Physical Therapy and Pulmonary Rehabilitation in COPD PDF

Physical Therapy and Pulmonary Rehabilitation in COPD Dr. Saif Mehmed,PT,MSc,Phd Lecturer of cardiopulmonary physical therapy and rehabilitation FOUNDER AND PRESEDENT OF ASPR [email protected] [email protected]  Learning Goals: 1. Unde...

Physical Therapy and Pulmonary Rehabilitation in COPD Dr. Saif Mehmed,PT,MSc,Phd Lecturer of cardiopulmonary physical therapy and rehabilitation FOUNDER AND PRESEDENT OF ASPR [email protected] [email protected]  Learning Goals: 1. Understand the Objectiv pathophysiology and clinical presentation of COPD. 2. Describe the components es of and benefits of pulmonary rehabilitation. the 3. Explain the role of physical therapy in COPD management. Lecture 4. Identify and interpret outcome measures. 5. Develop exercise testing and prescription plans for COPD patients. DR SAIF MEHMED : 10/20/2024 2 [email protected]  Learning Goals: 1. Mention guidelines about asthma treatment goals and medication Objectiv 2. Mention guidelines about the complementary and alternative medicine in bronchial asthma’ es of 3. 4. Talk about dyspnea Answer the question why to stimulate vagus nerve stimulation the 5. (VNS) ? Answer the question about sites of (VNS) ? Lecture 6. Discus published results about acute effect of (VNS) in attack of bronchial asthma 7. Possible mechanism of action of (VNS) in attack of bronchial asthma. DR SAIF MEHMED : 10/20/2024 3 [email protected]  OBSTRUCTIVE LUNG RESTRICTIVE LUNG DISEASE DISEASE TYPES OF LUNG DISEASES Chronic obstructive lung Interstitial diseases (interstitial fibrosis, disease sarcoidosis, occupational lung disease) COPD Asthma Neuromuscular diseases (Parkinson’s disease, multiple sclerosis) Bronchiectasis Chest wall diseases (Ankylosing spondylitis, kyphoscoliosis) Cystic fibrosis OTHER PULMONARY CONDITIONS  Lung cancer  Primary pulmonary hypertension  Obesity-related respiratory disease  Before and after thoracic and abdominal surgery DR SAIF MEHMED : 10/20/2024 4 [email protected]  DR SAIF MEHMED : 5 [email protected]  COPD:Finding on posterior- anterior and lateral chest X-ray Finding DR SAIF MEHMED :[email protected] 6 Obstructive lung disease: Airway obstruction causes an increase in resistance. A group of diseases that cause airflow blockage and breathing-related problems. Common obstructive diseases include asthma, bronchitis, and emphysema. DR SAIF MEHMED : 10/20/2024 7 [email protected]  Overview of COPD Definition: Chronic Obstructive Pulmonary Disease (COPD) is a progressive, inflammatory lung disease characterized by progressive irreversible airflow obstruction. Etiology: Smoking, air pollution, occupational exposure. Pathophysiology: Chronic bronchitis, emphysema, destruction of alveoli. DR SAIF MEHMED : 10/20/2024 8 [email protected]  Symptoms of COPD Chronic cough Dyspnea (Shortness of breath) Increased mucus production Wheezing Fatigue DR SAIF MEHMED : 10/20/2024 9 [email protected]  Patients typically have symptoms of chronic bronchitis and emphysema, but the classic triangle also includes asthma or a combination of the above. DR SAIF MEHMED : 10/20/2024 10 [email protected]  Diagnosis of COPD clinically and confirmed by spirometry Spirometry: Key Measurement: FEV₁/FVC ratio less than 0.70 post- bronchodilator. Classification: GOLD Staging: Based on FEV₁% predicted. GOLD 1: Mild GOLD 2: Moderate GOLD 3: Severe GOLD 4: Very Severe Clinically: the presence of a chronic productive cough for 3 months during each of 2 consecutive years (other causes of cough being excluded). DR SAIF MEHMED : 10/20/2024 11 [email protected] COMBINED ASSESSMENT OF COPD BASED ON SPIROMETRY ,SYMPTOMS AND EXCACERBATION DR SAIF MEHMED : 10/20/2024 12 [email protected]  DR SAIF MEHMED : 13 [email protected] 10/20/2024  Clinical Presentation Symptoms: Chronic cough with sputum production. Dyspnea, especially during physical activity. Wheezing and chest tightness. Signs: Barrel-shaped chest. Use of accessory muscles during respiration. DR SAIF MEHMED : 10/20/2024 14 [email protected]  Findings in severe disease include the following Tachypnea and respiratory distress with simple activities Use of accessory respiratory muscles. Cyanosis Elevated jugular venous pulse (JVP) Peripheral edema Patients may have signs of right heart failure (ie, cor pulmonale), such as edema and cyanosis. DR SAIF MEHMED : 10/20/2024 15 [email protected] Thoracic examination reveals the following: Hyperinflation (barrel chest) Wheezing – Frequently heard on forced and unforced expiration Diffusely decreased breath sounds Hyperresonance on percussion Prolonged expiration DR SAIF MEHMED : 10/20/2024 16 [email protected] Emphysema: destroys the walls of the alveoli of the lungs, resulting in a loss of surface area available for the exchange of oxygen and carbon dioxide during breathing.  Gradual damage of lung tissue, specifically the destruction of the alveoli Etiology Cigarette smoking Airway hyperresponsiveness Environmental factors: (air pollution) Connective tissue disorders: Marfan syndrome DR SAIF MEHMED : 10/20/2024 17 [email protected] 10/20/2024 DR SAIF MEHMED : [email protected] 18 10/20/2024 DR SAIF MEHMED : [email protected] 19 Management Strategies Lifestyle changers: Quitting smoking. Medicines: Bronchodilators, the inhaler may also contain steroids. Vaccines for the flu and pneumonia. Antibiotics if patient get a bacterial or viral lung infection Oxygen therapy PHYSICAL THERAPY AND PULMONARY REHABILITATION Surgery: Remove damaged lung tissue DR SAIF MEHMED : 10/20/2024 20 [email protected] Introduction to Pulmonary Rehabilitation Definition: A multidisciplinary program designed to improve the physical and emotional condition of people with chronic respiratory diseases. Goals: Reduce symptoms. Improve quality of life. Increase participation in daily activities. DR SAIF MEHMED : 10/20/2024 21 [email protected] Role of Physical Therapy I- INDUCTION Phase: Assessment of structure and function Insure good breathing mechanics Assessment of symtoms and exacerbation risk Decrease work of breathing Based on symptoms and signs through: Breathing retraining Techniques: Pursed-lip breathing. Diaphragmatic breathing. Dyspnea management Effective cough Airway Clearance Techniques: Techniques to remove mucus and improve ventilation. Energy conservation techniques Exercise testing II- Maintenance Phase: exercise Prescription: Individualized programs based on assessment DR SAIF MEHMED : 10/20/2024 22 [email protected]  Airway Clearance Techniques Goals: Remove secretions Prevent infections. Improve oxygenation decrease respiratory rate decrease work of breathing conserve energy Methods: 1. Active Cycle of Breathing Techniques (ACBT). 2. Autogenic Drainage. DR SAIF MEHMED : 10/20/2024 23 [email protected]  Airway Clearance Methods: Techniques 3. Mechanical Devices: positive expiratory pressure devices. High Frequency Chest Wall Oscil ation (HFCWO) device DR SAIF MEHMED : 10/20/2024 24 [email protected]  Airway Clearance Techniques Goals: Remove secretions Prevent infections. Improve oxygenation decrease respiratory rate decrease work of breathing conserve energy Postural drainage 10/20/2024 DR SAIF MEHMED : [email protected] 25  Outcome Measures 1. Symptom Assessment: Modified Medical Research Council (mMRC) Dyspnea Scale. Borg Scale for Rating Perceived Exertion. 2. Quality of Life Questionnaires: St. George's Respiratory Questionnaire (SGRQ). COPD Assessment Test (CAT). 3. Functional Measures: 6-Minute Walk Test (6MWT): Assesses endurance. Incremental Shuttle Walk Test (ISWT): Evaluates functional capacity 26 DR SAIF MEHMED : [email protected]  Outcome Measures 1. Symptom Assessment: Modified Medical Research Council (mMRC) Dyspnea Scale. Borg Scale for Rating Perceived Exertion. 2. Quality of Life Questionnaires: St. George's Respiratory Questionnaire (SGRQ). COPD Assessment Test (CAT). 8 domain 0:40 score higher score denotes more sever impact of COPD on persons life. 0:9 low score 11:20medium 21:30high31:40very high score 11:20 and higher ……referral to pulmonary rehabilitation 3. Functional Measures: 6-Minute Walk Test (6MWT): Assesses endurance. Incremental Shuttle Walk Test (ISWT): Evaluates functional capacity DR SAIF MEHMED : 10/20/2024 27 [email protected]  Outcome Measures 1. Symptom Assessment: Modified Medical Research Council (mMRC) Dyspnea Scale. Borg Scale for Rating Perceived Exertion. 2. Quality of Life Questionnaires: St. George's Respiratory Questionnaire (SGRQ). COPD Assessment Test (CAT). 3. Functional Measures: 6-Minute Walk Test (6MWT): Assesses endurance. Incremental Shuttle Walk Test (ISWT): Evaluates functional capacity DR SAIF MEHMED : 10/20/2024 28 [email protected]  Assessing Exercise Capacity Assessing exercise capacity in PR patients is important because it allows the health professional to: Determine the level of functional impairment and activity limitation. Determine the factors that limit exercise capacity. Provide information that will guide exercise prescription. Identify oxygen desaturation during exercise and aid prescription of supplemental oxygen during training. Evaluate the effectiveness of rehabilitation in altering exercise capacity and exertional dyspnoea. DR SAIF MEHMED : 10/20/2024 29 [email protected] Assessing Exercise Capacity Exercise capacity should be measured as part of the initial assessment for entry into a PR program. To evaluate the effectiveness of the program in relation to exercise capacity, the same assessment should be repeated at the completion of the program. DR SAIF MEHMED : 10/20/2024 30 [email protected]  Exercise Testing in COPD Purpose: Determine exercise capacity. Identify limitations. Establish baseline for prescription. Methods: Cardiopulmonary Exercise Testing (CPET). Field Tests: 6MWT, ISWT, ESWT DR SAIF MEHMED : 10/20/2024 31 [email protected] Assessing Exercise Capacity Three commonly used and validated field tests of exercise capacity for patients with chronic disease are: The Six-Minute Walk Test (6MWT) The Incremental Shuttle Walk Test (ISWT) The Endurance Shuttle Walk Test (ESWT) DR SAIF MEHMED : 10/20/2024 32 [email protected] 6-Minute Walk Test (6MWT) Procedure: Standardized protocol. Measures the distance walked in 6 minutes. Interpretation: Lower distances indicate greater functional impairment. Considerations: Monitor vitals before, during, and after the test. DR SAIF MEHMED : 10/20/2024 33 [email protected] 6-Minute Walk Test (6MWT) DR SAIF MEHMED : 10/20/2024 34 [email protected] 6-Minute Walk Test (6MWT) 10/20/2024 35 DR SAIF MEHMED : [email protected] The six minute walk test (6MWT) Unobstructed course (variable distance,30 meter best practice) Standardised instructions (own pace, habitual pace) A least two practice walks Standard encouragement Supervise from behind Outcome measures include : Monitor oximetry/ heart rate End exercise Borg Results in metres DR SAIF MEHMED : 10/20/2024 36 [email protected]  Responsiveness of the 6MWT To number of pulmonary rehabilitation sessions More effective if more sessions! 35.4m< 28 sessions vs 50.3 > 28 sessions DR SAIF MEHMED : 10/20/2024 37 [email protected]  Minimum clinically important difference Six minute walking test 54 m (95% CI: 37 to 71 m)- to stop rating themselves as "about the same" and start rating themselves as either "a little bit better" or "a little bit worse" (n = 112, mean age = 67 yr, mean FEV1 = 975 ml) Redelmeier DA et al Am J Crit Care Med 1997;155:1278-82 DR SAIF MEHMED : 10/20/2024 38 [email protected]  Incremental shuttle walk test (ISWT) 10 metre course marked by cones Audio signal sets the pace Pace increases each minute No encouragement End test when fails to make the cones Result expressed in metres measures of heart rate, symptoms, saturation's DR SAIF MEHMED : 10/20/2024 39 [email protected]  Additional monitoring During exercise test Metabolic & ventilatory responses Heart rate monitoring Oxygen saturation Symptoms Additional performance measures Strength DR SAIF MEHMED : 10/20/2024 40 [email protected]  Assessing Exercise Capacity Other Tests of Exercise Capacity Laboratory Tests :CPET Laboratory tests of exercise capacity, such as: incremental cycle ergometry or constant work rate cycle endurance tests, These tests provide detailed physiologic measurements that are useful for assessing the cause of exercise limitation and prescribing exercise. Constant work rate tests are responsive to changes in exercise capacity following PR. However, these tests require complex equipment, are costly and not available outside specialist centres. DR SAIF MEHMED : 10/20/2024 41 [email protected]  Assessing Exercise Capacity Strength Tests Sit-to Stand test for lower limb strength: Chair seat to be 48cm. Chair to be placed against wall. Arms to be crossed over chest. Allow 1 x Sit to stand for practice. Instructions: Stand up and sit down as quickly as possible 5 times, keeping your arms folded across your chest. Measurement: Stop timing when the participant stands the 5th time. Perform test once only (no practice test required). DR SAIF MEHMED : 10/20/2024 42 [email protected]  Assessing Exercise Capacity Strength Tests Sit-to Stand test for lower limb strength: Patients with COPD took 21% longer than healthy subjects to complete the 5STS test. patients with COPD reported a positive association between a slower 5STS time, the health-related quality of life, and the Medical Research Council’s dyspnea scores, as well as a negative correlation between 5STS time and exercise capacity (as measured by the Incremental Shuttle Walk Test [ISWT]), and a negative relationship between 5STS time and lower limb muscle strength DR SAIF MEHMED : 10/20/2024 43 [email protected]  Assessing Exercise Capacity Strength Tests Sit-to Stand test for lower limb strength: The 5STS time was reduced significantly (−1.4 s) in 239 patients with COPD after outpatient pulmonary rehabilitation there is a minimal clinically important difference, ranging from 1.3 to 1.7 seconds. The 5STS therefore seems to be reliable and responsive to pulmonary rehabilitation, in addition to being a time-efficient, low-cost, and simple test, with no apparent learning effect DR SAIF MEHMED : 10/20/2024 44 [email protected]  Assessing Exercise Capacity Upper Limb Tests A number of upper limb assessment tools are available, such as the incremental unsupported upper limb exercise test and the grocery shelving task. These tests are reliable and sensitive to change, however the minimal important difference has not been established. Upper limb tests are not routinely performed in PR. DR SAIF MEHMED : 10/20/2024 45 [email protected] Assessment Assessment Assessment ?????????????????????????????? ??????????? More Knowledge to best practice is our goal dr:saif mehmed DR SAIF MEHMED : 10/20/2024 46 [email protected]  Outcome measures BODE score score 0 1 2 3 Body-Mass Index, FEV1 >65 50-64 36-49 350 250-349 150-249 21