physiotherapy practice guidelines for copd

8/14/2019 Physiotherapy Practice Guidelines for COPD

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Physiotherapy Practice

Guidelinesfor COPD

PTCOC

March 2000


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ii

Working Group Members

Derek Chan, GHGalen Chan, HHH

Charles Cheung, TMH

Byran Chung, TPH

David Yu, KH

Annie Wu, ANNH

Alice Chiu, QMH


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I. Goals of Physiotherapy Practice Guidelines for COPDThe goal of developing the physiotherapy practice guidelines for COPD is to provide evidence-based supports to the physiotherapy practice in COPD management within the Hospital

Authority. It is an exercise of literature search and evaluation on related physiotherapy practices.

Due to various constraints, the guidelines do not cover all, but some common physiotherapyassessments and treatment interventions used and studied in the field.

Currently, there are several evidence-based clinical practice guidelines available providing

generic disease management of COPD conditions (ATS, 1995; BTS, 1997; ERS, 1996).

Although these documents are not physiotherapy specific, they form the backbone of the overallmanagement model in this guideline. There are several reviews on pulmonary rehabilitation

(Lacasse et al, 1996; ACCP/AACVPR, 1997; Cambach W et al, 1999; ATS, 1999) whichconstitute the base of this guideline on that particular subject. There are relatively few review on

physiotherapy practice, but some recent metaanalysis focused on physiotherapy interventions on

COPD (Jones & Rowe, 1999; Crockett AJ et al, 1999) are also included in this guidelines.Besides, other non-COPD specific evidence-based physiotherapy techniques guidelines, and

COPD related primary studies are also cited and used in this guidelines, so as to compliment thediscussion details of a particular practice.

II. Epidemiology and Defintions of COPDA.Epidemiology of COPDThere were total 10651 COPD patients admitted to the public hospitals throughout the territoryin the year 1997,(HAHO, 1997) and they occupied over 20000 bed days. In average, eachdiagnosed patient admitted 2.31 times and their unplanned readmission rate was as high as40.76%, which was the highest among all other disease groups. Unlike other chronic diseases

utilized mostly the rehabilitation hospitals, over 50 % of the total COPD admissions were to

acute hospitals. The data shown the huge demands of COPD patients on hospital services.

B. COPD DefinitionsCOPD is often used as a general term describing chronic lung disease, and its differentiationfrom other common chest conditions e.g. chronic bronchitis, emphysema and adult asthma is

often confusing. Clarification of the terms is important, and the definitions used in the guidelineare listed:

Chronic obstructive pulmonary disease (COPD) is a chronic, slowly progressive disordercharacterized by airflow obstruction (reduced FEV1 and FEV1/VC ratio) that does not change

markedly over several months (BTS, 1997). The impairment of lung function is largely fixed but

is partially reversible. The causes of airflow obstruction may due to chronic bronchitis oremphysema, or both.


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Chronic bronchitis is defined as the presence of chronic productive cough for 3 months in each

of two successive years in a patient in whom other causes of chronic cough have been excluded(ATS 1995).

Emphysema is defined as abnormal permanent enlargement of the air spaces distal to the

terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis.

(ATS 1995)

Adult asthma is characterized by inflammation with participation of complex cellular andchemical mediators (ATS 1995), and the condition is reversible. Absolute clinical differentiation

of severe COPD from chronic severe asthma is difficult since some degree of improvement in

FEV1(reversibility)in COPD can often be produced by bronchodilator therapy(BTS, 1997).

B. COPD Staging of Disease

Severity of Symptoms

COPD conditions are clinically classified into 3 stages: mild, moderate and severe, according tothe patients' severity of symptoms (ERS 1995, BTS 1997). The stages are described as following

(BTS, 1997):

Mild stage : In patients with mild COPD there are few or no symptoms. A history of morning

cough, recurrent respiratory infections, or shortness of breath on vigorous exertion or manuallabour may happen.

Moderate stage: Moderate COPD can present with a wide range of respiratory symptomsalthough there are few clinical signs. There is no single typical pattern but possibilities include

combinations of some or all of the following:

- cough and sputum production, especially if the sputum becomes discoloured;- breathlessness(wheeze) on moderate exertion such as physical work climbing hills;- acute worsening of symptoms associated with an infective exacerbation

Severe stage: Patients with severe COPD are usually troubled by progressively disabling

breathlessness or with complications (such as the development of oedema) or with an acuteexacerbation with or without respiratory failure. Cough and wheeze are almost invariably present

but are poor predictors of severity.

Spirometry findings

Objective measurements of airways obstruction by FEV1 over predicted value is widely used as

the physiological and practical indices for COPD severity classification. (ATS 1995, ERS 1995,BTS 1997) Table 1 illustrates COPD classifications according to FEV1 predicted values used by

major medical societies. The classifications are similar, but with different reference points for

management and treatment.


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Table 1: Classification of severity of COPD based on FEV1 % of predicted value

British Thoracic Society European Respiratory Society American Thoracic society

Severity

Mild

Moderate

Severe

FEV1 % pred

60-79

40-59


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III. Management of COPD

A. COPD Management Model

Early multidisplinary intervention is recommended for treating COPD patients (ATS 1995, BTS

1997). Once the diagnosis of COPD is established, the patient should be educated about thedisease and encouraged to actively participate in therapy (ATS 1995).

For stable COPD, the management varies according to the stages of the diseases. The COPD

Escalator summaries the therapies recommended, and its appropriate time of introduction

according to the stage of disease (BTS 1997) (Fig 1). Pulmonary rehabilitation is a generallyrecommended as a major component in COPD management (ATS 1995, BTS 1997, ERS 1995)

The COPD Escalator

Fig 1 The COPD Escalator: Summary of the principal components of a management plan for

COPD (modified from BTS Guideline for COPD)

Assessmentfor

LTOT

A

mbulatoryoxygen

Influenzavaccination

P

ulmonaryrehabilitation

Morefrequent/combination

bronchodilators

Steroidreveersibilitytrial:

inhaledsteroidsif+ve

Occasionalbronchodilatorasrequired

Antibioticsforacuteinfections

Smokingcessa

tion

Healthy population

Smoker's cough

Little or no dyspnoea

No abnormal signs

Dyspnoea on exertion

Cough and sputum

Some abnormal signs

Dyspnoea on mild

exertion

Hyperinflation and

cyanosis

Death

Increasing investigation and treatment

FEV1as%predicted

20

80

100

0

Symptoms


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Acute exacerbation of COPD present as a worsening of previous stable situation. Mild cases canbe treated in the community or at Emergency Unit, and many others will be admitted as

inpatients (BTS 1997). As in-patient, drugs as bronchodilators, antibiotics and corticosteroids arecrucial in controlling the acute symptoms. Stepwise drug therapy with rapid response is

recommended for uses (ATS 1995). Oxygen therapy is introduced and adjusted to correct

hypoxemia, and aims SaO2>90% (BTS 1997). Physiotherapy is commonly referred to treat

patients' chest related impairments. Prior discharge, a comprehensive discharge plan forindividual patient is recommended, so as to facilitate the long term caring of the disease(ATS1995, BTS 1997).

B. Objectives of Physiotherapy

1. Physiotherapy in unstable exacerbations- to control symptoms- to treat related chest problems e.g. sputum retention- to minimize disability- to recruit and plan for pulmonary rehabilitation

2. Physiotherapy in stable COPD- to improve physical fitness and cardiopulmonary function- to improve functional status and minimize disability- to enhance life quality and social roles- to educate and coach for activity modifications

C. Physiotherapy Assessment

Physiotherapy assessments of COPD patients include measures of impairments, disabilities and

handicaps. There is a wide spectrum of assessment tools available to evaluate the patients'conditions. Choosing appropriate tools is important and the choice depends on the treatment

objectives and patients' disease status.

1. Chest AssessmentChest assessment is widely used among physiotherapists as a means to evaluate the extent and

severity of respiratory impairments of COPD patients. It is extensively maneuvered for COPD

patients at all stages of the disease, whether stable or exacerbated. Chest assessment containspackage of assessment items (PTCOC, 1994), which are not tailored for COPD, but general lists

for chest conditions evaluations.

During exacerbation, chest assessment is important for physiotherapist to plan appropriate

interventions. Interventions like postural drainage therapy is not a routine treatment, but for

indicated cases(AARC, 1992). For stable patients or patients under rehabilitation programs, chestassessment is still useful for cases having chest problems, likes(Singh SJ 1997) :


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- recurrent chest infections- difficulties with chest clearance- inappropriate shortness of breath after exercise- abnormal breathing patterns- inappropriate inhaler technique

2. Assessment for pulmonary rehabilitationSince pulmonary rehabilitation is a team program, the assessment for COPD patients should be acollaborated process. Physiotherapist involves in the assessment process, but the practice and

extent of involvement varies among different program designs. American Thoracic Society

stated a comprehensive assessment of the rehabilitation candidate is necessary for the

development of an appropriate, individualized plan of care, and generally, the assessment shouldinclude (ATS 1999):

1. Clinical history2. Physical examination3. Review of pertinent records e.g. spirometry4. Educational assessment5. Incremental exercise testing6. Measurements of respiratory muscle strength7. Measurements of peripheral muscle strength8. Assessments of activities of daily living9. Assessments of health status10.Assessments of cognitive function, emotional and mood state11.Assessments of nutritional status/body composition

3. HRQOL assessmentDisease specific and generic instruments are available to measure health-related QOL of

candidates of pulmonary rehabilitation program. The Outcomes Committee of the American

Association of Cardiovascular and Pulmonary Rehabilitation recommended the uses of Chronic

Respiratory Questionnaries(CRQ) and St. George's Respiratory Questionnaries (SGRQ)(Pashlowet al, 1995). Although generic HRQOL instruments e.g. Short-form-36 Health Survey (SF-36)

may provide complementary information, they appear to be less responsive to therapeutic

interventions(Donald, 1998).

The CRQ developed by Guyatt and colleagues is a 20-items questionnaries evaluating fourdimensions of illness: dyspnea, fatigue, emotional function and mastery. Reliability and validity

estimates for the CRQ had been reported (Guyatt, 1987).

The SGRQ is a self-administrated 76-items questionnaries measuring three domains: symptoms,

activity and impact of disease on daily life. The "symptoms" category elicits information aboutcough, sputum, wheeze and dyspnea. The "activities" reflects the activity limitation imposed by

the disease and the "impacts" reflect overall impact on daily life and well-being. The SGRQ has

been translated into several languages and reliability and validity estimates have beenreported(Jones, 1992).


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4. Dyspnea RatingAccording to ATS official statement, dyspnea is a term used to characterize a subjective

experience of breathing discomfort that consists of quantitatively distinct sensations that vary inintensity (ATS, 1999). Often dyspnea is out of portion to the degree of impairment of lung

function and arterial blood gas analysis (Sweer & Zwillich, 1998), and is derived from

interactions among multiple physiological, psychological, social, and environmental factors, and

may induce secondary physiological and behavioral responses (ATS, 1999). Pathophysiologicfactors of dyspnoea is appended for reference (Appendix III). In assessing patient's severity orevaluating treatment outcomes, both exertional and overall dyspnea should be measured.

Exertional dyspnea is usually rated during exercise testing, while overall dyspnea is commonly

assessed through its impact on daily activities.

Dyspnea during exercise is usually measured with a category scale as Borg scale of perceived

exertion or a visual analog scale(VAS).A modified version Borg 10-point scale with verbalexpression of severity (Borg, 1976) was widely used in pulmonary rehabilitation programs. A

Chinese version is attached for reference (Appendix IV). The Visual Analogue Scale (VAS)

consists of a line, usually 100 mm in length, placed either horizontally or vertically on a page(Grit, 1989), with anchor to indicate extremes of a sensation. Scoring is accomplished by

measuring the distance from the bottom of the scale to the level indicated by the subject.

The day-to-day overall dyspnea can be measured by different instruments as the Medical

Research Coucil(MRC) dyspnea questionaire, the University of California San Diego Sortness ofBreath Questionnaire(UCSD-SOBQ), the dyspnea component of the Chronic Respiratory

Disease Questionnaire, the Baseline and Transitional Dyspnea Indexes(BDI and TDI), and the

Pulmonary Functional Status and Dyspnea Questionaire(PFSDQ) and its modifiedversion(PFSDQ-M) (ATS, 1999).

One of the most commonly used dyspnea instument is BDI. It is used to measure breathlessness

at a single point in time and is administered during a brief interview. BDI includes measurement

of functional impairment (the degree to which activities of daily living are impaired) and

magnitude of effort (the overall effort exerted to perform activities), in addition to magnitude of

task (Mahler et al, 1984).

Most recently, the University of California at San Diego Shortness of Breath Questionnaire

(USCDQ) was developed. The UCSDQ is a 24-item questionnaire measuring dyspnea during the

past week (Belman et al, 1996). In the modified version, patients are asked about the frequencyof dyspnea when performing 21 different activities inquire about activity limitations due toshortness of breath, fear of harm from overexertion, and fear of shortness of breath (Eakin et al,

1995).

5. Walking TestsTimed walking tests namely 6 Minutes Walk Test, 12 Minutes Walk Test and Shuttle Walk Test

are used to assess patient's functional ability of walking. These tests are simple and convenient toperform. The tests correlate with peak exercise performance on graded exercise tests and self


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reported data on functional test (ATS 1999). Standardization of test procedures is crucial to have

reliable findings (ATS 1999).

The progressive 10-m Shuttle Walk Test differ from ordinary timed walk tests in two aspects. Itis an incremental exercise test in nature, which rather measure exercise capacity than endurance.

Since the external sets the pace, self-pacing is eliminated. The Shuttle Walk Test is reproducible,

correlate with maximum oxygen consumption during incremental treadmill exercise and highly

responsive to therapeutic intervention (ATS 1999).

D. Physiotherapy Interventions

1. Bronchopulmonary Hygiene2. Breathing retraining3. Pulmonary Rehabilitation

3.1Exercise Reconditioning3.2Education

4. Alternative treatment modalities

1. Bronchopulmonary HygieneA metaanalysis on the effectiveness of bronchopulmonary hygiene physiotherapy techniqueswas conducted by Jones AP and Rowe BH in 1998(Jones & Rowe, 1998). The patient samples

include not just COPD, but also bronchiectasis patients.7 RCTs are included in the review, and

the results are summaried as following:

1. Demonstrable beneficial effects of bronchopulmonary hygiene physiotherapy techniquesBHPT have been confined to sputum production and radio-aerosol clearance only.

2. The impact of BHPT on lung function is not clearly established from studies includes in thereview. No study found a significant beneficial effect on pulmonary function or PaO2.

3. It is not possible from the trails reviewed to identify specific patients subgroups that mightbenefit from BHPT.

4. Insufficient reporting in publications precludes any comments on the adverse effects or harmassociated with BHPT.

5. In view of the lack of functional improvement and sample sizes of the trials, the research onBHPT is inconclusive. There is insufficient evidence to support or refute administration ofBHPT to patients with acute and stable COPD, chronic bronchitis or bronchiectasis.

Due to the limited quantity and quality of the reviewed RCTs, the review left many unansweredquestions. The review stated the research implications as:

1. there is a need to conduct RCTs of sufficient power that examine the effects of the variousforms of BHPT, both manual and mechanical

2. These trails should be conducted in clearly defined patient groups, with adequate controls,randomization and blinding. In addition, such studies need to measure not only primary

function. They also should measure symptoms, exercise performance, health status(quality oflife), recovery time and relapse rate.


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3. There also is a need to examine various BHPT regimens, rather than a single treatment.The review searched the related RCTs till July 1997, and the types of the BHPT included in the

review: postural drainage, manual techniques, directed coughing and forced exhalationtechniques(FET).

1.1 Coughing/Forced expiratory technique

There are evidence that both cough and FET can clear radioaerosol particles induced to lungsfield (Bennett WD et al, 1981; Hasani A et al, 1991; Van der Schans 1990). Since the presence

of severe obstructive airways and bronchospasm may hamper the effectiveness of directedcough(AARC, 1993), advantages of FET over cough had been suggested as less energy demand

(Langlands J, 1967), and better mucus transport effect(van der Schans et al, 1990 ). Directed

cough or FET can be readily used as an integral part other physiotherapy techniques as posturaldrainage (Olseni L et al, 1994).

Indications of the coughing and FET was suggested (AARC, 1993):- the need to aid in the removal of retained secretions from central airways- the presence of atelectasis- as prophylaxis against postoperative pulmonary complications- as a routine part of bronchial hygiene in patients with cystic fibrosis,

bronchiectasis, chronic bronchitis, necrotizing pulmonary infection, or spinal

cord injury- as an integral part of other bronchial hygiene therapies

1.2 Postural Drainage Therapy

In AARC Clinical Practice Guideline on Postural Drainage Therapy (PDT), PDT is defined to

include turning, postural drainage, percussion, vibration, and cough (AARC 1991). In actualclinical practice, physiotherapist should select appropriate techniques for treating indicated

COPD patients. Although COPD is not the primary diagnosis that indicated for PDT, unlikecystic fibrosis, bronchiectasis and cavitating lung disease(AARC, 1991), PDT still pertains its

roles in various chest problems and complications e.g. sputum retention.

Earlier studies support PDT can effectively clear secretion, without altering the pulmonary

parameters (Sutton et al, 1983; Newton & Stephenson, 1978; Bateman, 1979). Sutton et al (1983)reported that a 30 minutes period of PD alone doubled the sputum production and improved

tracheobronchial clearance above control. Newton and Stephenson(1978) found that the PDT

including PD, percussion, vibration and breathing exercise significantly improve both functionalresidual capacity and the airway conductance of acute patients with chronic bronchitis.

Improvement in airway conductance attributed to an altered distribution of sputum in the larger

airways. Bateman et al ((1979) showed that the PDT significantly increased clearance of sputumfrom central, intermediate and peripheral lungs regions. There is no evidence PDT causing harm

to COPD patients. Buscaglia et al (1983) studied the oxygen saturation during PDT on acute

patients with COPD, and showed that PDT did not appear to produce dangerous hypoxaemia


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even on acutely ill patients with severe COPD. Other studies on PDT is complied in Appendix

VI for reference.

2. Breathing Retraining

Breathing Retraining for COPD patients may be started early during the inpatient admissionperiod at excerabation, and continued throughout their rehabilitative and maintenance phases.

There are many techniques used by physiotherapists for such purposes, some common names

include breathing control, pursed-lip breathing, diaphragmatic breathing. The adjunct positioningand relaxation skills are also important to achieve good training results.

2.1 Breathing Control/Active Control Breathing Technique

Breathing control at rest is defined as gentle breathing using the lower chest with relaxation ofthe upper chest and shoulders; it is performed at normal tidal volume, at a natural rate, and

expiration should not be forced (Webber & Pryor, 1993). Slow and controlled breathingproduced an increase in tidal volume and a reduction in the arterial partial pressure of carbon

dioxide (PaCO2)(Mortley, 1963). It is common that breathing control is taught and practiced

during activities in pulmonary rehabilitation. Few researches had, however, been done on this

technique and its usefulness during activities. Another commonly used breathing retrainingtechnique for COPD is Active Control Breathing Technique ACBT (Miller et al, 1995; White et

al, 1996). Its effectiveness reflected in some trials in treating cystic fibrosis, but with limited

evidence in managing COPD conditions.

2.2 Diaphragmatic Breathing

Diaphragmatic breathing is to consciously expand the abdominal wall during inspiratory

diaphragm descent. In theory, this would increase the efficiency of the diaphragm while reducing

the ineffective movement of upper chest wall and accessory muscle works. Despite the theory,studies had demonstrated that taught diaphragmatic breathing increased the sensation ofdyspnoea and asynchrony of the chest wall, and reduced mechanical efficiency with COPD

(Vitacca et al, 1998; Gosselink et al, 1995). In view of the results, the routine use of

diaphragmatic breathing training in pulmonary rehabilitation is not recommended(ATS, 1999).

2.3 Pursed-lips breathing

Pursed-lips breathing is a technique commonly adopted by some COPD patients, typically those

with some degree of emphysema. The lips are pursed during expiration, creating some end-

expiratory pressure and thus maintaining small-airway patency. This technique has beendocumented to reduce respiratory rate, and to increase tidal volume and oxygen saturation

(Webber & Pryor, 1993; Mueller et al, 1970; Tiep et al, 1986). Despite these physiologicoutcomes, the effectiveness of purse-lip breathing in reducing dyspnea in COPD is controversial,

with some studies actually demonstrating an increase in breathlessness at rest and during

exercise (ATS, 1999).


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2.4 Positioning

Physiotherapists used to teach or help patients to adopt a relaxed position to relief dyspnea

during acute exacerbation of COPD. There are, however, limited studies on the efficacy of thepractise, and research study is rarely found in 1990s.

Positioning affect the efficiency of breathing mechanism. Most COPD patients prefers leaning

forward position. Such position had the greatest Pimax and least work of breathing in comparingto other positions(O Neil & McCarthy, 1983), and effectively reduced the sensation ofbreathlessness (Sharp et al, 1980). For COPD patients, sitting is usually more comfortable than

supine position, and the Pimax and Pemax is higher in sitting position (Heijdra e al, 1994).

Activities cause greater respiratory demand to COPD than healthy subjects( Baarends et al,

1995), hence mastering of comfortable and less demanding positions may be an importantteaching component in COPD management.

3. Pulmonary Rehabilitation

Pulmonary rehabilitation programs are used to be delivered in either in-patient or out-patient

models. Both delivery models of pulmonary rehabilitation showed promising result of patient's

outcomes. Recently, there were researches to study the feasibility and effectiveness of home-based rehabilitation for COPD patients (Strijbos JH et al, 1996; Wiljkstra PJ et al, 1994, Bauldoff

Gs et al, 1996). At present, there is no consensus on optimal practices of pulmonary

rehabilitation (ATS, 1999). Questions on what are the essential components and cost-effectiveness of pulmonary rehabilitation had been raised and remained unanswered

(ACCP/AACVPR, 1997).

Pulmonary rehabilitation is a multidisplinary program, and physiotherapists share roles as one of

the team member. Physiotherapists involve in education and some psychosocial interventions,

but exercise therapy remains the distinct contribution in pulmonary rehabilitation.

3.1 Exercise Reconditioning

3.1.1 Training Principles

Aims of Exercise reconditioning- to improve muscle strength and endurance- to improve cardiopulmonary fitness- to minimize disabilities and maximize functional abilities- to enhance psychological wellbeing

Tolerance training

Exercise tolerance training is often termed aerobic or endurance exercise training. Exercise

tolerance improvement is not just based upon the overall exercise regimes prescribed to the

patients, but also the synergy effects of all the elements in the rehabilitation program. In generalpulmonary rehabilitation practice, walking with or without treadmill, and stationary cycling are


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two common exercises prescribed for cardiopulmonary and tolerance training. The frequency

and intensity of exercises prescribed vary among programs.

Strength Training

Peripheral muscle strength influence exercise performance of COPD patients, and its relation

was shown in 6 minutes walking performance(Troosters T et al, 1996). The strength ofQuadriceps contributes significantly to six minutes walking distance and maximal oxygen uptake

(Hamilton N et al, 1995; Gosselink R et al, 1996).

Relative few studies have evaluated the effectiveness of strength training in COPD patients.

Despite of this, there is evidence that peripheral strengthening exercises not only can improvemuscles functions (O'hara WJ et al, 1984; Simpson K et al, 1992; Clark CJ et al, 1996), but also

can have positive effects on overall exercise performance (O'hara WJ et al, 1984; Clark

CJ,1996)and quality of life(Simpson K et al,1992) as well.

Training Intensity

Use of heart rate as a descriptor of aerobic exercise intensity is widely applicable. In healthy

subjects, aerobic training is usually targeted at 60 to 90% of the predicted maximal heart rate

Recently, American Thoracic Society suggested higher training intensity of 60%-75% ofmaximal heart rate as an effective training zone for COPD patients(ATS, 1999). For those who

cannot tolerate long period (20 to 30 minutes) of high intensity training, interval training with 2

to 3 minutes high intensity exercise and equal period of rest, may be an alternative(ATS, 1999).

Beside heart rate, use of dyspnea ratings (Borg-scale either for dyspnea or leg fatigue) obtainedfrom a maximal graded exercise test can also be reliably as a training target to produce specificexercise intensities in symptom-guided exercise training (Horowitz et al, 1996).

American college of sports medicine considered the impairment level of different COPD patientsand suggested 4 different approaches in exercise prescription (ACSM, 1995):

1. Exercise at 50% of Maximum Oxygen Uptake (VO2max or VO2peak): for patients withmoderate to severe COAD who are deconditioned, training at this threshold intensity for

improvement of aerobic capacity should improve exercise performance.

2. Exercise at intensity above the anaerobic threshold (AT): for patients with mild COADto reduce VE and lactate. Use heart rate as a monitor. (AT and VO2max should be obtained

from Cardiopulmonary Exercise Test).3. Exercise at a near-maximal intensity: for patients with moderate to severe COAD who can

sustain ventilation at a high percentage of their maximal minute ventilatory volume. It is

suggested that 95% of VO2peak for a few minutes can increase endurance.

4. Use ratings of dyspnea to define intensity: for patients with moderate to severe COAD whoare limited by exertional dyspnea. Target dyspnea rating is 3 (moderate) for exercise training

at an intensity of 50% VO2peak and 6 (between severe and very severe) for training at anintensity of 85% VO2peak


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3.1.2 Lower extremity training

In pulmonary rehabilitation, lower extremity training is often used as a major means for

endurance and cardiopulmonary training for COPD patients. The training effects is welldocumented, and include improve peak oxygen consumption (Peak VO2) (Ries AL et al, 1995;

Wijkstra PJ et al,1994) reduce minute ventilation (VE) (O'Donnell DE et al, 1995), improve

timed walking distance (McGavin CR et al, 1977; Cockcroft AE et al, 1981; Lake FR, 1990;

Alison JA, 1981; Goldstenin RS, 1994), improve maximum working capacity (Alison JA et al,1981) and decrease dyspnea ratings (Reardon J et al, 1994; Ries AL et al, 1995; O'Donnell DE etal, 1995).

ACCP/AACVPR recommendations (Appendix VII)

The strength of evidence is graded A. COPD patients who undergo a program of lower extremityexercise training consistently improve measures of exercise tolerance without evidence of

adverse outcome. A program of exercise training of the muscles of ambulation is recommendedas part of pulmonary rehabilitation.

Common lower extremities exercises include cycle ergometer training, treadmill walking,

ground-based walking, or combined exercises. Studies showed that all exercises are effective in

improving maximal work rate and endurance(ATS, 1999).Reviewed studies varied considerablyin training design: durarion, frequency, and intensity(ACCP/AACVPR, 1997). Only a few

studies describe their training regimen in great detail (Casaburi R et al, 1991; Maltais F et al,1996). The optimal specific training regimens for patients with COPD still be

defined(ACCP/AACVPR, 1997).

3.1.3 Upper extremity training

Upper limbs endurance training is important to COPD patients for their daily activities, and it is

common for COPD patients report limitations of ADL involving the upper extremities(Tangri &

Woolf, 1973). Upper extremity training can improve exercise capacity of upper extremity (Ries

AL et al, 1988), and decrease ventilatory demand for similar arm work (O'Tiara WJ et al, 1984).The effect of upper extremity training alone is less effective than lower extremity training in

improving overall function.(Ries Al et al, 1988; Lake FR et al, 1990) The addition of upper

extremity training to lower extremity training can significantly improve functional status when

compared to either exercise alone(Lake FR et al, 1990)

ACCP/AACVPR recommendations

The strength of evidence is graded B. Strength and endurance of the upper extremities improvearm function in COPD patients. Arm exercises are safe, and should be included in rehabilitation

programs for COPD patients.

Patients can perform upper limbs exercises with arms supported or not. The supported arm

exercise commonly prescribed is upper limb ergometer, while unsupported arm exercises by free

weights, dowels and stretching elastic bands. Either training methods can effectively improvearm endurance(ATS, 1999), though it was suggested that unsupported arms exercises have better


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functional outcomes(Martinez FJ et al, 1993).

There is no standard way to train the arms, but ACCP/AACVPR had illustrated two forms of

common upper extremity training(ACCP/AACVPR, 1997).Upper extremity ergometer trainingis achieved by having patients cycle at approximately 50 rpm. The load increases at 5-W

intervals from zero until 20 to 30 min of exercise. The arms can also be trained by lifting weight

up to shoulder level , the weights are increased as tolerated until 20 to 30 min of exercise . The

patient's performance is monitored with arms fatigue and dyspnea .

3.1.4 Inspiratory Muscle Training IMT

Inspiratory muscle function may be compromised in COPD, an impairment that may contribute

to dyspnea, exercise limitation and hypercapnia (ATS, 1999). Inspiratory muscle training (IMT)

is exercise specifically designed to build endurance and strength of the muscles powering theventilatory pump, aimed to minimize patients' disabilities.

ACCP/AACVPR recommendationsThe strength of evidence is graded B. The scientific evidence at present time does not support the

routine use of IMT as an essential component of pulmonary rehabilitation. However, IMT may

be considered in selected patients with COPD who have decrased respiratory muscle strengthand breathlessness.

Echo to the ACCP/AACVPR recommendations, after reviewing 7 mixed interventions, Lacasseconcluded that the evidence of IMT confers any additional benefit to COPD pulmonary

rehabilitation is equivocal (Lacasse et al, 1996). The recent metaanalysis of long term pulmonaryeffect on pulmonary rehabilitation also shared the same view (Cambach et al, 1999). Althoughthe beneficial effects of IMT alone on disabilities and handicaps of COPD patients remained

inconclusive (ATS 1999), there are clear evidence that IMT increase inspiratory muscle strength

(Gosselink R, 1997), reducing dyspnea and improving exercise tolerance of COPD patients(Sonne et al, 1982; Falk et al, 1985; Goldstein et al, 1989; Reid & Dechman, 1995).

There have been large variations in IMT program and training methods. Respiratory muscle

strength is usually estimated by measuring maximal negative inspiratory pressure (Pimax), andthe minimal load required to achieve a training effect is 30% of the Pimax (Smith et al, 1992)

The 3 main types of IMT are sustained hyperpnea, resistive loading and thresholdloading(Appendix VIII). Training systems for sustained hyperpnea are institutional and require

monitoring, while the last 2 methods are convenient for patients self-practise and have been

studied more extensively.

3.2 Psychosocial and Education InterventionsDepression, anxiety and selected psychiatric symptoms are common in patients with COPD.

There is a positive association of psychological distress with pulmonary impairment, poor bodyimage, increased loneliness, reduced social support, dissatisfaction with social support and


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negative self concept (Nicholas PK et al, 1992; Keele CG et al, 1993; Kersten L et al,

1990) .There is also documented impairment on tests of cognitive or neuropsychologicalfunctioning among COPD patients, indicating deficits in higher-level cognitive tasks such as

attention, complex visual motor processes, abstraction ability and verbal tasks ( Incalzi Ra et al,1993;Grant I et al, 1982; Fix AJ et al, 1982)

Pulmonary rehabilitation programs usually include psychosocial or behavioral components in

addition to exercise training. It can be in the forms of educational talks, patient support groups,or stress management groups (Emery CF et al, 1991;Ries AL et al, 1995).There areMultidisciplinary involvement in such service, and physiotherapy may share roles in such

interventions.

ACCP/AACVPR recommendationsThe strength of evidence is graded C. Evidence to date does not support the benefits of short-

term psychosocial interventions as single therapeutic modalities, but long-term interventions maybe beneficial. Although scientific evidence is lacking, expert opinion supports the inclusion of

educational and psychosocial interventions as components of comprehensive pulmonary

rehabilitation programs for COPD patients.

Exercise training itself is also a means to improve COPD patients' psychological wellbeing.

Benefits of exercises are both physiologic and psychological. Psychological benefits such asincrease motivation, antidepressant effects of exercise, loss of fear of dyspnea, desensitization to

dyspnea (Iiaas F et al, 1993), improve skill of performance (Paez PN et al, 1967; Pierce AK,1964).

4. Alternative treatment modalities

4.1 Flutter

Aiding expectoration is an important factor for patients suffering form bronchial hypersecretion.The Flutter valve was developed in Switzerland in the late 1980s as a hand-held mucus clearance

device designed to combine PEP with airway oscillation

Most of the evidence of effectiveness of Flutter was found in patients with cysticfibrosis(Konstan M et al, 1994; Ernst M et al, 1998).

Weiner et al studied the effect of Flutter in COPD patients (n=20). After 3 months of treatment,

lung function (FEV1 and FVC) as well as 12 minutes walk test were higher than those

performing the placebo Flutter. Arterial blood gases, the maximum voluntary ventilation, andrespiratory rate at rest were unchanged in both groups. (Weiner P et al, 1996).

4.2 Long Term Oxygen Therapy LTOT

COPD patients usually develop progressive hypoxemia, which can rapidly lead to damagingcellular hypoxia. The administration of domiciliary long term oxygen therapy (LTOT) can be life

preserving, and physiotherapist may share roles in the management. The Cochrane Group's


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metaanalysis on 4 related RCTs concluded LTOT improves survival in a selected group of

COPD patients with severe hypoxaemia(arterial PO2 is less than 8.0kPa), and it does not appearto improve survival in patients with moderate hypoaemia nor in COPD patients with nocturnal

desaturation only( Crockett et al, 1999).

Patients survival is one of the major outcome measures in evaluating LTOT effectiveness. Two

of the four RCTs included in the review, NOTT and MRC, demonstrated a significant survival

advantage for the selected COPD subjects receiving LTOT. In the NOTT study there was asignificant improvement in mortality for hypoxaemic COPD patients after 24 months oftreatment with continuous LTOT over nocturnal oxygen therapy group(NOTT, 1980). In the

MRC study LTOT produced a small but significant overall improvement in survival in patients

with chronic lung diseases(MRC, 1981). Beside survival, other outcome measures as HRQOL

and physiological parameters also found in related studies, but was not included in themetaanalysis.

According to American Thoracic Society (ATS) statement 1995, COPD patients whose disease

is stable on a full medical regimen, with PaO2 < 55 mmHg (50% in exercise tolerance

or breathlessness on exercise (Leach et al, 1994).

4.3 Non-invasive Positive Pressure Ventilation

Patients with acute exacerbation of COPD are prone to develop acute respiratory failure and is

associated with high mortality. Some patients are treated with intubation and mechanical

ventilation but this carries a high morbidity and may have difficulty in weaning off. These

problems have led to the use of non-invasive positive pressure ventilation (NIPPV) (Doherty &Greenstone, 1998).

NIPPV was first introduced in 1987(Ellis et al, 1987). The benefit of NIPPV over conventional

treatment in selected exacerbated COPD patients with respiratory failure had been documentedin some RCTs (Bott et al, 1993; Brochard et al, 1995; Kramer et al, 1995). The proven benefitsincludes improved arterial blood gas tensions, decreased breathlessness, reduced intubation

needs, reduced mortality and length of hospital stay. A metaanalysis of NIPPV in exacerbationsof respiratory failure due to COPD is developing by the Cochrane Group to evaluate its

effectiveness.


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4.4AcupunctureAcupuncture has traditionally been used in asthma (a condition overlaps with COPD) treatment

in China, and is increasingly applied in other countries. A recent Cochrane review stated there isinconclusive evidence that short term(1-12 weeks) acupuncture treatment has a significant effect

on the course of asthma (Linde K et al, 1998), and there is an urgent need for quality research.Few trials specifically evaluated the side-effect and morbidity profile of acupuncture treatments,

but the overall safety profile appears to be excellent (Linde K et al,1998). Despite of the

controversial on acupuncture for asthma, its development worth our concern. At present, there isno review of acupuncture on COPD as the primary diagnosis. A RCT was conducted to compare

two group COPD patients received acupunture and placebo acupunture respectively, theacupunture group had significant benefit in subjective breathlessness and six minutes walk scores.

( Jobst K et al, 1986)


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Appendix

1.Pathophysiological factors of Dyspnoea2.Chinese version of Modified Borg Scale3.Summery table of Postural Drainage Therapy studies4.Grading of ACCP/AACVPR Practice Guidelines5.Training methods of IMT6.Standardization of 6 minutes walk test


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Appendix I : Pathophysiological factors of dyspnoea

Table illustrates the pathophysiologic factors in COPD that promotes breathlessness:

Increased airways resistance

Elevated minute ventilation due to inefficient gas exchange

Hyperinflation resulting in

Reduced ability of diaphragm to generate tensionReduced efficiency of diaphragm in generation of negative intrathoracic pressure

Reduced outward recoil of chest wall

Respiratory muscle weakness

Respiratory muscle fatigue

Recruitment of needed accessory respiratory muscles during arm exercise

PostureHypoxemia and hypercapnea

Pulmonary hypertension


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Appendix II: Chinese version of Modified Borg Scale

0

0.5 , ()

1

2 ()

3

4

5 ()

6

7

8

9

10 , ()

(RPD). Borg Category Ratio Scale for Perceived DyspneaFrom: Borg, G. Medicine and science in sports and Exercise, 1982


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Appendix III: Table of some Postural Drainage Therapy Studies

Investigators Patient Comparison Study Design Measurement

Postural Drainage (PD)

Olseni et al (1994) COPD PD+FET PD+PEP RCT Mucus Clearance

Newton & Stephenson

(1978)

Chronic

Bronchitis

Chest physio.

PD vibration percussion Breathing ex.

RCT FEV1, VC, FRC, airw

resistance & conducta

blood gases

Bateman et al (1979) Stable COPD Chest physio.

PD vibration percussion

RT cross-over Sputum clearance

van-Hengstum et al (1988) Chronic

bronchitis

PEP+Br.+huffing+cough

FET+PD+Br. Ex.RT cross-over Sputum clearance

Buscaglia and St. Marie

(1983)

COPD Positioning Clinical trial O2 saturation

May and Munt (1979) Chronic

bronchitis

Percussion + PD Heat Clinical trial Sputum producti Lung function.

Blood gases.Stiller et al (1990) Lobar atelectasis PD + vibration + bagging +

suction

Bagging + suctionRT Resolution of atelecta

Mazzocco et al (1985) Bronchiectasis PD + percussion RCT FVC, SpO2, FEV1, H

PEF, sputum amount.

Mortensen et al (1991) CF PD + FET PEP + FET RCT cross-over Sputum clearance


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Percussion & Vibration

Newton & Stephenson

(1978)

Chronic

Bronchitis

Chest physio.


Breathing ex.

RCT FEV1, VC, FRC, airw

resistance & conducta

blood gases

May and Munt (1979) Chronic

bronchitis

Percussion + PD Heat Clinical trial Sputum producti Lung function.

Blood gases.Bateman et al (1979) Stable COPD Chest physio.


RT cross-over Sputum clearance

Bateman et al (1981) PD + vibration + shaking +percussion.

Cough.RCT cross-over Sputum clearance.

Buscaglia and Marie (1983) COPD Positioning Clinical trial O2 saturation Mazzocco et al (1985) Bronchiectasis PD + percussion RCT FVC, SpO2, FEV1, H

PEF, sputum amount.

Van der Schans (1991) CAO Percussion. PD + percussion + coughing +

breathing ex..

PD + coughing + breathing ex..

RCT cross-over Sputum clearance

Gallon (1991) Bronchiectasis PD + deep breathing ex. (DBE) +FET

PD + DBE + FET + fast manualpercussion

PD + DBE + FET + slow manualpercussion

RCT cross-over Sputum clearance

Rivington-Law et al (1984) Chronic

bronchitis

DBE DBE + vibration RCT cross-over FRC - ERVRV

SpO2


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Appendix IV

Grading of ACCP/AACVPR Practice Guidelines

Grade Description

A Scientific evidence provided by well-designed, wellconducted, controlled trials (randomized andnonrandomized) with statistically significant results

B Scientific evidence provided by observationalstudies or by controlled trials with less consistentresults

C Expert opinion. Scientific evidence available did notpresent consistent results or controlled trails werelacking

Appendix V: Training methods of IMT

Inspiratory resistive loading

Patient inspires through a nonlinear resistive device, the resistance depends on the inspiratory

flow rate. Monitoring of patient's breathing pattern and flow rate is necessary.

The treatment regime suggested is 30 minutes (range = 15-50 min)daily for 4 weeks to 6 months(Reid 1995). Some studies related to its effectiveness as: Dekhuijzen 1991, Belman 1988, Harver1989.

Threshold Loading

Patient inspires against a threshold load and breathes out unimpeded. It was documented that

varying inspiratory flow rates did not appreciably alter inspiratory pressures, and thus thresholdloading devices functioned effectively (Larson JL et al, 1988; Goldstein R et al, 1989) Adequate

training stimulus is essential so as to provide a positive effect on inspiratory muscle function.

The pressure loads of at least 30% of maximal inspiratory mouth pressure (PImax or MIP) have

been suggested (Larson JL et al, 1988; Lisboa C et al, 1994) as a adequate training load. Theduration of training was 10 minutes to 1 hour; the frequency of training was 3 times per week to

daily, and the time course of training sessions ranged from 4 weeks to 6 months (Reid WD,1995).

Isocapnic hyperventilation(Maximum sustained voluntary ventilation)

Isocapnic hyperventilation was introduced in 80s. Patient hyperventilate for 15 to 30 minutes

through a rebreathing device to maintain the partial pressure of arterial carbon dioxide (i.e.

isocapnia) at a target level. (Ries AL & Moser KM, 1986).The clinical usage of Isocapnichyperventilation is questionable for its inconvenience and costly. (Reid WD, 1995). Studies


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supported the effectiveness of the isocapnic hyperventilation for COPD patients include as: Ries

AL & Moser KM, 1986; Belman MJ, 1980;Levine S, 1986.The duration of training was usually15 to 30 minutes per session, the frequency of training was 3 to 6 times a week, and the time

course of training was 4 to 6 week (Reid WD, 1995)..

- Dekhuijzen PNR, Folgering HTM, van Herwaarden CIA 1991. Target flowinspiratory muscle training during pulmonary rehabilitation in patients with

COPD. Chest99: 128-133.)- Belman MJ, Shadmehr R 1988. Targeted resistive ventilatory muscle training

in chronic obstructive pulmonary disease.J Appl Physiol 65: 2726-2735.

- Harver A, mahler DA, Daubenspeck JA 1989. Targeted inspiratory musclefunction and reduces dyspnea in patients with chronic obstructive pulmonary

disease.Ann Intern Med111: 117-124.- Larson JL, Kim MJ, Sharp JT, et al (1988). Inspiratory muscle training with a

pressure threshold breathing device in patients with chronic obstructivepulmonary disease.Am Rev Respir Dis. 138:689-696.

- Goldstein R, De Rosie J, Long S, et al (1989). Applicability of a thresholdloading device for inspiratory muscle training in patients with COPD.Chest96: 564-571.

- Lisboa C, Munoz V, Beroiza T, Leiva A,Cruz E (1994). Inspiratory muscletraining in chronic airflow limitation: comparison of two different trainingloads with a threshold device.Eur Respir J. 7: 1266-74.

- Reid WD, Samral B(1995). Respiratory muscle training for patients withchronic obstructive pulmonary disease.Physical Therapy 75(11): 996-1006).

- Ries AL, Moser KM (1986). Comparison of isocapnic hyperventilation andwalking exercise training at home in pulmonary rehabilitation. Chest90(2):285-289

- Belman MJ, Mirtman C (1980). Ventatory muscle training improves exercisecapacity in chronic obstructive pulmonary disease patients.Am Rev Respir Dis

121: 273-280.

- Weiser P, Gillen J(1986). Evaluation of a ventilatory muscle endurancetraining program in the rehabilitation of patients with chronic obstructive

pulmonary disease.Am Rev Respir Dis 133: 400-406.


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Appendix VI: Six Minutes Walk Test

Equipment

Method to measure walking distance (e.g., rolling distance marker); ideal walking distance at

least 100 feet in length with minimal traffic; stopwatch; cutaneous pulse oximeter; copy of the

10-point Borg scale in large print; sphygmomanometer; stethoscope; a walker, cart, orwheelchair for patients who require supported walking (e.g., patients with severe dyspnea or

orthopedic conditions, etc.); chairs to be positioned along the walking course to be used if

needed.

Procedure:

1. Prior to the walk test following information may be documented: blood pressure, pulse,oxyhemoglobin saturation, dyspnea level (show patient 10-point Borg Scale), medications,oxygen, and assistive devices. Patients who use prescribed medications prior to

exercise/activity (e.g., inhaled beta agonist, nitroglycerin) should do so before performing

the test. Also patients who use oxygen with exercise/ activity should do so during the test attheir prescribed liter flow. The portable oxygen equipment may be carried by the staff, or it

may be placed in a cart or wheelchair for the patient to push as determined by the patient'sindividual needs. The walker, cart, or wheelchair may also be used for the patients who

require supported walking.

2. If a team member accompanies the patient during the test, that member should walk behindthe patient so that she does not influence the patient's pace. During the test the team member

may provide words to encouragement (e.g., "you're doing great." "keep up the good work,""hang in there").3. Oxyhemoglobin saturation should be assessed continuously during the test. Patients who

desaturate to levels below 88% may be allowed to continue the test if severe symptoms arenot present (e.g., increased dyspnea, chest pain). Realize that some patients may enter the

pulmonary rehabilitation program with severe hypoxemia who have been functioning with

these levels at home. The urgency to stop the test, therefore, may not be warranted unless the

patient is experiencing significant symptoms. We want to document what is truly happeningto the patient at home. If oxygen therapy is ordered and initiated these patients may then beretested.

4. Documentation during the walk test may include oxyhemoglobin saturation, heart rate,dyspnea level, patient symptoms and comments, and frequency and length of rest periods.5. Documentation post walk test may include oxygenhomoglobin saturation; heart rate; bloodpressure; dyspnea level; symptoms; patient and team member comments: if test was

performed on room air or with oxygen (document liter flow); if patient required supportedwalking via a cart, walker, or wheelchair. The total time for the test is 6 or 12 minutes,

which includes any rest stops. Example: Patient performed a 6-minute walk test and rested

twice for 30 seconds each, for a total rest time of 1 minute. Patient walked 5 minutes of the6-minute test and covered a total distance of 1,050 feet.

6. The following instructions should be given to the patients:"The purpose of this test is to assess your exercise ability and to obtain a baseline ofinformation (i.e., oxygen saturation, dyspnea level, blood pressure, heart rate, and distance


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walked). You will begin at the designated starting point and follow the walking course as

directed, covering as much distance as possible or walking at your own pace in the 6- or 12-minute period. If you need to, you may stop and rest. You will be asked to rate your

dyspnea level during the walk test and told to stop when the 6 or 12 minutes are up. To saveyour breath for the test do not carry on a conversation while walking." Patients should then

be asked to repeat the instructions to verify that they understand them.

7. If two walk tests are performed, at least 10-15 minutes of rest between each test is advised.Another option is to perform the tests on separate days.

Adapted from "Exercise Assessment and Training" by American Association of Cardiovascular

& Pulmonary Rehabilitation, 1998. In Guidelines for Pulmonary Rehabilitation Programs, 2nd ed.

(Champaign: Human Kinetics), p58.


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Further Readings

Some major cited documents are attached as soft files in the floppy for references:

1.AARC Clinical Practise Guideline1.1Use of Positive Airway Pressure Adjuncts to Bronchial Hygiene Therapy1.2Postural Drainage Therapy1.3Directed Cough2.Cochrane Reviews2.1Bronchopulmonary hygiene2.2Acupunture on chronic asthma2.3Domiliary Oxygen3.Reviews/Guidelines3.1 ACCP/AACVPR Pulmonary Rehabilitation Guidelines

physiotherapy practice guidelines for copd

Documents