. Quad cough – is used for clients without abdominal muscle control (SC injuries)

While the client breathes out with a maximal expiratory effort, the client or nurse pushes inward & upward on the abdominal muscles toward the diaphragm, causing the cough.

Procedure:

After using bronchodilators treatment (if prescribed), inhale deeply and hold your breath for a few seconds.

Cough twice. The first cough loosens the mucus; the second expels the secretions. For huff coughing, lean forward and exhale sharply with a “huff” sound. This technique helps

you keep your airways open while moving secretions up & out of the lungs. Inhale by taking rapid short breaths in succession (“sniffling”) to prevent mucus from moving

back into smaller airways. Rest. Try to avoid prolonged episodes of coughing because these may cause fatigue & hypoxia.

Gravity-assisted PositioningPhysiological effects of Positioning

1. Optimizes oxygen transport

2. Increases lung volumes

3. Reduces the work of breathing

4. Minimizes the work of heart

5. Enhances mucuciliary clearance (postural drainage)

Postural Drainage isn’t…

a separate technique. Its just an example of

positioning which has the particular aim of

clearing airway secretions with the assistance of

gravity.

Postural Drainage

Patients are positioned with the area to be

drained the upper most, but modifications should

be done wherever necessary.

Drainage times vary, but ideally each position

requires 10 minutes (gumery et al, 2001).

Positioning

• Positioning restores ventilation to dependent lung regions more effectively than PEEP or large tidal volumes (Froese & Bryan, 1974).

• Positioning has a marked influence on gas exchange because of unevenly damaged lungs (Tobin, 1994).

• Side lying reduces lung densities in the upper most lung (Brismar, 1985).

…contd

• Right side lying may be more beneficial for cardiac output than left side lying (Wong, 1998).

• Simply turning from supine to side lying can clear atelectasis from dependent regions (Brismar, 1985).

• Positioning affects lung volume• Lung volume is related to the

position of the diaphragm

…contd

• Positioning affects compliance (Wahba et al found that work of breathing is 40% higher in supine than in sitting)

• Positioning affects arterial oxygenation by improving V/Q mismatch (V/Q is usually mismatched if the affected lung is dependent- Gillespie et al)

“Bad lung up” position

Positioning…

Which position to choose…

?

Chest Maneuver

Chest Vibrations

Chest Percussion/Clapping

Clapping/Chest Percussion

Percussion consists of rhythmic clapping on the chest with loose wrist & cupped hand.

Effect : Dislodges & loosens secretions from the lung

Hand PositionHand Position

Chest Vibration

• Vibrations consists of a fine

oscillation of the hands directed

inwards against the chest, performed

on exhalation after deep inhalation.

• Effects: Helpful in moving loosened

mucous plugs towards larger airway

Manual Hyperinflation

Was originally defined as inflating the lungs with oxygen and manual

compression to a tidal volume of 1 liter requiring a peak inspiratory

pressure of between 20 and 40 cm H2O (Med j Aust, 1972).

More recent definitions include providing a larger tidal volume than

base line tidal volume to the patient (Aust j physiotherapy, 1996)

and using a tidal volume which is 50% greater than that delivered

by the ventilator (chest, 1994).

Indications

To aid removal of secretions

To aid reinflation of atelectatic segments

To assess lung compliance

To improve lung compliance

Techniques

Slow deep inspiration

Inspiratory hold (at full inspiration)

Fast expiratory release

Hand-held PEEP

Hazards of MHI

Reduction in blood pressure

Reduced saturation

Raised intracranial pressure

Reduced respiratory drive

Contraindications

• Undrained Pnuemothorax

• Potential bronchospasm

• Severe bronchospasm

• Gross cardiovascular instability inducing arrhythmias and hypovolaemia

• Unexplained Haemoptysis

• Patient on High PEEP

Advantages of MH

Reverses atelectasis (Lumb 2000)

Improves oxygen saturation and

lung compliance (Patman et

al.,1999)

Improves sputum clearance

(Hodgson et al., 2000)

Disadvantages of MH

Haemodynamic and metabolic

upset (Stone, 1991 & Singer et

al.,1994)

Risk of barotrauma

Discomfort and anxiety

Suctioning

• Suctioning is the mechanical aspiration of pulmonary secretions from a patient with an artificial airway in place.

• Indications• Inability to cough effectively• Sputum plugging• To assess tube patency

Contraindications

Frank haemoptysis

Severe brochospasm

Undrained pneumothorax

Compromised cardiovascular system

Guidelines:

The suction catheter used must be less than half the diameter of endotracheal tube.

The vacuum pressure should be as low as possible. (60-150mmHg)

Suction should never be routine, only when there is an indication

Hazards of suctioning

Mucosal trauma

Cardiac arrhythmias

Hypoxia

Raised intracranial pressure

What to suction?

Nasal and oral suction

Endotracheal suction

Tracheostomy suction

Closed-circuit suction

Mobilization

Critically Ill

(Frequent Position changes, Kinetic & Kinematic Therapy)

Stable

(Progressive tilting & Ambulation)

Mobilization

ICU rehabilitation has been shown to accelerate recovery (o’leary & coackley, 1996)

Early mobilization for unconscious patients starts right from turning the patient every two hours. ( Brooks- brunn, 1995).

Graded exercises can be started as soon as the patient regains consciousness.

Mobilization

• Activity is required to maintain sensory input, comfort, joint mobility and healing ability (Frank et al, 1994).

• Activity minimizes the weakness caused by loss of up to half the patients muscle mass (Griffiths & Jones, 1999).

• Graded ambulation can be started depending on patients condition

Thank you