crc 432 subacute care pulmonary rehabilitation. pulmonary rehabilitation goals –maximize...
TRANSCRIPT
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CRC 432 Subacute CarePulmonary Rehabilitation
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Pulmonary Rehabilitation
Goals– Maximize patient’s functional ability– Minimize impact in
• Patient
• Family
• Community
– Improve quality of life– Control & alleviate symptoms
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Pulmonary Rehabilitation
Historical Perspective– 1951: Dr Barach recommended physical
reconditioning for COPD patients• Walk without becoming dyspneic
– Barach was ignored; O2 therapy & bed rest prescribed
• Skeletal muscle deterioration• Fatigue & weakness• Increased dyspnea• Homebound, room bound, bed bound
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Pulmonary Rehabilitation
Historical Perspective– 1962: Pierce confirmed Barach– Pierce found that exercising COPD patients
• Decreased pulse
• Decreased respiratory rates
• Decreased minute ventilation
• Decreased CO2 production
• Improved pulmonary function
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Pulmonary Rehabilitation
Historical Perspective– Paez demonstrated
• Efficiency of motion• Decreased O2 consumption
– Smoking cessation included– Education added
• Pathophysiology• Equipment• Medications
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Pulmonary Rehabilitation
Scientific Basis– Focus on patient– Include clinical sciences
• Quantify degree of physiologic impairment• Establish outcomes for reconditioning
– Include social sciences• Psychological • Social• Vocational
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Pulmonary Rehabilitation
Physical Reconditioning– Exercise increases energy demands
• Increased circulation• Increased ventilation• Increased O2 deliver• Increase CO2 elimination
– If O2 demands NOT met• Blood lactate level increase• CO2 increases as lactic acid buffered• Increased stimulus to breathe
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Pulmonary Rehabilitation
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Pulmonary Rehabilitation
This point is called the “onset of blood lactate accumulation,” or OBLA
Abrupt rise in PaCO2 & minute ventilation: called “ventilatory threshold”
Beyond VT, metabolism = anaerobic respiration (decreased NRG production efficiency, lactic acid rise, fatigue)
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Pulmonary Rehabilitation
Physical Reconditioning– MVV index of respiratory system’s ability to
handle increased physical activity– MVV = FEV1 x 35– Normal: 60%-70% of pred MVV during max
exercise– Indicates adequate respiratory reserve– Indicates ventilation NOT primary limiting
factor for ending exercise
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Pulmonary Rehabilitation
Physical Reconditioning– MVV decreased with COPD– COPDs have limited exercise ability
• Increased CO2 production
• Respiratory acidosis
• SOB
• O2 consumption increases faster than normal
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Pulmonary Rehabilitation
Physical Reconditioning– Rehab programs must:
• Physically recondition
• Increase exercise tolerance
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Pulmonary Rehabilitation
Psychosocial Support– Indicators bettor predictors of frequency &
LOS for COPD patients compared to PFTs– Psychosocial indicators better determine rehab
program completion than physical reconditioning
– COPD negatively affects person’s outlook on life
– Can reduce motivation
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Pulmonary Rehabilitation
Psychosocial Support– Depression/hostility occur with acute & chronic
disease– Economic loss & fear of death produce hostility – Interaction among patients is beneficial– Patient’s lacking social support at higher risk
for re-hospitalization– Intolerance for physical exertion lessens social
activity
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Pulmonary Rehabilitation
Psychosocial Support– Physical reconditioning & psychosocial support
linked– Reducing exercise intolerance & improving
cardiovascular response to exercise = independent, active lifestyle
– Improve social importance & self-worth– Occupational training & job placement
important
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Pulmonary Rehabilitation
Program Goals– Control respiratory infection– Basic airway management– Improve ventilation & cardiac status– Improve ambulation & other physical activities– Reduce medical costs– Reduce hospitalizations
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Pulmonary Rehabilitation
Program Goals– Reduce LOS when hospitalized– Reduce # of MD office visits– Provide psychosocial support– Occupational training/job placement– Family education, counseling, support– Patient education, counseling, support
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Pulmonary Rehabilitation
PROGRAM OBJECTIVES– 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– Proper use of medications, oxygen, and breathing equipment (if
applicable)– Application of airway clearance techniques (when indicated)– Focus on group support– Provisions for individual and family counseling
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Pulmonary Rehabilitation
Chronic lung disease progressive & irreversible
Rehabilitation does NOT alter progressive deterioration
Rehabilitation improves utilization of O2 by:– Increasing muscle use effectiveness– Promoting effective breathing techniques
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Pulmonary Rehabilitation
O2 cost for given amount of ventilation is excessive
Training skeletal muscle groups alone NOT beneficial
Training respiratory related muscles improves exercise tolerance
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Pulmonary Rehabilitation
Evaluation of Rehabilitation Program Outcomes– Changes in exercise tolerance– Before and after 6 minute walking distance– Review of patient home exercise logs– Strength measurement– Flexibility and posture– Performance on specific exercises (e.g., ventilatory muscle,
upper extremity)– Changes in symptoms– Dyspnea measurement comparison– Frequency of cough, sputum production, or wheezing– Weight loss or gain– Psychological test instruments
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Pulmonary Rehabilitation
Evaluation of Rehabilitation Program Outcomes– Other changes– Activities of daily living (ADL) changes– Postprogram follow-up questionnaires– Preprogram and postprogram knowledge tests– Compliance improvement with pulmonary rehabilitation
medical regimen– Frequency and duration of respiratory exacerbations– Frequency and duration of hospitalizations– Frequency of emergency department visits– Return to productive employment
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Pulmonary Rehabilitation
Potential Hazards– Cardiovascular abnormalities
• Cardiac arrhythmias (can be reduced with supplemental oxygen during exercise)
• Systemic hypotension
– Blood gas abnormalities• Arterial desaturation• Hypercapnia• Acidosis
– Muscular abnormalities• Functional or structural injuries• Diaphragmatic fatigue and failure• Exercise-induced muscle contracture
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Pulmonary Rehabilitation
Potential Hazards– Miscellaneous
• Exercise-induced asthma (more common in young patient with asthma than in patients with COPD)
• Hypoglycemia
• Dehydration
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Pulmonary Rehabilitation
Patient Selection– Evaluation– Testing
Patient Evaluation– History (medical, psychological, vocational,
social)– Questionnaire/interview form– Physical exam– CXR
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Pulmonary Rehabilitation Patient Evaluation
– CBC
– Electrolytes
– Urinalysis
– PFTs (spirometry, volumes, DLCO, pre/post)
– Cardiopulmonary exercise evaluation
• Quantifies initial exercise capacity
• Provides basis for exercise prescription
• Renders baseline data for assessing progress
• Shows degree of hypoxemia/desat during exercise
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Pulmonary Rehabilitation
Common Physiological Parameters Measured During Exercise Evaluation– Blood pressure– Heart rate– ECG– Respiratory rate– Arterial blood gases (ABGs)/O2 saturation– Maximum ventilation (VEmax)– O2 consumption (either absolute VO2 or METS, the metabolic
equivalent of energey expenditure)– CO2 production (VCO2)– Respiratory quotient (RQ)– O2 pulse
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Pulmonary Rehabilitation
Exercise Evaluation– Graded levels (ergometer or treadmill)– 3-min intervals allow steady state– ABGs at rest & at peak exercise
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Pulmonary Rehabilitation
Relative Contraindications to Exercise Testing– Patients who cannot or will not perform the test– Severe pulmonary hypertension/cor pulmonale– Known electrolyte disturbances (hypokalemia, hypomagnesemia)– Resting diastolic blood pressure > 110 mm Hg or resting systolic blood
pressure > 200 mm Hg– Neuromuscular, musculoskeletal, or rheumatoid disorders exacerbated
by exercise– Uncontrolled metabolic disease (e.g., diabetes)– SaO2 or SpO2 < 85% with the subject breathing room air– Untreated or unstable asthma
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Pulmonary Rehabilitation
Indications for Pulmonary Rehabilitation– Symptomatic patients with COPD
– Patients with bronchial asthma and associated bronchitis (asthmatic bronchitis)
– Patients with combined obstructive and restrictive ventilatory defects
– Patients with chronic mucocilliary clearance problems
– Patients having exercise limitations due to severe dyspnea
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Pulmonary Rehabilitation
Patient Selection– Ex-smokers– Smoking cessation program for smokers
Patients Excluded– Concurrent problems limit or preclude
exercising– Condition complicated by malignant
neoplasms, e.g., bronchogenic carcinoma
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Pulmonary Rehabilitation
Program Design– Open-ended format
• Participate until predetermined objectives achieved
• No set timeframe
• Completed at patient’s pace
• Good format for self-directed patients
• Good format for schedule difficulties
• Good format for individual attention
• Lack group support/involvement
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Pulmonary Rehabilitation Program Design
– Closed design• Set timeframe (8 to 16 weeks; 1 to 3 sessions/wk)• Insurance coverage may dictate length for which
person qualifies• Sessions last 1 to 3 hours• Presentations formal• Offer group support/involvement• Schedule determines program completion
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Pulmonary Rehabilitation
ContentComponent Focus Time Frame
Education Welcome (group interaction) 5 mins
Review of program diaries
(past week’s activities) 20 mins
Presentation of education topic 20 mins
Questions, answers, and group
discussion 15 mins
Physical Physical activity and reconditioning 45 mins
Reconditioning Individual goal-setting and session
summary 15 mins
Total: 120 minutes (2 hours)
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Pulmonary Rehabilitation
Physical Reconditioning– Excise prescription with target HR based on
initial exercise evaluation– Target HR set using Karvonen’s formula– THR = [(MHR-RHR) x (50% to 70%)] + RHR
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Pulmonary Rehabilitation
Physical Reconditioning
MHR = 150 bpm
RHR = 90 bpm
THR = [(150 – 90) x (0.6)]+ 90 = 126 bpm
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Pulmonary Rehabilitation
Exercise Prescription– Lower extremity aerobic exercises– Timed walking– Upper extremity aerobic exercises– Respiratory muscle training
Monitoring during Exercise– Pulse oximetry– Blood pressure
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Pulmonary Rehabilitation
Lower Extremity– Walking (treadmill/flat surface)
• Goals for distance, time, grade on treadmill
• 6 minute flat surface/increase distance
– Bicycling (stationary) Upper Extremity
– Arm ergometers– Rowing machines
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Pulmonary Rehabilitation
Inspiratory resistance breathing device– Adjustable flow resistor– One-way valve– Inhale through restricted orifice (variable size)– Change inspiratory load– Exhalation through one-way valve
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Pulmonary Rehabilitation Instruction
– Sit upright– Breathe slowly through device (10 – 12 bpm)– MIP < 30% of measured Pimax, use next smaller
orifice– Repeat effort until 30% is consistently achieved– 1 or 2 daily sessions for 10 – 15 minutes/session– When 30% is consistently achieved, increase
resistance– Increase session time to 30 minutes
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Pulmonary Rehabilitation Introduction and welcome, program orientation Respiratory structure, function, and pathology Breathing control methods Relaxation and stress management Proper exercise techniques and personal routines Methods to ad secretion clearance (bronchial hygiene) Home oxygen and aerosol therapy Medications: their use and abuse Medications: use of MDIs and spacers Dietary guidelines and good nutrition Recreation and vocational counseling Activities of daily living Follow-up planning and program evaluation Graduation
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Pulmonary Rehabilitation Program Results
– Evaluate• Patient
• Program outcomes
– Preprogram/current program status– Data
• Physiological
• Psychological
• Sociological